Legal and Ethical Issues

in Obstetrics

Itismita Biswal
1st Year M.Sc. Nursing
Sum Nursing College
Bhubaneswar
PRINCIPLES OF ETHICS
Beneficence
Beneficence is to act in the best interests of
the patient, and to balance benefits against
risks. The benefits that medicine is competent
to seek for patients are the prevention and
management of disease, injury, handicap, and
unnecessary pain and suffering and the
prevention of premature or unnecessary
death.
Autonomy
Autonomy means to respect the right of the
individual. Respect for autonomy enters the
clinical practice by the informed consent. This
process usually understood to have 3
elements, disclosure by the physician to the
patient’s condition and its management,
understanding of that information by the
patient and a voluntary decision by the patient
to authorize or refuse treatment.
Non maleficence
It means that a health personnel should
prevent causing harm and is best
understood as expressing the limits of
beneficence. This is commonly known as
‘primum non nocere’ or first to do no harm.
Justice
Justice signifies, to treat patients fairly and
without unfair discrimination, there should
be fairness in the distribution of benefits
and risks. Medical needs, and medical
benefits should be properly weighed.
Confidentiality
Confidentiality is the basis of trust
between health personnel and patient.
By acting against this principle one
destroys the patient trust.
Patient Rights

The right to be treated with respect and

dignity without reference age, marital,
socio-economic, ethnic, national, political,
mental, physical or religious status.
 LEGAL & ETHICAL PRINCIPLES
IN THE PROVISION OF
HEALTH SERVICES
1. Informed decision making.
Patients or individuals who require health care
services have right to make their own decision
about the opinions for treatment or other
related issues. The process of obtaining
permission is called informed consent.
Autonomy:
Autonomous persons are those who, in their
thoughts, work, and actions, are able to follow
norms chosen of their own without external
constraints or coercion by others. It is to be
noted that autonomy is not respect for
patient’s wish against good medical
judgement. Simply put, a health provider can
refuse a treatment option chosen by the
patient, if the option is of no benefit to the
patient.
Surrogate decision makers:
Surrogate decision makers [ Parents ,
caregivers, guardians] may take the decisionif
the affected individual’s ability to make a
choice is diminished by factors such as
extreme youth, mental processing difficulties,
extreme medical illness or loss of awareness.
2. Privacy and confidentiality
A patient’s family, friend or spiritual guide has no right to
medical information regarding the patient unless
authorized by the patients. The following points of
confidentiality are to be kept in mind:
Health care providers duties to protect patient’s
information against unauthorized disclosures.
Patient’s right to know what their health care
providers think about them.
Health care provider’s duties to ensure that patients
who authorize releases of their confidential health
related information to others, exercise an
adequately informed and free choice.
 3. Competent delivery services:

Every individual has a right to receive treatment by a competent

health care provider who knows to handle such situations quite well.
According to the laws, medical negligence is shown when the
following 4 elements are all established by a complaining party.

• A legal duty of care must be owed by a provider to the

complaining party.

• Breach of the established legal duty of care must be shown, which

means a health care provider has failed to meet the legally
determined standards of care.

• Damage must be shown.

• Causation must be shown.

4. Safety and efficacy of products:
Health care providers are responsilble
for any accidental or deliberate use of
products that differs from their
approved purposes or methods of use,
for instance, the dosage level for
drugs. Look for the drug
contraindications, drug expiry,
damage of diluted sterilization
solvents etc.
5. Code of ethical midwifery practice
Midwives rights:

