LEGAL & ETHICAL ISSUES IN OBSTETRIC NURSING

INTRODUCTION
Obstetricians-Gynecologists have an ethical duty to be advocates for women’s health care. As
members of a learned profession, they have a body of knowledge that includes sexual and
reproductive health. They are usually the first professional that women approach with health
problems in this area. They therefore have a duty to provide care based on this knowledge and
experience. The knowledge base and social standing of physicians places them in a position with
the potential to influence policies regarding women’s health.

This obligation is increased by the unique vulnerability of women because of their reproductive
function and role. Social discrimination and abuse based on gendered undervaluing of women
may further compromise women’s health. Concern for family welfare may take precedence over
individual health and also increase their health risks. Laws and ethics are often seen as
complimentary to each other , but at same time they are also seen as opposite sides of a coin.
Midwives must follow standard and regulations that range from the national level to the
individual area of practice, such as hospital, labor and delivery unit.
  NATIONAL STANDARDS OF PRACTICE –

various levels of legal regulations and standards define midwifery practice. National standards
provide an expectation of delivery care. The educational programs of midwifery assure that all
new nurse midwives can safely deliver care within the scope of usual midwifery practice

STATE LICENSE
• Midwifery practice is regulated in the state of practice through license to practice. If a midwife
practices in two states, she must be licensed by both states. State license is meant to protect the
consumers by ensuring that the midwife has appropriate education for the profession and can
provide safe care.

• It tells that a midwife’s duty must be evaluated according to the availability of medical and
practical knowledge that would be used in the treatment of similar patients under similar
circumstances , by competent midwives, given the facilities , resources and options available.

3.COMMUNITY STANDARDS-

 INSTITUTIONAL POLICIES
• The hospital laws govern midwives working in the hospital. The midwife working in the
hospital should review the policies of the units in which midwifery care is provided.

PROFESSIONAL NEGLIGENCE

• Medical malpractice is the legal error committed by medical personnel. In legal terms, this
error is tort a civil wrong that injuries a person. If a tort is intentional , it becomes a crime of
assault or battery . Negligence, a form of malpractice, is an unintentional tort.

To prove a negligent tort occurred , 4 elements must be there;

 A duty must exist between the injured party and the professional accused of wrong doing.
 A breach of duty must have occurred. The midwife must have practiced outside the
standard of care for a breach to occur.
 The breach of duty must be proximate cause of the claimed injury.
 There must be damage or injuries to the claimant that are recognized by the law and
compensable.
  LEGAL ISSUE IN OBSTETRIC AND GYNAECOLOGY-

• Many legal issues are involved in obstetric and gynecology. Law suites against the nurse
include the following;

 PROBLEMS OF MEDICATION:
nurses provide medication to the clients . Certain problems can occur during giving
medication which can result into allegation against nurses, such as improper dosage of
medication, improper client medication, wrong route of medication and wrong time.
 FAILURE IN MONITORING OF THE CLIENT :
it is the responsibility of the nurse to monitor the client regularly depending upon the
condition of the client. She is expected to monitor the condition of the client admitted
with any gynecological problem.
During antenatal period also, monitoring is essential so that any complication can be
prevented. Nurse has to monitor the client during antenatal , intranatal and postnatal
period. Failure of this can result into a legal issue.

 FAILURE TO REPORT CHANGES IN THE PATIENT :

nurses do the regular monitoring and the assessment of the client. During assessment , she
may notice any change in the client’s condition. This has to be brought to the notice of
the physician. With this, a precious life can be saved.

 FAILURE IN ASSESSING THE CLIENT :

assessment is the first thing which nurses have to do . Based on the assessment care is provided
to the patients. She is responsible for assessing and reporting any minute change in the client’s
condition. Higher levels of assessment skills have to be maintained by the nurses in all the
specialty areas.

 ABORTIONS :

many abortions are performed illegally. Nurses have the right to refuse to assist in the procedure
of the abortion. If the abortion is performed under the act of medical termination of pregnancy,
she can assist the physician in this. Patient who has undergone abortion needs care and
monitoring . It is the nurses legal responsibility to care for such client.

 NURSING CARE OF NEWBORN :

nurses have many responsibility for the newborn. She has to take the foot print of the newborn,
cord is clamped, wrist band has to be put for the identification , proper warming is maintained
etc. there are many responsibilities which the nurses have to carry.
 ETHICAL FRAMEWORK FOR

 GYNECOLOGIC AND OBSTETRIC CARE-

1) Women tend to be vulnerable because of social, cultural and economic circumstances.

