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The Ethics of Obstetric Care. Dr. Evita Fernandez. Hyderabad, INDIA Website : www.fernandezhospital.com. All India Congress of Obstetrics and Gynaecology , 19.1.2013, Mumbai .

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the ethics of obstetric care

The Ethics of Obstetric Care

Dr. Evita Fernandez

Hyderabad, INDIA

Website : www.fernandezhospital.com

All India Congress of Obstetrics and Gynaecology, 19.1.2013, Mumbai

slide3

Ethical principles and virtues should be understood to apply to ALL physicians, regardless of their personal, religious and spiritual beliefs

obstetrics
Obstetrics

The branch of medicine

that specializes in care of women

before, during and after childbirth.

ethical dimensions unique to obstetrics
Ethical Dimensions Unique to Obstetrics
  • Two inter-woven patients – interest may be at odds
  • Vulnerability of pregnant woman undergoing tests and procedures
  • Pregnant woman’s autonomy and physician’s judgement
beneficence
Beneficence
  • Best interests of the patient
  • Good over harm
slide8

Women who get pregnant

should have the basic human right

of humane

and evidence based

maternity care

slide9

It is NOT about the right to give birth

It is about the right to receive

appropriate care when you do.

appropriate care
Appropriate Care
  • The right to information and informed decision making
informed consent
Informed Consent
  • Disclosure
  • Comprehension
  • Free consent

Communication

justice
Justice

The fair distribution of health resources and the decision of who gets what treatment i.e. fairness and equality

all women should have support throughout labour and birth
All women should have support throughout labour 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
Support in Labour

Spouse / Partner

Family members

Midwife / student trainee

* Doulas

single most important intervention
Single Most Important Intervention

The need for analgesics

Rate of oxytocin

Instrumental deliveries

Caesarean sections

5 min APGAR score of < 7

slide18

“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

pain of indignities
Pain of Indignities
  • Enemas
  • Shaving of pubic hair
  • Lying flat on the back
  • Legs in stirrups for hours
  • Lack of privacy
justice1
Justice

The fair distribution of health resources and the decision of who gets what treatment i.e. fairness and equality

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

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.

the benefits of early skin to skin contact
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
  • 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
Human Rights in Childbirth

Birthing women have a fundamental human right to choose the circumstances in which they give birth.

nonmaleficence
Nonmaleficence

First, Do no harm

(Primum non nocere)

interventions that may cause harm
Interventions that may cause harm
  • Induction of labour
  • Oxytocin drip
  • Rupture of fore-waters
  • Repeated vaginal examinations
autonomy
Autonomy

The right to choose

and follow

one’s own plan of

life and action

caesarean delivery upon maternal request cdmr
Caesarean Delivery upon Maternal Request (CDMR)

... in the absence of any specific medical indication

national institute of health march 2006
National Institute of HealthMarch 2006

“Insufficient evidence

to issue a recommendation concerning

the relative safety of

planned Caesarean births

and called for further study”

slide34

FIGO : Ethically not justified

  • ACOG : Not recommended for women “desiring several children”
slide35

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

caesarean delivery upon maternal request cdmr1
Caesarean Delivery upon Maternal Request (CDMR)

International Caesarean Awareness Network (ICAN)

- Unethical and immoral

www.ican-online.net

caesarean delivery upon maternal request cdmr2
Caesarean Delivery upon Maternal Request (CDMR)

Proponents of natural births

- Undermines a woman’s confidence

in her own body and minimizes

her participation in the birthing practices

cdmr potential risks
CDMR : Potential Risks
  • ↑ Neonatal respiratory morbidity
  • Potential surgical complications
  • Future pregnancies – abnormal placentation

– uterine rupture

cdmr potential benefits
CDMR : Potential Benefits
  • Convenient time
  • Lowered risk of haemorrhage
  • ↓ Neonatal injury
ethical question cdmr
Ethical Question : CDMR
  • Do these surgeries represent

Patient

Choice

Demand

Request

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

talking points for informed consent on cdmr
Talking Points for Informed Consent on CDMR
  • Do not recommend / offer
  • Enquire WHY / EDUCATE / ADDRESS MYTHS
  • Be explicit in discussing risks / benefits
  • Risks to future pregnancies
  • Refer to another health care provider

ACOG, ObstetGynecol 2007;110 : 1501-4

slide42

A woman giving birth is the

final decision maker in the birth process.

Doctors, midwives and others can

inform, advise and support.

informed consent1
Informed Consent
  • Disclosure
  • Comprehension
  • Free consent

Communication

slide44

The state of pregnancy does NOT deprive a woman of her right to decide what should happen to her body

birth plan
Birth Plan
  • What are your wishes during a normal labour and delivery ?
  • How do you hope for your baby to be treated immediately after birth
slide48

Only one rule

in medical ethics need concern you

– that action on your part which best

conserves the interests of your patient

– Martin H. Fischer