The right to refuse care to patients with whom no midwife-

patient relationship has been established.
The right to discharge patients from her acre, provided
adequate information from patients upon which caring
is based.
The right to receive honest, relevant information from
patients upon which caring is based.
The right t receive reasonable compensation for
services rendered.
Midwives responsibilities:
The obligation to serve as the guardian of
normal birth, alert to possible complications,
but always on guard arbitrary interference in
the birthing process for the sake of convenience
or the desire to use human beings in scientific
studies and training.
The obligation to honour the confidence of
those encountered in the course of midwifey
practice and to regard everything seen and
heard as inviolable, remembering always that a
midwife’s highest loyalty is owed to her patient
and not to her health care providers.
 The obligation to provide complete,
accurate and relevant information to
patients so that they can make informed
choices regarding their health care.
The obligation, when referring a patient to
another health care provider, is to remain
responsible for the patient until she is either
discharged or formally tranfered.
 The obligation never to comment on
another midwife’s or other health
provider’s care without first contacting that
practitioner personally.
The responsibility to develop and utilize a
safe and efficient mechanism for medical
consultation, collaboration and referral.
 The obligation to pursue professional
development through ongoing evaluation of
knowledge and skills and continuing
education including diligent study of all
subjects relevant to midwifery.
The responsibility to assist others who wish
to become midwives by honestly and
accurately evaluating their potential and
competence and sharing midwifery
knowledge and skills to the extent possible
without violating another section in this
code.
The obligation to know and comply with all legal
requirements related to midwifery practice within
the law to provide for the unobstructed practice of
midwifery within the state.
The responsibility to maintain accountability for
all midwifery care delivered under her supervision.
Assignment and delegation of duties to other
midwives or apprentices should be proportionate
to their educational preparation and demonstrated
proficiency
The obligation to accurately document the
patient’s history, condition , physical progress and
other vital information obtained during patient care
Unprofessional conduct:
Knowingly or consistently failing to
accurately document a patient’s condition,
responses, progress or other information
obtained during care. This includes failing to
make entries, destroying entries or making
false entries in the records pertaining to
midwifery care.
Performing or attempting to perform
midwifery techniques or procedures in which
the midwife is untrained by experience or
education.
 Failing to give care in a reasonable and
professional manner, including maintaining a
patient load, which does not allow for
personalized care by the primary attendant.
Leaving a patient intrapartum without
providing adequate care for the mother and
infant.
Delegation of midwifery care or responsibilities
to a person who lacks ability or knowledge to
perform the function or responsibility in
question.
 Manipulating or affecting a patient’s
decision by withholding or misrepresenting
information in violation of patient’s right to
make informed choices in their health care.
Failure to report to the applicable state
board or the appropriate authority in the
association, within a reasonable time, the
occurrence of any violation of any legal or
professional code.
ETHICAL & LEGAL ISSUES IN
OBSTETRICS

Issues mainly divided into 3 types-

1. Maternal Issue
2. Fetal Issue
3. Other Issue
Maternal Issues

Surrogacy: The issue of Surrogacy can cause great moral, ethical &
legal debate within the community. A surrogate mother is someone
who gestates (Conceives& Carries within the uterus) & then gives
birth to a child for another person, with the full intention of handling
the child over to that person after birth.

The following are situations where surrogacy arrangement may be

considered. E.g.
• A woman is unable to become pregnant
• A woman may have a health condition which makes pregnancy
dangerous.
Egg donation
Egg donation may be used successfully in treatment of multiple causes of
infertility, as well as some genetic diseases.
The following are situations where surrogacy arrangement may be
considered. E.g.
1. Patient is either in menopause or early menopause & is unable to
produce her own eggs.
2. Patient with absent ovaries.
3. Patient at risk of passing on a genetic disease which may not be
prevented through pre-implantation genetic diagnosis.
4. Patient who has had prior invitro fertilization failures.
Artificial Reproductive technique
• Artificial Insemination: The primary indication for AID (Artificial
Insemination of the donors) are male Infertility& genetic problems
Issue-
i. Informed consent to be taken
ii. The donors not know the identity of the husband and
wife and vice versa and that the physician can be
given permission to select the donor.
iii. Donor insemination raises the issue whether the child
should be told about his genetic father or not.
• Invitro Fertilization: In IVF the ovum is fertilized outside the body &
then implanted into the uterus. Between 15 to 20 embryos may result
from a single fertilization effort. only 3 to 5 of these implanted in the
uterus. Ethical questions may arise what to do with the remaining
embryos.
Abortion

Ethical Consideration: From an ethical perspective, abortion is essentially

the removal of woman’s support from the fetus, leading to the fetal death.
Camenish (1976) point of view that one does not have the right to inflicted
pain & tragic consequences of certain detectable serious disease on an
innocent infant.