This is the case within the doctor-patient relationship, because in the past women’s care
has often been dominated by the paternalism of their advisors.
2) The principle of autonomy emphasizes the important role women should play in
decision-making in respect to their health care.Physicians should try to redress women’s
vulnerability by expressly seeking women’s choices and respecting their views.
3) When decisions regarding medical care are required, women should be provided with full
information on available management alternatives including risks and benefits. Informing
women and obtaining their input and consent, or dissent, should be a continuing process.
4) Because of the intimate personal nature of obstetric and gynecologic care, there is a
special need to protect patient confidentiality.
5) In addition to the provision of medical services, physicians have a responsibility to
consider women’s well-being and psychologicalsatisfaction with their gynecologic and
obstetric care.
6) In the delivery of health care to women, justice requires that all be treated with equal
consideration, irrespective of their socioeconomic status.
7) If a physician is either unable or unwilling to provide a desired medical service for non-
medical reasons, he or she should make every effort to achieve appropriate referral.
8) Ob/gyns should address barriers to women’s health care and services, including barriers
due to social discrimination against and devaluation of women.
9) Ob/gyns should ensure that policies that affect the direct care of women’s health are
based on best available evidence.
10) Ob/gyns should act as advocates for fair and affordable access to women’s health
services, in particular regard to women’s sexual health, irrespective of a woman’s age,
marital, racial, ethnic, socioeconomic or religious status.

 ETHICS IN MIDWIFERY AND GYNAECOLOGY

 According to Thompson and Thompson , to be professional is to be ethical, and to be
ethical is to be professional . To be ethical requires an understanding of ethics, values,
moral reasoning, and ethical decision – making . The nature of ethics requires one to
focus on what it means to be human and how to interact with others in a respectful
manner.
 The goal of ethical midwifery is to do the right thing for the right reasons. Knowing how
to make good decisions as well as why these decisions were made constitutes of ethical
midwifery practice.
 The study of ethics will provide the framework for exploration and aid resolution of
dilemmas. Different people may understand different things from the same words. So
ethics helps them to understand , what they think and feel about any given situation.
 A neonatal nurse is a professional with special training, skill, and knowledge in the care
of newborns and their families. The neonatal nurse is accountable to the patient,
profession , and employer. Failure of the neonatal nurse to meet these obligations can
result in liability in the profession, liability in the employment , a civil suit, or a criminal
conviction.
1) Ethical principle of beneficence: the ethical principle of beneficence requires one to act in
a way that is expected reliably to produce the greater balance of benefits over harms in
the lives of others.
2) Non- maleficence: It means that health professionals should prevent causing harm and is
understood as expressing the limits of beneficence.
3) Respect for autonomony: This principle requires one always to acknowledge and carry
out the value based preference to adult, competent patient. www.freelivedoctor.com
4) Beneficence and respect for autonomy in gynecological practice: Beneficence based and
autonomy based clinical judgment in gynecology practice are usually in harmony. For
example; a woman may present with an ectopic pregnancy. The gynecological must
explain diagnostic findings and potential for maternal death and unlikelihood of
spontaneous resolution When there is no reasonable alternative to manage the patient’s
condition, clinical judgment is beneficence based.
Example- Screening for cervical cancer by pap smear which will protect and promote the
health interest of patient.
5) Caring: the health professionals usually care for their clients and as such would always
have their best interest in mind. Making decisions on behalf of others is caring for clients
because health professional education and training enables them to know best. At the
same time, it does not give right to the health professionals to override someone’s views
and wishes.

 Empowerment and advocacy; One of the important role of the midwife is to support and
help woman to exercise their autonomy . This is empowerment. Educating and
supporting is one of the major roles of midwife, as well as laying emphasis on the public
health and health promotion.
 Advocacy means speaking out for someone’s rights. It is considered useful in the
situations where the clients have been unable to make their own choices. It means
speaking up for what the person wants to happen.
 Health as a basic right for all: Women often lacked basic human rights because they were
viewed as less than human, less than person, by many societies. Maternal deaths and
disabilities are the tragic example of this. In order for the women to be healthy and
valued for themselves, not as a producer of children or a sexual playmate, they must be

given the same status as men in society (ICM 1990). Women must also demand equal
treatment and equal right to health and well being.
• Some other ethical issues are:

 Conceptus issues related to IVF, Cloning, Surrogate mother.

