ETHICAL AND SOCIAL

ISSUES IN PERINATAL
 A critical approach to medical ethics requires
a rudimentary understanding of the history of
ethics in health care. Although it seems
quaint to us now, ethical questions about
health, illness, and medical care were once
considered to be best left to the judgment of
physicians. As experts on the body and its
ailments, physicians were thought to be in
the best position to decide on “good” and
“bad” medicine, the duties of doctors, and
the proper responsibilities of patients.
.” First described in The Belmont Report (the product of a government
commission assembled to make recommendations for the
protection of research subjects from abuse at the hands of
researchers), “principlism” sets forth three “basic ethical principles”
that should “underlie the conduct of biomedical and behavioral
research involving human subjects” (National Commission for the
Protection of Human Subjects of Biomedical and Behavioral
Research, 1979, paragraph 1). These basic principles are:
 
 Respect for persons: The acknowledgment of individual autonomy
(i.e., the right to make decisions about what is done to one's body—
and recognition of the need to protect those, such as children and
prisoners, with diminished autonomy).

 Beneficence: The need to seek the well-being of an individual.

 
 Justice: Fairness in distribution.
 The principlist approach is more fully elaborated and explained by
Beauchamp and Childress (2009) in their book, Principles of
Biomedical Ethics. In this much-used, much-cited text, the authors
(both of whom helped write The Belmont Report) set forth four
principles: respect for autonomy, beneficence, nonmaleficence,
and justice; furthermore, the authors recommended their use in
deliberations about proper practice in research and in the clinic.
Two things about this revision of the principles are worth noting.
First, respect for persons has become respect for autonomy. This
more narrowly defined principle lies behind the need to obtain
“informed consent” from research subjects and patients. Before a
health professional or researcher does something to a person's
body, that person must (a) understand what is to be done and (b)
give his or her voluntary, uncoerced consent. The second revision
—separating of the principle of beneficence into two principles:
nonmaleficence (first, do no harm) and beneficence (do good)—
serves to underscore the duty of physicians to avoid wittingly or
unwittingly hurting patients in their care.
 The principles are particularly useful in pluralistic and
secular societies such as the United States. Although
we citizens of modern, diverse societies may appeal to
our own religious tradition or ideology in making
moral decisions for ourselves, we are unable to
convince others with different belief systems of the
moral correctness of our position. The principles offer
a way around this problem. Appeals to respect
autonomy, to do good, and to be fair can be made by
persons from very different moral traditions. For
example, a Christian may justify the need to respect
autonomy because of her belief that all humans are
made in the image of God, while an agnostic may call
upon humanistic values to support the same principle.
RESPECTING PARENT CHOICE
 All of the choices associated with childbirth begin
with one choice: the choice to become a parent.
With the advent of reliable contraception,
conception is less often an unintended
consequence and more a conscious choice. There
is, of course, much discussion of the ethics of
contraceptive choice, discussions that turn on
questions about the moral status of egg, sperm,
and fetus. This debate is not the topic of our
essay. Here, we focus on the decisions and
practices that parents confront after a planned or
desired pregnancy has been confirmed.
Parents’ Choices in the Prenatal Period
 Prenatal testing I: Informed consent. Within the first months of
pregnancy, a woman will face her first postconception decision:
“Should I or should I not do prenatal testing?” She will be presented
with several types of prenatal tests and may or may not be told that
her initial choice will demand and influence further choices. Should she
do some type of screening test, such as an ultrasound scan or a triple
screen (a blood test for chromosomal abnormalities)? If the screen
shows an abnormal result (or even if it does not), should she agree to a
diagnostic test? The most common diagnostic tests are amniocentesis
and chorionic villus sampling, both of which require an invasion of the
womb and both of which increase the risk of miscarriage. Pregnant
women also will be offered tests for conditions or diseases that may
pose a risk to the fetus (e.g., HIV). Faced with all these options, it is
important that women and their partners be given the information
they need to make an informed choice. But are parents well-informed
as they enter and make their way through this maze of prenatal tests?
 Informed consent often fails to provide information that
matches parents’ interests, concerns, and values.
Protocols for prenatal testing are typically based on a
mythical “average patient,” ignoring the social, religious,
and moral particularities of the parents in question
(Marini, Sullivan, & Naeem, 2002). Atkins (2008) found
that health-care workers involved in counseling for
prenatal testing did not take into consideration the
patient's situation or try to understand how this situation
may affect her priorities or decisions. Individuals have
complex and sometimes contradictory views on the
different conditions and disabilities identified by prenatal
tests, and the informed-consent process rarely allows
patients the chance to work through these views before
deciding whether or not to undergo the test (Bryant,
Green, & Hewison, 2006; Gates, 2004).
 Prenatal testing II: Limits on choice? Respect for
autonomy requires that parents be given accurate,
understandable information about prenatal tests in a
way that respects their values. But does respect for
autonomy also require that parents have unlimited
choice of prenatal tests? At present, we can use genetic
testing to identify more than 500 different genetic
conditions, not all of which are severe (Ekberg, 2007).
Should we allow parents to test for hemophilia in order
to prevent the birth of a daughter who would carry the
disease, but not suffer from it (Boyle & Savulescu, 2003)?
Should we allow amniocentesis to be used to test for
chromosomal abnormalities in all women, and not only in
women considered to be at increased risk for this type of
condition (Kuppermann & Norton, 2005)?
 Typically, these questions are framed in terms of
the autonomy of the woman and her partner,
emphasizing their right to choose which tests they
will use. Less often discussed, but clearly
implicated here, are questions of justice and
nonmaleficence. Fair distribution of health-care
resources requires limits on patient demands—not
everything a patient can afford should be done
(Callahan, 2003). Further, “doing no harm”
demands consideration of the ways false-positive
and false-negative results of prenatal testing can,
in Rothman's (2001) words, “spoil the pregnancy”
 We need to better understand how the attitudes
parents have about prenatal tests are affected
by cultural perceptions of illness and disability
and available economic and social support for
living with a disabled child (Rothman, 2001;
Ward, 2002). The very idea of informed consent
assumes that all information relevant to medical
decision making is included on the consent form,
ignoring all the ways parents use other sources
of information (e.g., the experiences of friends,
cultural attitudes, and recommendations from
Web sites) in making their choice.
ALTERNATIVE WAYS IN GIVING
BIRTH
Birth Methods
There Are Only Two Basic Birth Methods
 When you peel back the layers of mystery surrounding
labor and delivery, you’ll see that there are only two basic
birth methods: vaginal delivery and cesarean section.
Everything else is just a variation on these two methods.
As you’ll see with vaginal delivery, you can change where
you give birth and what tools and procedures are
involved, but it is still a vaginal delivery. When it comes to
cesarean section, your doctor will help determine if that
is the right delivery method for you. Before we explore
the many options involving vaginal delivery, let’s first
define cesarean section so you’re familiar with the
process.
Cesarean Section
 A cesarean section, or c-section for short, is a surgical
procedure performed when vaginal delivery is not
possible. Sometimes, a cesarean section is planned
beforehand. Sometimes, the doctor may switch to a
cesarean section during a vaginal delivery if problems
arise. The process is pretty straightforward. First, the
mother is anesthetized. Then, an incision is made
through the abdomen and the uterus to reveal the
baby. Delivery occurs through the incision. The entire
process can take anywhere from one to two hours
and will require an extended hospital stay—between
two and four days—after the baby is born.
 Because a cesarean section is an invasive surgical
procedure, delivery will occur in a hospital.
Additionally, the pain management techniques
associated with a vaginal delivery are largely moot
because the mother will be placed under anesthesia.