Social issues Sex selective abortion& female infanticide

Ethical Issues
• During the first trimester, the state cannot bar anywhere women from
obtaining abortion from a licensed physician.
• In the second trimester a state can regulate the performance of an
abortion if such regulation relates to protection of the woman’s health.
• In 3rd trimester, the state can regulate and even prohibit abortions,
except those demand necessary to protect the woman’s life & health &
the state may impose safeguards for the fetus.
Ethics & medico-legal aspects of obstetric anesthesia
and informed consent
Before treatment, diagnostic procedures or experimental therapy a
patient must informed of the reasons of the treatment as well as the
possible adverse effects and alternative treatments.
The physician must obtain signed consent.

Prenatal Screening

Sexual Counselling

Sterilization

Genetic Counselling
Ethical Issues related to preimplantation genetic
diagnosis
Preimplantation Genetic Diagnosis(PGD) is a procedure that aims to weed
out genetically defective embryos before they have a chance to develop. It
is a procedure that is done in conjunction with in vitro fertilization(IVF).

Ethical & Legal Issues in Prenatal &Labor care:

Fetal Monitors
During Labor& Delivery
Maternal Complications
Still born infants
Neonatal Complications
Ethical Issues In neonatal care and resuscitation
Fetal Issues
1. Fetal research:
2. Fetal therapy:
A. Fetal tissue research
B. Eugenics and gene manipulation
C. Preterm and high-risk neonate treatment
D. Cord Blood Banking
3. Embryonic stem cell research
4. Female foeticide
5. The Human Genome Project
Other Issues

• Colostrum feeding
• Hymen reconstruction
• Trans-sexualism
STANDARDS OF MIDWIFERY PRACTICES
Midwifery practice as conducted by certified nurse-midwives (CNMs) and
certified midwives (CMs) is the independent management of women's
health care, focusing particularly on pregnancy, childbirth, the post partum
period, care of the newborn, and the family planning and gynecologic needs
of women.

STANDARD I - MIDWIFERY CARE IS PROVIDED BY QUALIFIED

PRACTITIONERS
The midwife:
Is certified by the ACNM designated certifying agent.
Shows evidence of continuing competency as required by the ACNM
designated certifying agent.
STANDARD II - MIDWIFERY CARE OCCURS IN A SAFE ENVIRONMENT
WITHIN THE CONTEXT OF THE FAMILY, COMMUNITY, AND A SYSTEM
OF HEALTH CARE.
The midwife:
Demonstrates knowledge of and utilizes federal and state regulations that
apply to the practice environment and infection control.

STANDARD III - MIDWIFERY CARE SUPPORTS INDIVIDUAL RIGHTS AND

SELF-DETERMINATION WITHIN BOUNDARIES OF SAFETY
The midwife:
Practices in accord with the Philosophy and the Code of Ethics of the American
College of Nurse-Midwives.
Provides clients with a description of the scope of midwifery services and
information regarding the client's rights and responsibilities. ACNM Standards
for the Practice of Midwifery 1
STANDARD IV - MIDWIFERY CARE IS COMPRISED OF KNOWLEDGE,
SKILLS, AND JUDGMENTS THAT FOSTER THE DELIVERY OF SAFE,
SATISFYING, AND CULTURALLY COMPETENT CARE.
The midwife:
Demonstrates the clinical skills and judgments described in the ACNM Core
Competencies for Basic Midwifery Practice.
Practices in accord with the ACNM Standards for the Practice of Midwifery.

