ETHICS IN MIDWIFERY PRACTICE

INTRODUCTION

Ethics is an essential dimension of obstetric and gynecologic practice Preventive

ethics helps to build and sustain a strong physician–patient relationship in the practice of
obstetrics and gynecology. The key components of the ethical framework are definitions of
ethics and medical ethics and an explication of the fundamental ethical principles of medical
ethics, beneficence and respect for autonomy. The next concern is how these two ethical
principles should interact in gynecologic clinical judgment and practice. Again how these
two ethical principles should interact in obstetric judgment and practice, with emphasis on
the concept of the fetus as a patient, which is unique to the practice of obstetrics. There are
different concepts of the ethical principles of justice. It is important that ethical issues are
responsible in resource management, emphasizing the virtues of the physician as a
professional. Finally, provide a guide for critically appraising the literature of ethics in
obstetrics and gynecology

TWO DEFINITIONS AND TWO ETHICAL PRINCIPLES

Ethics is the disciplined study of morality. Morality concerns our actual behaviors
and our beliefs about what standards our behavior should meet.

Medical ethics is the disciplined study of morality in medicine and concerns the
obligations of physicians and health-care organizations to patients as well as the obligations
of patients.

It is important not to confuse medical ethics with the many sources of morality in a
pluralistic society. These include the law, our political heritage, the world’s religions, ethnic
and cultural traditions, families, the traditions and practices of medicine, and personal
experience. Medical ethics, since the eighteenth century European and American
Enlightenments, has been secular. It makes no reference to God or revealed tradition, but
to what rational discourse requires and produces. At the same time, secular medical ethics
aims not to be intrinsically hostile to religious beliefs. This can be a real challenge in the
ethics of obstetrics and reproductive medicine. In medical ethics, ethical principles and
virtues should be understood to apply to all physicians, regardless of their personal religious
and spiritual beliefs.

The Ethical Principle of Beneficence

The ethical principle of beneficence in its general meaning and application requires
one to act in a way that is expected to reliably produce the greater balance of benefits over
harms in the lives of others. To put this principle into clinical practice requires a reliable
account of the benefits and harms relevant to the care of the patient, and of how those

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benefits and harms should be reasonably balanced against each other when not all of them
can be achieved in a particular clinical situation, such as a request for an elective cesarean
delivery. In medicine, the ethical principle of beneficence requires the physician to act in a
way that is reliably expected to produce the greater balance of clinical benefits over harms
for the patient.

Beneficence-based clinical judgment has an ancient pedigree in the history of medical

ethics. The first expression of the ethical principle of beneficence in the history of Western
medical ethics occurs in the Hippocratic Oath and accompanying texts. These texts make an
important claim: to interpret reliably the health-related and other interests of the patient
from a medical perspective. This perspective is provided by accumulated medical research,
clinical experience, and reasoned responses to uncertainty. On the basis of this rigorous
clinical perspective, focused on the best available evidence, beneficence-based clinical
judgment identifies the clinical benefits that can be achieved for the patient in medical
practice based on the competencies of medicine.

The clinical benefits that medicine is competent to seek for patients are the
prevention and management of disease, injury, disability, and unnecessary pain, distress,
and suffering, and the prevention of premature or unnecessary death. Pain, distress, and
suffering become unnecessary when they do not result in achieving the other benefits of
medical care, e.g. allowing a woman to labor without effective analgesia.

The Ethical Principle of Nonmaleficence

Nonmaleficence means that the physician should prevent causing only or net clinical harm
to patients and is best understood as expressing the limits of beneficence. Nonmaleficence
is also known as “Primum non nocere” or “first do no harm.” This commonly invoked rule
emphasized beneficence while avoiding harm when approaching the limits of medicine.
Nonmaleficenceshould be incorporated into beneficence-based clinical judgment: when the
physician approaches the limits of beneficence-based clinical judgment, i.e. when the
evidence for expected net clinical benefit diminishes and the risks of clinical harm increase,
then the physician should proceed with great caution. The physician should be especially
concerned to prevent serious, far-reaching, and irreversible clinical harm to the patient.

The preventive ethics response to paternalism is for the physician to explain the diagnostic,
therapeutic, and prognostic reasoning that leads to his or her clinical judgment about what
is in the interest of the patient so that the patient can assess that judgment for herself. This
general rule can be put into clinical practice in the following way: The physician should
disclose and explain to the patient the clinically salient or important factors of this reasoning
process, including matters of uncertainty.