 As choices go, a cesarean section is pretty straight

forward as you’ll be in a hospital under anesthesia. A
vaginal delivery, on the other hand, can be a much
more tailored experience. You can choose where you
want to give birth and how you want to manage
pain along with a whole host of other variables. Let’s
explore some of those options now.
Natural Vaginal Delivery
 Natural vaginal delivery is when your baby is born through the
birth canal. This is the most common way to give birth because it
is the body’s natural method. In fact, roughly sixty-eight percent
of women give birth vaginally every year. Vaginal delivery reduces
the risk that your infant will develop respiratory problems,
asthma, food allergies, and lactose intolerance. That’s not to say
that this birth method isn’t without risk. The baby can undergo
physical trauma while passing through the birth canal. This can
lead to bruising, swelling, and, in rare cases, broken bones.
Complications during labor can also lead to additional problems if
not properly handled.
 
 As mentioned, natural vaginal delivery is a very common birth
method. Sometimes, though, the mother needs a bit of
assistance. This is where the first variation of this birth method
occurs.
Assisted Vaginal Delivery
 
 Assisted vaginal deliveries are still vaginal deliveries
so this isn’t a completely new birth method. Rather,
as the name implies, it depends on the type of
assistance you receive from your doctor during labor.
Those types of assistance are discussed below.
 
