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The Ethics of

Obstetric Care

Hyderabad, INDIAWebsite : www.fernandezhospital.com

All India Congress of Obstetrics and Gynaecology,

19.1.2013, Mumbai

Dr. Evita Fernandez

Ethical principles and virtues should be

understood to apply to ALL physicians,

regardless of their personal, religious and

spiritual beliefsspiritual beliefs

Obstetrics

The branch of medicine

that specializes in care of women

before, during and after childbirth.

Ethical Dimensions

Unique to Obstetrics

� Two inter-woven patients – interest may

be at odds

� Vulnerability of pregnant woman � Vulnerability of pregnant woman

undergoing tests and procedures

� Pregnant woman’s autonomy and

physician’s judgement

PrinciplesPrinciplesPrinciplesPrinciples

1 Beneficence

2 Nonmaleficence2 Nonmaleficence

3 Autonomy

4 Justice

Beneficence

� Best interests of the patient

� Good over harm� Good over harm

Women who get pregnant

should have the basic human right

of humane

and evidence based

maternity carematernity care

It is NOT about the right to give birth

It is about the right to receive

appropriate care when you do.appropriate care when you do.

Appropriate Care

� The right to information and

informed decision making

Informed Consent

� Disclosure

� Comprehension

� Free consent

Communication

Justice

The fair distribution of health resources and

the decision of who gets what treatment

i.e. fairness and equalityi.e. fairness and equality

All women should have

support throughout labour

and birth.and birth.

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C.

Continuous support for women during childbirth.

Cochrane Database of Systematic Reviews 2007

Support in Labour

� Spouse / Partner

� Family members

� Midwife / student trainee

* Doulas

Single Most Important Intervention

� The need for analgesics

� Rate of oxytocin

� Instrumental deliveries� Instrumental deliveries

� Caesarean sections

� 5 min APGAR score of < 7

“They expose you, they shave you,

they cut you, they leave you alone

And don’t come when you call,

and they won’t allow

your relatives to be with you”

Pauline Kolenda, birth in a hospital / village, India

Obstetric Violence(Venezuela)

1Untimely and ineffective attention of obstetric

emergencies

2Forcing the woman to give birth in a supine

position with legs raisedposition with legs raised

3Impeding the early attachment of the child with his

/ her mother

4

Altering the natural process of a low-risk delivery

by using acceleration techniques without obtaining

voluntary expressed and informed consent

5 Performing a C Section that is unnecessary

1Untimely and ineffective attention

of obstetric emergencies

Forcing the woman to give birth in a Forcing the woman to give

Obstetric Violence(Venezuela)

2Forcing the woman to give birth in a

supine position with legs raised

3Impeding the early attachment of

the child with his / her mother

2

Forcing the woman to give

birth in a supine position

with legs raised

Pain of Indignities

� Enemas

� Shaving of pubic hair

� Lying flat on the back� Lying flat on the back

� Legs in stirrups for hours

� Lack of privacy

Justice

The fair distribution of health resources and

the decision of who gets what treatment

i.e. fairness and equalityi.e. fairness and equality

Newborn care

facilitating early bonding

Obstetric Violence(Venezuela)

1Untimely and ineffective attention

of obstetric emergencies

Forcing the woman to give birth in a Impeding the early

2Forcing the woman to give birth in a

supine position with legs raised

3Impeding the early attachment of

the child with his / her mother

3 attachment of the child

with his / her mother

Early skin-to-skin contact

for mothers and their

healthy

Moore ER, Anderson GC, Bergman N.

Early skin-to-skin contact for mothers and their healthy newborn infants.

Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.:

CD003519. DOI: 10.1002/14651858.CD003519.pub2.

healthy

newborn infants

The Benefits of

Early Skin to Skin Contact

� Positive effects on breastfeeding (OR 1.82)

� Improved maternal bonding

� Infants cried for a shorter length of time� Infants cried for a shorter length of time

� Better cardio-respiratory function

� No adverse effects were found

Moore ER, Anderson GC, Bergman N.

Early skin-to-skin contact for mothers and their healthy newborn infants.

Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.:

CD003519. DOI: 10.1002/14651858.CD003519.pub2.

Human Rights in Childbirth

Birthing women have a fundamental

human right to choose the circumstances

in which they give birth.in which they give birth.

Nonmaleficence

First, Do no harm

(Primum non nocere)(Primum non nocere)

Obstetric Violence(Venezuela)

4

Altering the natural process of a

low-risk delivery by using

acceleration techniques without

obtaining voluntary expressed and

Altering the natural process of a

low-risk delivery by using

acceleration techniques obtaining voluntary expressed and

informed consent

5Performing a C Section that is

unnecessary

4acceleration techniques

without obtaining voluntary

expressed and informed

consent

Interventions

that may cause harm

� Induction of labour

� Oxytocin drip

� Rupture of fore-waters

� Repeated vaginal examinations

Autonomy

The right to choose

and follow

one’s own plan of

life and action

Caesarean Delivery

upon Maternal Request (CDMR)

... in the absence of any

specific medical indication

National Institute of HealthMarch 2006

“Insufficient evidence

to issue a recommendation concerning

the relative safety of

planned Caesarean births

and called for further study”

� FIGO : Ethically not justified

� ACOG : Not recommended for

women “desiring several children”

Consent for Caesarean Section should be

requested AFTER providing evidence based

information in a manner that respects the

woman’s dignity, privacy, views and culture,

apart from the clinical consideration.

NICE Guidelines, Nov. 2011

International Caesarean Awareness

Network (ICAN)

Caesarean Delivery

upon Maternal Request (CDMR)

Network (ICAN)

- Unethical and immoral

www.ican-online.net

Proponents of natural births

- Undermines a woman’s confidence

Caesarean Delivery

upon Maternal Request (CDMR)

in her own body and minimizes

her participation in the birthing practices

CDMR : Potential Risks

� ↑ Neonatal respiratory morbidity

� Potential surgical complications

� Future pregnancies – abnormal placentation

– uterine rupture

CDMR : Potential Benefits

� Convenient time

� Lowered risk of haemorrhage

� ↓ Neonatal injury

Ethical Question : CDMR

� Do these surgeries represent

Choice

Am. Fam. Med 2006;34 : 265-8

Patient Demand

Request

Talking Points for Informed

Consent on CDMR

� Do not recommend / offer

� Enquire WHY / EDUCATE / ADDRESS MYTHS

� Be explicit in discussing risks / benefits� Be explicit in discussing risks / benefits

� Risks to future pregnancies

� Refer to another health care provider

ACOG, Obstet Gynecol 2007;110 : 1501-4

A woman giving birth is the

final decision maker in the birth process.

Doctors, midwives and others can

inform, advise and support.

Informed Consent

� Disclosure

� Comprehension

� Free consent

Communication

The state of pregnancy

does NOT deprive a woman

of her right to decide what

should happen to her body

Birth Plan

� What are your wishes during a normal labour

and delivery ?

� How do you hope for your baby to be treated � How do you hope for your baby to be treated

immediately after birth

BIRTH PLAN

Mode of delivery

Gestational age

EpiduralEpidural

Support in labour

Episiotomy

Breast Feeding

Only one rule

in medical ethics need concern you in medical ethics need concern you

– that action on your part which best

conserves the interests of your patient

– Martin H. Fischer