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Rape-Sexual Assault - Violence, Rev PDF
Rape-Sexual Assault - Violence, Rev PDF
OB-GYN
Rowena M. Auxillos, MD, FPOGS, MBA-H
1
4 Basic Principles
• Clinicians and others often make
decisions without appealing to ethical
principles for guidance or justification.
• But when they experience unclear
situations, uncertainties, or conflicts,
principles often can be helpful.
• The major principles that are
commonly invoked as guides to
professional action and for resolving
conflicting obligations 2
A 28-y/o , G1P0, 25 weeks AOG, twin
pregnancy, previously diagnosed in another
hospital as Intrauterine Fetal Demise for both
babies. You give her treatment options and
she chose induction of labor. 7 days passed
and the babies are still undelivered. She was
given only a month by her employer , based
in Singapore, to go on maternity leave. The
patient and her husband withdrew informed
consent for induction of labor and opted for
hysterotomy. If the OB acceded to this
request, which bioethical principle is she in
conformity with?
3
A.Beneficence
B.Nonmaleficence
C.Autonomy
D.Justice
E.Double
effect
4
KEY
PRINCIPLES
• Obligation to do good
• includes the obligation
BENEFICENCE to produce a net
balance of benefits over
harm.
Obligation not to harm
others, including not killing
NON-MALEFICENCE
them or treating them
cruelly.
5
KEY PRINCIPLES
AUTONOMY Obligation to respect the choices of
competent persons
Patient Control
Consumerist Mutuality
High
9
MUTUALITY
Optimal relationship
11
Obligation
Mother
BENEFICENCE AUTONOMY
Physician
BENEFICENCE
Fetus
BENEFICENCE
12
A G1P0, 24-25 weeks AOG, in preterm
labor. The OB advised admission for
tocolysis but the patient refused .
Which is the next best thing that a
clinician should do?
A.The clinician should prescribe tocolytics as
home meds
B.Focus on fetal well-being rather than
maternal well-being
C.Control the pregnant woman's options and
decisions in this situation
D.Ask the patient to sign a HAMA form
13
GENERAL ISSUES IN
WOMEN’S HEALTH
AND ADVOCACY
14
ISSUES
32
A.do outright CS as requested
B.counsel the patient on the benefits of
an epidural anesthesia
C.refer to another obstetrician who is
willing to do the CS
D.do the CS after explaining to the
patient the risks involved and getting
a well informed written consent
33
ISSUES
REGARDING
PREGNANCY
AND
MATERNAL/FETAL
ISSUES
When a woman requests elective delivery by
cesarean section in the absence of medical
indication, the OB-GYN should acknowledge the
legitimacy of the request and explore the reasons
ETHICAL
underlying it. If after full discussion the patient
ASPECTS
persists with a request for delivery by cesarean
REGARDING
section, the OB-GYN has the following options:
CESAREAN
1. Agree to perform the cesarean section,
DELIVERY ON
providing the patient is able to demonstrate an
MATERNAL
understanding of the risks and benefits of the
REQUEST
course of action she has chosen. In this case,
a well-written informed consent approved by
the Institutional Ethical Review Board (ERB)
should be signed by the patient prior to the
conduct of the elective cesarean section. 34
ISSUES
REGARDING
PREGNANCY
AND
MATERNAL/FETAL
ISSUES
2. Decline to perform the cesarean
section in circumstances where the
ETHICAL OB-GYN believes there are
ASPECTS significant health concerns for
REGARDING mother or baby if this course of
CESAREAN action is pursued, or the patient
DELIVERY ON appears to not have an
MATERNAL understanding sufficient to enable
REQUEST informed consent to the procedure.
3. Advise the patient to seek the advice
of another OB-GYN for a second
opinion.
35
A clinician finds difficulty in doing
salpingostomy in an unruptured ectopic
pregnancy with a live embryo in a 23-
year old primipara. She believes that it
is directly killing the embryo once the
procedure is done. Which of the
following principles should be upheld?
A.Beneficence
B.Maleficense
C.Autonomy
D.Double effect
36
ISSUES REGARDING PREGNANCY AND
MATERNAL/FETAL ISSUES
No woman should be
ETHICAL
forced to undergo an
GUIDELINES
unwished-for medical or
REGARDING
surgical procedure in order
INTERVENTIO
to preserve the life or
NS FOR
health of her fetus, as this
FETAL WELL
would be a violation of her
BEING
autonomy and
fundamental human rights.
