The Ethics of Obstetric Care
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Transcript of The Ethics of Obstetric Care
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The Ethics of Obstetric Care
Hyderabad, INDIAWebsite :
www.fernandezhospital.comAll India Congress of Obstetrics and Gynaecology,
19.1.2013, Mumbai
Dr. Evita Fernandez
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Ethical principles and virtues should be
understood to apply to ALL physicians,
regardless of their personal, religious and
spiritual beliefs
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ObstetricsThe branch of medicine
that specializes in care of women before, during and after childbirth.
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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
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Principles
1 Beneficence2 Nonmaleficence
3 Autonomy4 Justice
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Beneficence
Best interests of the patient
Good over harm
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Women who get pregnant should have the basic human right
of humane and evidence based
maternity care
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It is NOT about the right to give birth
It is about the right to receive appropriate care when you do.
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Appropriate Care
The right to information and
informed decision making
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Informed Consent
Disclosure
Comprehension
Free consent
Communication
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Justice
The fair distribution of health resources and
the decision of who gets what treatment
i.e. fairness and equality
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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
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Support in Labour
Spouse / Partner
Family members
Midwife / student trainee
* Doulas
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Single Most Important Intervention
The need for analgesics Rate of oxytocin Instrumental deliveries Caesarean sections 5 min APGAR score of < 7
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“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
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Obstetric Violence(Venezuela)
1 Untimely and ineffective attention of obstetric emergencies
2 Forcing the woman to give birth in a supine position with legs raised
3 Impeding the early attachment of the child with his / her mother
4Altering 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
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1 Untimely and ineffective attention of obstetric emergencies
2 Forcing the woman to give birth in a supine position with legs raised
3 Impeding the early attachment of the child with his / her mother
2Forcing the woman to give birth in a supine position with legs raised
Obstetric Violence(Venezuela)
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Pain of Indignities
Enemas
Shaving of pubic hair
Lying flat on the back
Legs in stirrups for hours
Lack of privacy
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Justice
The fair distribution of health resources and
the decision of who gets what treatment
i.e. fairness and equality
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Newborn carefacilitating early bonding
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Obstetric Violence(Venezuela)
1 Untimely and ineffective attention of obstetric emergencies
2 Forcing the woman to give birth in a supine position with legs raised
3 Impeding the early attachment of the child with his / her mother
3Impeding the early attachment of the child with his / her mother
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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.
Early skin-to-skin contact for mothers and their
healthynewborn infants
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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.
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Human Rights in Childbirth
Birthing women have a fundamental
human right to choose the circumstances
in which they give birth.
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Nonmaleficence
First, Do no harm(Primum non nocere)
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Obstetric Violence(Venezuela)
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
4
Altering the natural process of a low-risk delivery by using acceleration techniques without obtaining voluntary expressed and informed consent
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Interventions that may cause harm
Induction of labour Oxytocin drip Rupture of fore-waters Repeated vaginal examinations
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Autonomy
The right to choose
and follow
one’s own plan of
life and action
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Caesarean Delivery upon Maternal Request (CDMR)
... in the absence of any
specific medical indication
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National Institute of HealthMarch 2006
“Insufficient evidence to issue a recommendation concerning
the relative safety of planned Caesarean births
and called for further study”
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FIGO : Ethically not justified
ACOG : Not recommended for
women “desiring several children”
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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
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International Caesarean Awareness
Network (ICAN)
- Unethical and immoral
Caesarean Delivery upon Maternal Request (CDMR)
www.ican-online.net
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Proponents of natural births- Undermines a woman’s confidence
in her own body and minimizes her participation in the birthing practices
Caesarean Delivery upon Maternal Request (CDMR)
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CDMR : Potential Risks
↑ Neonatal respiratory morbidity
Potential surgical complications
Future pregnancies – abnormal placentation
– uterine rupture
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CDMR : Potential Benefits
Convenient time
Lowered risk of haemorrhage
↓ Neonatal injury
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Ethical Question : CDMR
Do these surgeries represent
Am. Fam. Med 2006;34 : 265-8
Patient
Choice
Demand
Request
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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, Obstet Gynecol 2007;110 : 1501-4
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A woman giving birth is the final decision maker in the birth process.
Doctors, midwives and others can inform, advise and support.
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Informed Consent
Disclosure
Comprehension
Free consent
Communication
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The state of pregnancy
does NOT deprive a woman
of her right to decide what
should happen to her body
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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
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BIRTH PLANMode of delivery
Gestational age
Epidural
Support in labour
Episiotomy
Breast Feeding
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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