Induced Labor
 A doctor will induce labor for a wide variety of
reasons. Chief amongst these reasons are a past-due
pregnancy, ruptured membranes, a smaller-than-
average infant, or high blood pressure in the mother.
Episiotomy
 An episiotomy is a surgical incision made in the skin between the
vagina and the anus. It allows the baby’s head to pass more
easily through the birth canal and helps prevent the skin from
tearing.
 
Amniotomy
 An amniotomy is the purposeful rupture of the amniotic sac. This
rupturing is done for multiple reasons: to induce labor, to assess
the baby’s health, or to check for the baby’s first stool.
 
Forceps Extraction
 In a forceps delivery, an instrument shaped like salad tongs is
used to grasp the baby’s head to guide it through the birth canal.
 
Vacuum Extraction
 During a vacuum extraction, a soft cup
attached to a vacuum pump is applied to the
baby’s head to help guide it through the birth
canal.
Alternative Birth Locations 

 Barring an emergency, a cesarean section is always performed in

a hospital. Vaginal delivery, on the other hand, can be performed
pretty much anywhere. Common choices include home birth and
water birth.

Home Birth

 Giving birth at home can help soon to be mothers feel more

comfortable and relaxed. A home birth also gives you more
control over your labor position, the conditions of your
environment, and the people present. Home birth is not without
its risks, though. If serious complications arise, emergency care
can be a long time coming. Most home births are supervised by a
midwife who will provide coaching, basic procedures for delivery,
and medical tools like oxygen, sutures, and an IV.
Water Birth

 Water births can be done at home or in a hospital if the facility

offers that option. In a water birth, you spend the duration of
your labor in a waist-deep pool of clean, warm water. One of
the biggest benefits of a water birth is that it greatly reduces
the likelihood of needing an epidural to manage the pain. As
your cervix dilates, the warm water helps to soothe and relax
the body and mind. Some women may choose to leave the tub
after the cervix is fully dilated, but many follow through with a
true water birth, where the baby is delivered in the tub. The
doctor or midwife will bring the baby’s face up into the air right
after birth. Water birth eases the strain on the mother, and the
transition for the baby is less of a shock to their system.
Preparation Practices & Pain Management
 There are many preparation practices available these
days. The variety means you can tailor your birthing
experience to your own particular needs. All of the
practices prepare you to deal with the stress and pain of
labor.

Yoga
 With prenatal yoga, you will learn to control your main
respiratory muscle and diaphragm through breathing
techniques and relaxation. You will also learn and
practice helpful postures for use during labor. The
breathing and relaxation techniques are also useful
during delivery to help you calm contractions, facilitate
dilation, and ease pushing.
Haptonomy

 Haptonomy is a means of in-utero communication between the

parents and the baby. The technique also teaches actions and
postures that act in harmony with muscle tone and endorphin
secretion to ease the trauma to mother and child. In theory,
Haptonomy also creates a strong sense of security for the unborn
child through the reassuring voices of the parents.

Bonapace Method
 The Bonapace Method aims to limit the need for medical
intervention by developing control of pain through massage,
breathing, and visualization. For example, while the mother
exercises the breathing and visualization techniques practiced
before labor, a partner gently massages certain points on the
mother’s body to soothe contractions and encourage secretion of
endorphins that mute pain.
Epidural
 An epidural is the most common type of pain management used
during labor. It’s administered by an anesthetist and is only available
in a hospital. The epidural is a regional anesthetic that numbs your
belly, uterus, and cervix and greatly reduces the pain associated with
delivery. An epidural will not affect your baby but it increases the
chance that your blood pressure may drop. This drop in pressure can
decrease the flow of oxygen to your baby. Talk to your doctor about
the pros and cons of having an epidural.

Acupuncture
 Acupuncture is a traditional Chinese practice that uses strategically-
placed thin needles to stimulate points on the body that help balance
the natural flow of energy. This energy balance can help reduce pain,
strengthen uterine contractions, and make labor easier. Be sure to
talk to a trained professional regarding the use of acupuncture during
labor.
Which Birth Method Is Right For You?
 Your choice of birth method is personal and important, so take
the time to think about which one is right for you and your baby.
We recommend that you investigate all the options, get all the
facts, weigh the pros and cons, and choose the route that is
most comfortable and exciting for you. Once you’ve made your
decision, you can begin to plan the next steps like breastfeeding,
bonding with your baby, and postpartum care.

 Whether you choose a water birth at home or a vaginal delivery

in the hospital, you’ll be prepared for what’s to come and ready
for that magical moment when you hold your happy, healthy
baby for the very first time.