 Abortion, foetal rights versus rights to mother.
 Use of fetal tissue for research
 Resuscitation continuation
 Number of procedures as child www.freelivedoctor.com

American college of Nurse –

Midwives: Code of ethics A certificate nurse-midwife has professional moral obligations.
The purpose of this code is to identify obligations which guide the nurse-midwife in the practice
of nurse-midwifery.
This code further serves to clarify the expectations of the profession to consumers, the public,
other professionals and to potential practitioners. www.freelivedoctor.com

1) Nurse-midwife exists for the good of women and their families. This good is safeguarded
by practice in accor-dance with the ACNM philosophy and ACNM standards for the
practice of Nurse – Mid wifery.
2) Nurse – Mid wives uphold the belief that child bearing and maturation are normal life
processes . When intervention is indicated, it is integrated into care in a way that
preserves the dignity of the woman and family .
3) Decision regarding Nurse Mid-wifery care requires client participation in an ongoing
negotiation process in order to develop a safe plan of care. This process consider cultural
diversity, individual autonomy and legal responsibilities.
4) Nurse Mid-wives share professional information with their clients that leads to informed
participation and consent. This sharing is done without coercion, or deception.
5) Nurse mid-wives practice competently. They consult and refer when indicated by their
professions scope of practice and/or personal limitations.
6) Nurse mid-wives provide care without discrimination based on race, religion, life- style,
sexual orientation, social – economic status or nature of health problem.
7) Nurse mid-wives maintain confidentially except when there is a clear, serious and
immediate danger or when mandated by law.
8) Nurse Mid-wives take appropriate action to protect clients from harm when endangered
by incompetent or in ethical practices.
9) Nurse Mid-wives interact respectfully with the people with whom they work and
practice.
10) Nurse Mid-wives participate in developing and improving the care of women and
families through supporting the profession of nurse
– midwifery, research, and the education of nurse
– midwifery students and nurse
 – midwives.
Nurse mid-wives promote community, state, and national efforts such as public education
and legislation, to ensure access to quality care and to meet the health needs of women
and their families.

 GUIDELINES REGARDING INFORMED CONSENT-

1) The obligation to obtain the informed consent of a woman before any medical
intervention is undertaken on her derives from respect for her fundamental human rights.
These rights have been widely agreed on and are laid down in such documents as the
Universal Declaration
a. of Human Rights (1948); the twin International Covenants on Civil
b. and Political Rights and Economic, Social and Cultural Rights (1975);
i. the International Convention on the Elimination of All Forms of
c. Discrimination Against Women (1979); and the International Convention on the
Rights of the Child (1989). Sexual and Reproductive Human Rights have also
been identified by the International Conference on Population and Development,
in Cairo(1994), and reaffirmed by the Fourth World Conference on Women, in
Beijing (1995), and the UNESCO Declaration on Bioethics and Human Rights
(article 6) 2005.

2) The following definition1 of informed consent flows from these human rights and is
endorsed by the Committee for the Study of Ethical Aspects of Human Reproduction and
Women’s Health:“Informed consent is a consent obtained freely, without threats
orimproper inducements, after appropriate disclosure to the patient of adequate and
understandable information in a form and language understood by the patient on:
a. the diagnostic assessment;
b. the purpose, method, likely duration and expected benefit of the proposed
treatment;
c. alternative modes of treatment, including those less intrusive, and
d. possible pain or discomfort, risks and side effects of the proposed
e. treatment.”

3) Although these criteria are clear, to implement them may be difficult and time
consuming, for example where women have little education, or where very unequal
power relationships in a society mitigate against women's self-determination.
Nevertheless, these difficulties do not absolve physicians caring for women from
pursuing fulfillment these criteria for informed consent. Only the woman patient can
decide if the benefits to her of a procedure are worth the risks and discomfort she may
undergo. Even if, for example, other family members feel they should make the decision,
it is the ethical obligation of the physician to ensure that the woman’s human right of
self-determination is met by the process of communication that precedes any informed
consent.
 4) Consent can be withdrawn at any time.

5) It is important to keep in mind that informed consent is not asignature, but a process of
communication and interaction.

6) The opinion of children or adolescents on a medical intervention should be assessed

within the limitations posed by their level of development or understanding.

7) Even if a woman is unable to decide for herself because of mental incapacity or mental
retardation, nevertheless she must be involved in the decision-making process to the
fullest extent her capacity allows, and her best interests must be taken into account.