STANDARD V - MIDWIFERY CARE IS BASED UPON KNOWLEDGE, SKILLS,

AND JUDGMENTS WHICH ARE REFLECTED IN WRITTEN PRACTICE
GUIDELINES AND ARE USED TO GUIDE THE SCOPE OF MIDWIFERY CARE
AND SERVICES PROVIDED TO CLIENTS.
The midwife:
Maintains written documentation of the parameters of service for
independent and collaborative midwifery management and transfer of
care when needed.
STANDARD VI - MIDWIFERY CARE IS DOCUMENTED IN A FORMAT THAT
IS ACCESSIBLE AND COMPLETE.
The midwife:
Uses records that facilitate communication of information to clients,
consultants, and institutions.
Maintains confidentiality in verbal and written communications.

STANDARD VII - MIDWIFERY CARE IS EVALUATED ACCORDING TO AN

ESTABLISHED PROGRAM FOR QUALITY MANAGEMENT THAT INCLUDES
A PLAN TO IDENTIFY AND RESOLVE PROBLEMS.
The midwife:
Participates in a program of quality management for the evaluation of
practice within the setting in which it occurs. ACNM Standards for the
Practice of Midwifery 2 ACNM Standards for the Practice of
Midwifery 3 .
STANDARD VIII - MIDWIFERY PRACTICE MAY BE EXPANDED BEYOND
THE ACNM CORE COMPETENCIES TO INCORPORATE NEW
PROCEDURES THAT IMPROVE CARE FOR WOMEN AND THEIR
FAMILIES.
The midwife:
Identifies the need for a new procedure taking into
consideration consumer demand, standards for safe practice,
and availability of other qualified personnel.
Ensures that there are no institutional, state, or federal
statutes, regulations, or bylaws that would constrain the
midwife from incorporation of the procedure into practice.
STANDING ORDERS FOR MIDWIFERY
A standing order is a document containing orders for the conduct of
routine therapies, monitoring guidelines, and/or diagnostic procedure
for specific client with identified clinical
problem. Standing orders are approved and signed by the physician in
charge of care before their implementation.

Standing Orders are orders in which the nurse may act to carry out
specific orders for a patient who presents with symptoms or needs
addressed in the standing orders. They must be in written form and
signed and dated by the Licensed Independent Practitioner.

OBJECTIVES
• To maintain the continuity of the treatment of the patient.
• To protect the life of the patient.
• To create feeling of responsibility in the members of health
team.
 ANTEPARTUM
ANALGESIA Paracetamol 1gram as a single dose, once only.
ANTACID Maalox suspension 10ml as a single dose, once only
Or
Peptac liquid 10-20ml as a single dose, once only.
LAXATIVE Ispaghula Husk 3.5g one sachet in water, once only.
PROPHYLAXIS MENDELSON’S FOR Ranitidine tablet 150mg at 22.00 on night before theatre, repeated two
SYNDROME IN ELECTIVE LSCS hours before theatre. Sodium Citrate 0.3mg 30ml orally once only immediately
prior to transfer to Theatre.
I.V. THERAPY Compound Sodium Lactate 1 litre i.v. over 8-12 hours, to a maximum of two
liters.
CANNULA Heparin 10IU/ml 5ml instilled into i.v. When required every 4-8 hours.

LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to cannulation once only.

Amethocaine gel 4% 1g 45 minutes prior to venous cannulation once only.

NIGHT SEDATION Temazepam 10mg as a single dose up to 2.00am in the morning.

DINOPROSTONE VAGINAL GEL As per induction of labor guidelines.
FOLIC ACID Folic acid 400microgram tablet once daily, until 12-14 weeks gestation.

DEMULCENT COUGH PREPARATION Simple linctus 5ml once only

ANTISPASMODIC Peppermint water 10ml in plenty of water, once only.