37
ISSUES REGARDING PREGNANCY AND
MATERNAL/FETAL ISSUES
ETHICAL Maternal-fetal conflict occurs
ASPECTS IN when interventions to save
THE the life of the mother
MANAGEMENT inadvertently result in death
OF AN of the fetus.
ECTOPIC
PREGNANCY In managing cases of ectopic
WITH A LIVE pregnancy where the fetus is
FETUS alive, the principle of double-
effect is upheld
38
A 75 -year-old woman with stage IV
ovarian cancer refuses chemotherapy.
She wants to "go home to die." The
next step in evaluating this patient is to
A.determine
insurance
coverage
for
this
action
B.call
the
family
for
a
conference
C.accept
the
patient's
wishes
and
discharge
her
from
the
hospital
D.assess
the
patient's
comprehension
and
look
for
evidence
of
impaired
decision
making 39
ISSUES REGARDING PREGNANCY AND
MATERNAL/FETAL ISSUES
Chemotherapy and Radiation in
Pregnancy
ETHICAL 1. Radiation therapy, if
ASPECTS ON THE indicated, is preferably
MANAGEMENT OF withheld until after delivery,
since it may be harmful to the
PREGNANCIES fetus at any stage of
WITH development.
GYNECOLOGICAL 2. Chemotherapy, if needed, is
CANCERS given after the period of
embryogenesis, preferably
after 14 weeks gestation.
40
A 28-year old primi discovered that she
is carrying an anencephalic baby after
an ultrasound was done on her 24th
week of pregnancy. After learning from
her obstetrician that such condition is
not compatible with life, she wants her
OB to terminate the pregnancy ASAP.
Should the OB agree to this?
A.Yes
B.No
41
ISSUES REGARDING FETUS /
NEONATES
ETHICAL
ISSUES
Termination of pregnancy
CONCERNING
is not an option in prenatal
PRENATAL
diagnosis of congenital
DIAGNOSIS
anomaly.
OF DISEASE
IN THE
CONCEPTUS
42
ISSUES REGARDING FETUS / NEONATES
The severely malformed
fetus/neonate is entitled to the
same respect of human rights, in-
utero and after birth, as provided
ETHICAL
for legally (See Appendix: 1987
ASPECTS IN THE
Philippine Constitution Article II,
MANAGEMENT OF
Section 12)2 and morally.
THE SEVERELY
POGS advocates respect for
MALFORMED
human life starting from
FETUS/NEONATE
conception and consider it
unethical to terminate a pregnancy
because of fetal defects that have
been detected on ultrasound or
invasive fetal testing. 43
32-year-old patient has delivered at 23 weeks
of gestation, 3 days after premature rupture of
the membranes. She requests that no
attempts at resuscitation should be made. At
delivery breathing movements were noted.
The pediatrician decides that intubation be
done. In this case, the individual with the
clearest primary responsibility for this decision
is the
A.obstetrician
B. pediatrician
C. mother
D. hospital
attorney
44
ISSUES IN POGS upholds that
CONTRACEPTION human life begins at
AND ABORTION fertilization.
While POGS respects that
an OB-GYN may refuse to
render emergency
GUIDELINES IN contraception because of
EMERGENCY personal beliefs and
CONTRACEPTION convictions, it must also
uphold the patient’s right
to information and access
to this
45
POGS upholds that any
abortion procedure
purposely done is not
only illegal but also
ETHICAL
immoral. Abortion
ASPECTS OF
through any means
INDUCED
done for the purpose of
ABORTION
contraception has never
been and will never be
condoned by any
member of POGS.
46
LESBIAN, GAY, BISEXUAL,
AND TRANSGENDER
HEALTH CARE
47
LESBIAN,
GAY,
BISEXUAL,
AND
TRANSGENDER
HEALTH
CARE
• Increased
rate
of
• Depression
• Anxiety
disorder
• Substance
abuse
• High
risk
for
suicide
attempt
• High
rate
of
alcohol
and
drug
dependence
King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self-harm in
lesbian, gay, and bisexual people. BMC Psychiatry. 2008;8:70.
