the ethics of obstetric care · early skin to skin contact positive effects on breastfeeding (or...
TRANSCRIPT
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