 INTRAPARTUM
ANALGESIA Entonox inhalation as required.
Diamorphine i.m. 5-10mg every 3-4 hours (women <50kg before
pregnancy 5mg only) providing delivery is not imminent, up to a
maximum of 2 doses without reference to a registrar. Monitor
respirations for 30 minutes after administration).

ANTI-EMETICS Cyclizine 50mg i.m. every 8 hours as required to a maximum of

150mg/24 hours.
Metoclopramide 10mg i.m. every 8 hours as required to a maximum of
30mg in 24 hours or 500 micrograms per Kg in 24 hours for women<60kg

ACTIVE MANAGEMENT OF Oxytocin 10 i.u.as per unit policy.

LABOUR Syntometrine 1ml i.m. with anterior shoulder at delivery.
I.V. THERAPY Compound Sodium Lactate 1 litre i.v. over 8-12 hours as required to a
maximum of 2 litres.
Heparin 10u/ml 5ml instilled into i.v. cannula every 4-8 hours when
required.
LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to cannulation, once only.
Amethocaine gel 4% 1g prior to cannulation once only.

LAXATIVES Glycerin Suppository 1 or 2 per rectum

or
Docusate sodium 90mg micro enema as required.
EPISIOTOMY Lignocaine 1% 10ml by perineal infiltration.
 EPISIOTOMY REPAIR Lignocaine 1% by perineal infiltration to a maximum of 20m

ANALGESIA NSAID ANALGESIC Only one NSAID should be prescribed at any

one time.

Cesarean Section for first 24 hours: Anesthetist will be responsible for analgesia. Unless contra-indicated diclofenac
suppository 100mg will be given rectally in Theatre. One dose of an NSAID can be
given 14-16 hours after the suppository. If Diclofenac is given, the total dose
must not exceed 150mg by all routes in any 24 hours period.

Vaginal delivery or Cesarean Ibuprofen tablet or syrup 400mg or 600mg three times a day.
Section after first 24 hours: Diclofenac tablet or suppository 50mg three times a day (to a maximum of
150mg in 24 hours by any route).

PARACETAMOL BASED Only one PARACETAMOL BASED ANALGESIC should be prescribed at any one
time.
Paracetamol 1gram every 4-6 hours to a maximum of 4grams in any 24 hours as
plain or effervescent tablets or rectally as suppository.
Co-dydramol 2 tablets every 4-6 hours to a maximum of 8 tablets in any 24
hours.

ANTIEMETIC Cyclizine 50mg i.m. every 8 hours as required to a maximum of 150mg/24 hours.
Metoclopramide 10mg i.m. every 8 hours as required to a maximum of 30mg in
24 hours or 500 micrograms per Kg in 24 hours for women<60kg.

LAXATIVES Ispaghula Husk 3.5g, 1 sachet in water twice daily.

Lacunose 10ml orally twice daily.
Glycerin suppository 1 or 2 per rectum as required.
POSTPARTUM
HAEMORRHOID PREPARATIONS Anusol cream apply twice daily and after each bowel movement.
Scheriproct ointment apply twice daily for 5-7 days then once daily until
symptoms cleared.

I.V. THERAPY Compound Sodium Lactate 1-liter i.v. every 8-12 hours as required to a maximum
of 2 liters.
Heparin 10u/ml 5ml instilled into i.v. cannula every 4-8 hours when required.

LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to cannulation, once only.

Amethocaine gel 4% 1g prior to venous cannulation once only.

ANTI –D Anti-D Immunoglobulin 500i.u or more. by i.m. injection to Rh D negative women

with a Rh D positive baby within 72 hours of delivery as per obstetric unit
guidelines.
VACCINES Rubella vaccine (live) 0.5ml by deep subcutaneous or intramuscular injection if
mother not immune.
IRON SUPPLEMENT Ferrous sulphate tablet 200mg three times a day if haemoglobin below 10g/dl.

DEMULCENT COUGH Simple linctus 5ml 3-4 times a day.

PREPARATION

ANTISPASMODIC Peppermint water 10ml in plenty of water, once only.

THANK YOU…