8) If physicians, for reason of their own religious or other beliefs, do not wish to fulfill the
above criteria for informed consent because they do not want to give information on
some alternatives, they have an ethical obligation, as a matter of respect for their patients’
human rights, to disclose their objection, and to make appropriate referrals so that the
patients may obtain the full information necessary to make

PREPARING FOR PARENTHOOD AND PRECONCEPTION PLAN-

 Pregnancy preparedness makes sense, particularly because many pregnancies are

unexpected. A developing fetus is highly susceptible to birth defects and other problems
during the eight weeks of pregnancy, a time when women may not realize they are
expecting and typically long before their first visit with a healthcare professional to
address their pregnancy, we need to start pregnancy care Before conception. To start care
before conception requires planning.
 But this planning is critical in making ‘’every child a wanted child” and every pregnancy
as healthy as possible for both mother and baby.
 Experts agree that the first step in planning a healthy pregnancy begins before
conception. Important genetic developments in the embryo occur before a woman realize
that she is preganant;therefore, maintaining a healthy lifestyle before pregnancy occurs
can reduce of complication later on in the pregnancy.
 Smoking:
Smoking is the risk of unborn baby, reducing the baby’s chance of growing to their full
potential in the womb and increasing the chances of complications such as premature
birth. Smoking increases baby’s chances of respiratory problems and ‘cot death’
Smoking increases the likelihood of baby developing asthma and other allergic
conditions. Actually it increases the chances of nearly everything.
 Alcohol:
-It affects ovulation, increases rate of mis carriage, growth retardation, prematurity.
-It can lead fetal alcohol syndrome, which leads to learning and physical disability and
behavior problem.
  At this stage carry on exercising as normal.
Swimming is ideal throughout pregnancy, so is walking and even more strenuous forms
of exercise such as running and cycling are suitable pre and during pregnancy.
-It is important to exercise regularly and maintain a proper weight before and during
pregnancy.
-Women who are overweight may experience medical problem such as high blood
pressure and diabetes.
-Women who underweight may have babies with low baby

 Diet:
Eating a balanced diet before and during pregnancy is not only good for the mother’s
overall health, but essential for nourishing the fetus. Being overweight or underweight
can affect normal ovulation, decrease chance of getting pregnant and increase pregnancy
complications.
 The length of time between pregnancies:
A short amount of time between pregnancies is known to be a risk factor for preterm
birth, low birth weight and infant deaths. It is recommended that the time from delivery
of one child to conception of next child at least 18 months.
 Assessment of chronic conditions:
Women who have chronic medical conditions, like diabetes and hypothyroidism, should
talk to their doctors before becoming pregnant. It is important to have the disease under
control before pregnancy.
 Advice for men:
Wear loose fitting shorts, trousers.
Avoid hot baths, instead take cold showers. Cut down smoking alcohol.
Loose weight and avoid exposure to chemicals.
- See doctor regularly and follow instructions about sensible eating, vitamin supplements
and exercise.
Ask the doctor to recommend a good book on prenatal care and preparing for baby.
 Choose a birthing facility. Whether you select a traditional hospital, a center staffed by
midwives or another delivery option will depend on your health, your baby’s health, your
doctor’s advice, your special needs, your personal philosophy and your insurance
coverage. www.freelivedoctor.com
 Choose a child birth class. Investigate classes available at your local hospital, community
health center or community college. You can also ask your doctor or mid wife for
recommendations. Find out who teaches the classes, what method is used and how much
information on labor and deliver is offered.

Aspects of Pre- Pregnancy care Exercise & Relaxation

 Regular moderate exercise Avoid Hazards

 Smoking
 Alcohol
 Drugs Diet
 Well balanced Diet
 Bread & Cereals
 Fresh fruits & Vegetables

 Fresh containing protein

 Dairy products Avoid exposure to pollutants
 Lead
 Pesticides
 Ionizing radiations Avoid exposure to infections
 Expose to Rubella infection

 Avoid pregnancy following immunization of rubella

 Treat infection such as Urinary, Vaginal etc. Before conceiving
 PARENTHOOD PREPARATION
It includes various aspects such as:
 Physical preparation
 Psychological preparation
 Functional preparation
 Physical preparation:

 Age more than 18 years for girls & 21 years for boys.
 Diet- She should not be anaemic or malnourished.
 No hazards exposure: She should not be exposed to hazardous substances before &
during pregnancy.
 Free of infections such as Rubella.
 Avoid contraceptive pills: She should discontinue oral contraceptives at least 3 and
preferably 6 months before trying to get pregnant.

 Psychological preparation

 Mentally the couple should be prepared to have a baby.