48
LESBIAN,
GAY,
BISEXUAL,
AND
TRANSGENDER
HEALTH
CARE
Healthcare
risks
• Cardiovascular
• Obesity
• Smoking
• Lower
rates
of
physical
exams
and
paps
• Preference
for
alternative
healthcare
providers
King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self-harm in
lesbian, gay, and bisexual people. BMC Psychiatry. 2008;8:70.
49
LESBIAN,
GAY,
BISEXUAL,
AND
TRANSGENDER
HEALTH
CARE
Disclosure
of
sexual
orientation
• Artificial
insemination
• Adoption
Obstetriciang-ynecologists need to be comfortable treating and advising
LGBT women and couples, not just for pregnancy but also for general
health issues, or should refer them to an appropriate provider
50
51
RAPE,
SEXUAL
ASSAULT,
AND
INTIMATE
PARTNER
VIOLENCE
52
RAPE,
SEXUAL
ASSAULT,
AND
INTIMATE
PARTNER
VIOLENCE
• Sexual
assault
encompasses
many
acts
including
• Rape
• Unwanted
genital
touching
• Rape
is
a
legal
term
and
refers
to
any
penetration
of
a
body
orifice
with
threat
of
force
or
actual
force
and
non
consent.
• Sexual
violence
:
any
sexual
act
performed
by
one
person
on
another
without
that
person’s
consent. 53
Republic Act 9262Anti-Violence Against Women and Their Children Act of 2004
Physical
Violence
bodily
or
physical
harm;
rape
acts
of
lasciviousness
Sexual
violence
sex
trafficking
"Violence
against
women
prostitution
and
their
children
intimidation
Psychological
violence
harassment
stalking
withdrawal
of
financial
support
"Economic
abuse
deprivation
pf
financial
support
54
RAPE
and
SEXUAL
ASSAULT
55
Sexual Violence
•One in twenty five women age 15-49 who have ever had sex ever experienced forced first sexual
intercourse
•One in ten women age 15-49 ever experienced sexual violence
56
Statistics on violence against Filipino women 2014-05-13 15:07
57
Sexual
Violence
Unwanted
Taking nude touching
photos
without Rape
consent Sexual
Violence
Sexual
Peeping harassment
Threats
58
Sexual
Assault:
Susceptible
Persons
• Homeless
• Mentally
ill
• Very
young
• Very
old
• Physically
handicapped
60
61
Essential
components
of
Rape
62
63
You
were
called
to
the
ER
for
a
13-‐y/o
claiming
to
have
been
assaulted
by
her
uncle.
Upon
inspection
of
the
genital
area,
you
noted
bruising
on
the
inner
aspect
of
the
thigh.
The
hymen
appeared
not
to
be
intact.
64
What
laboratory
tests
can
you
do
to
identify
possible
transmission
of
STDs
to
this
patient?
65
While
awaiting
for
the
laboratory
test
results,
what
is
the
shortest
antibiotic
course
could
you
possibly
give
to
prevent
STD
transmission?
The CDC recommends the woman can be given
a
• single dose of ceftriaxone 250 mg
intramuscularly, for gonorrhea prophylaxis
plus single dose azithromycin, 1 g PO for
chlamydia prophylaxis plus metronidazole 2
grams orally in a single dose or tinidazole 2
grams PO in a single dose for trichomonas. 66
The family is concerned about possible
pregnancy. What contraceptive methods
should you advice?
There
are
two
emergency
contraceptive
pill
regimens
that
can
be
used:
1.THE
LEVONORGESTREL-‐ONLY
REGIMEN:
1.5
mg
of
levonorgestrel
in
a
single
dose
(this
is
the
recommended
regimen;
it
is
more
effective
and
has
fewer
side-‐effects)
2.THE
COMBINED
ESTROGEN-‐PROGESTOGEN
REGIMEN
:
two
doses
of
100
micrograms
ethinyl
estradiol
plus
0.5
mg
of
levonorgestrel
taken
12
hours
apart 67
The family is concerned about possible
pregnancy. What contraceptive methods
should you advice?