 Loved & Secured
 Away from violence
 Mature enough by brain

 Financial preparation
 The couple should prepare themselves to meet the increasing need of finances for the
care required during pregnancy, delivery & the entry of the new corner i.e new born
baby.
 BENEFITS OF PRECONCEPTION CARE:
 Increased fertility for you and your partner( Even for older couples)
 Healthy conception, pregnancy and birth
 Reduced risk of miscarriage, premature birth or abnormality
 Decreased occurrence of common complaints such as morning sickness
 A successful alternative to assisted reproductive programs for many fertility problems
 May improve the success rate of IVF
 Increased chance of a natural, intervention free birth
 Reduced risk of post natal depression
 Successful and long term breast feeding
 Children those are healthy, intelligent, well balanced, and happy.

• Special preconception advices in specific cases:

1) Condition- Obesity Problem in Pregnancy; Neural tube defects, diabetes, cesarean

section, high blood pressure. Preconception advice; Weight loss before pregnancy
decreases the risks of this bad outcomes.
2) Condition – Smoking Problem in Pregnancy ; Low birth weight, Preterm birth
Preconception advice; Stop smoking before pregnancy. www.freelivedoctor.com
3) Condition – Diabetes Problem in Pregnancy ; Miscarriage, increase in birth defects if
poorly controlled, macrosomia. Preconception advice; Work with your doctor to manage
blood sugars.
4) Condition – Folic acid deficiency Problem in Pregnancy ; Neural tube defects. The neural
tube is already formed by the 14th day of pregnancy. Preconception advice;
Supplementing diet with folic acid reduces Neural tube defects. www.freelivedoctor.com
5) Condition – Alcohol Problem in Pregnancy ;Fetal alcohol syndrome and other alcohol
related syndrome. Preconception advice; Stop taking alcohol during pregnancy.
6) Condition – Epilepsy Problem in Pregnancy ; Some epilepsy medications can cause fetal
abnormality. Preconception advice; Work with your doctor to adjust medications.
www.freelivedoctor.com
7) Condition – Hyper tension Problem in Pregnancy ;There is an increased risk of
preeclampsia, Kidney problems and fetal growth retardation. Preconception advice; Work
with your doctor to ensure blood pressure is controlled.
8) Condition – Sexually transmitted infections Problem in Pregnancy ; Gonorrhea,
chlamydia: Infertility, fetal death, fetal disability (E.g: Mental retardation, blindness),
chronic pelvic pain. HIV: Can be transmitted to fetus and cause disability and death.
Preconception advice; Early diagnosis and treatment will decrease risk of mother to child
transmission.
9) Condition – Hypothyroidism Problem in Pregnancy ;Early in pregnancy, women need an
increase in thyroid medication. This ensures that the fetus has appropriate development of
its neurological system . Preconception advice; Works with your doctor to ensure the
doses of thyroid medicine are adjusted.
10) Condition – Dental caries, gingivitis, oral health Problem in Pregnancy ; Can lead to
preterm delivery and preterm labor. Preconception advice; Maintain good oral hygiene,
regular dental visits.
 Parenthood brings about extensive changes to one’s life in its entirely, having an impact
on various aspects of life. The mother experience significant physical changes all through
the period of pregnancy while a birth of a newborn can also influence one’s home, job
and financial options. By putting in place an effective parenting plan will enable
individuals to tackle these points conveniently before they turn out to be issues of major
concern. Being a parent is the most unselfish act of attention one can make. By becoming
a parent it implies that one is willingly dedicating ones entire life to look after the child
since a parent’s responsibility is an enduring task, which has the biggest pleasure and

reward but at the same time it is a job from which one can never really quit. Parenting
can be one of life’s most challenging experience. With proper guidance parenting also

can be one of life’s most rewarding experience. Communications with the partner is of
utmost importance in making decisions about child bearing.

• Some of the important facts to look for are:

1) Before the arrival of the baby it is vital to make the necessary alterations in the house to
enable more space.
2) Working mothers need to make an applications for maternal leave and make proper
endeavors to get hold of financial funds as they will be certainly be required to pay off
the various expenses that parent have to incur during the birth of baby as well the days
following it.
3) Financial planning is extremely important and is something that should be kept in place
with the progress of the child’s life. Necessary funds have to made available to the child
for his or her varied requirements including the expenses that have to met while the child
goes to school, college and other such activities.

Having a birth is a vital decision. There are some practical issues that need to be looked at when
planning pregnancy: Financial, Emotional, the strength of couple’s relationship and their values
and belief concerning child rearing. As well, pregnancy planning is an opportunity to focus on
one’s physical health. Some steps need to be taken care of, as the couple is preparing for
parenthood.