Forensic evidence
documentation
•PC Crime Lab-Camp Crame
•Women and Children Protection
Unit-UP-PGH
72
VAWC Units in Different Government Agencies
73
TRIAGE
ACUTE CASE WTHIN 72
HOURS
NON-ACUTE CASE
74
ABUSE
INTIMATE
PARTNER
VIOLENCE
75
Intimate Partner
Violence
>age 16 with evidence of
Partner abuse physical abuse on at least
Domestic one occasion
violence
Battered woman
symptom
complex in a
Spouse abuse Battered Wife woman
Syndrome resulting from
violence
inflicted
76
Range of Abuse
Verbal
abuse, Throwing
objects Pushing Slapping
threats
Threatening
Kicking Hitting Beating or use of a
weapon
Mental
abuse Intimidation
77
78
Common
sites
of
Injury
Abdome Upper
Head Neck Chest Breast extremitie
n s
79
Red Flags Of Abuse Behavoral
Presentation
Minimize injuries
80
Red Flags Of Abuse Behavoral
Presentation
Eating
disorders,
sleep
disturbances
Early
initiation of Alcohol,
sexual
activity,
drug, and
compulsive tobacco
sexual abuse
behaviors
Self-
Aggression neglect,
towards self malnutritio VAW-ACOG Fact sheet, 2007
and others n, failure to
thrive
81
Red Flags Of Abuse Obstetrical Presentation
Unintended pregnancy
Warshaw C., Improving Health Care Response to Violence: A Trainer’s Manual For Health Care Providers,
Family Violence Prevention Fund 1998
82
RED FLAGS
OF ABUSE
OBSTETRICAL GYNECOLOGIC
PRESENTATION PRESENTATION
• Preterm labor • Chronic pelvic pain,
• Infection Abdominal complaints
• Anemia • Severe premenstrual
• Poor weight gain syndrome
• Low-birth-weight infants • Multiple or recurrent STDs
or recurrent vaginitis
Warshaw C., Improving Health Care Response to Violence: A Trainer’s Manual For Health Care
Providers, Family Violence Prevention Fund 1998
83
Somatic
Complaints
in
Abused
Women
84
How
do
we
manage
cases
of
violence
if
the
patient
answers
YES to abuse ?
85
Encourage her to Listen non- Validate her
talk about it. judgmentally experience
• You are not alone”.
• “No one has to live
with violence”.
• “You do not deserve
to be treated this
way”.
• “You are not to
blame”.
• “What happened to
you is a crime”.
• “Help is available to
you”.
86
Essential elements in the provision of appropriate
intervention for GBV cases
90
Essential elements in the provision
of appropriate intervention for
GBV cases
92
Approaches to Intervention :
collaborative
SUPPORT
PHYSICIAN NURSING COMMUNITY
SERVICE
REPRESENTA REPRESENTA REPRESENTA
REPRESENTA
TIVES TIVES TIVES
TIVES
• internists, • social • shelter
family services, counselors/
physicians, alcohol and directors,
OB-Gyns, drug abuse legal
emergency services, services for
physicians, employee battered
general assistance women,
surgeons, personnel, clergy,
ENT, clergy, and police,
ophthalmolo security district
gists, attorneys,
maxillofacial victims/survi
93
and plastic vors
surgeons,
Approaches to Intervention :
collaborative
• Physician
representatives
• internists, family physicians, OB-
Gyns, emergency physicians,
general surgeons, ENT,
ophthalmologists, maxillofacial
and plastic surgeons, orthopedic
surgeons, pediatricians, and
psychiatrists
94
Approaches to Intervention :
collaborative
• Nursing
representatives
• Support
service
representatives
• social services, alcohol and drug
abuse services, employee
assistance personnel, clergy, and
security
95
Approaches to Intervention :
collaborative
• Community
representatives
• shelter counselors/directors, legal
services for battered women,
clergy, police, district attorneys,
victims/survivors
96
Where to go
97
What
referral
options
can
we
offer
the
victims
of
violence?
98
Referral options
☞Health professionals should be aware of the
resources in their area or be able to refer the
woman to someone who does.
Individual communities
• Women’s shelters
• Crisis Centers
• Rape Crisis Centers
• Legal Services
• Program for Partners who Batter
• Support Group 99
• Individual Counseling
Referral options
• Health professionals should be aware of the
resources in their area or be able to refer the
woman to someone who does
• Individual communities
• Women’s shelters
• Crisis Centers
• Rape Crisis Centers
• Legal Services
• Program for Partners who Batter
• Support Group
• Individual Counseling 100
Thank
You
101