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One advantage for the physician in carrying out this approach to communicating with the
patient would be, we believe, to increase the likelihood of compliance. This is an especially
pertinent consideration in gynecologic practice, where the patient often must monitor
herself for clinical changes (e.g., a woman at risk for ectopic pregnancy), and take an active
role in preventive medicine (e.g., breast self-examination), as well as in obstetric practice
(e.g., self-observation for unusual weight gain or bleeding). Another advantage would be to
provide the patient with a better-informed opportunity to make a decision about whether
to seek a second opinion.

The Ethical Principle of Respect for Autonomy

In contrast to the principle of beneficence, there has been increasing emphasis in the
literature of medical ethics on the principle of respect for autonomy.In general, this ethical
principle requires one always to acknowledge and carry out the value-based preferences of
the adult, competent patient, unless there is compelling ethical justification for not doing
so, e.g. prescribing antibiotics for viral respiratory infections. The female or pregnant patient
increasingly brings to her medical care her own perspective on what is in her interest. The
principle of respect for autonomy translates this fact into autonomy-based clinical
judgment. Because each patient’s perspective on her interests is a function of her values
and beliefs, it is impossible to specify the benefits and harms of autonomy-based clinical
judgment in advance. Indeed, it would be inappropriate for the physician to do so, because
the definition of her benefits and harms and their balancing are the prerogative of the
patient.

To understand the moral demands of the ethical principle of respect for autonomy, we need
an operationalized concept of autonomy to make it relevant to clinical practice. To do this,
we identify three sequential autonomy-based behaviors on the part of the patient:

(1) Absorbing and retaining information about her condition and alternative diagnostic and
therapeutic responses to it;

(2) Understanding that information (i.e., evaluating and rank-ordering those responses and
appreciating that she could experience the risks of treatment); and

(3) Expressing a value-based preference.

The physician has a role to play in each of these. They are, respectively,

(1) To recognize the capacity of each patient to deal with medical information, provide
information and recognize the validity of the values and beliefs of the patient.

(2) Not to interfere with but, when necessary, to assist the patient in her evaluation and
ranking of diagnostic and therapeutic alternatives for managing her condition; and

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(3) To elicit and implement the patient’s value-based preference.

The legal obligations of the physician regarding informed consent were established in a
series of cases during the early twentieth century. In 1914, Schloendorff v. The Society of the
New York Hospital established the concept of simple consent, i.e. whether the patient says
“yes” or “no” to medical intervention. To this day in the medical and bioethics literature,
this decision is quoted: “Every human being of adult years and sound mind has the right to
determine what shall be done with his body, and a surgeon who performs an operation
without his patient’s consent commits an assault for which he is liable in damages.”
Simple consent is based on the legal concept of battery, or unconsented-to touching.

The Ethical Principle of Distributive Justice

Considered as one type of justice, distributive justice is a central concept and is closely
linked to the concepts of human dignity, the common good, and human rights. Considered
as an ethical principle, distributive justice refers to what society or a larger group owes its
individual members in proportion to: 1) the individual’s needs, contribution and
responsibility; 2) the resources available to the society or organization (market
considerations would be included under this, as well as other financial considerations); and
3) the society’s or organization’s responsibility to the common good. In the context of
health care, distributive justice requires that everyone receive equitable access to the basic
health care necessary for living a fully human life insofar as there is a basic human right to
health care.

THREE CONCEPTS OF JUSTICE

Ethical concerns about justice arise when resources are scarce. Justice requires that in the
distribution of resources, each should receive what is due to him or her. Different concepts
of justice define ‘due’ in different ways. Each strives to result in a fair distribution of
benefits, i.e. access to resources, and burdens, the risks that could follow from lack of such
access.

Utilitarianism is a theory of justice that makes central the obligation to produce the greatest
good for the greatest number in the management of scarce resources. To be successful in
guiding practical, day-to-day decisions about the allocation of resources, utilitarianism
requires an account of the greatest good. For society overall, it has been difficult, if not
impossible, to define what the greatest good is. The value of utilitarianism is the balance it
seeks to achieve among benefits and burdens of scarce resources, so that inequalities do
not become inequities, i.e. unfair. Critics of utilitarians have pointed out that sometimes
utilitarianism results in inequities, i.e. shared distributions of benefits and burdens.

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Two other concepts of justice have been developed to address this problem. The first of
these is a libertarian concept of justice. This concept of justice was developed to correct for
tyrannical burdens that pure utilitarianism could create. In particular, libertarianism was
developed to give priority to individual freedom and property rights, as correctives to the
potential excesses of utilitarianism and, in the political realm, of state power. Libertarians
argue that in a market that places different values on different services and products, and in
which there is an equal opportunity to develop one’s talents, those who provide more
highly valued services rightly earn more than those who provide less valued (though not
necessarily less intrinsically valuable) services. Everyone should get to keep what he or she
earns through these marketplace exchanges, reflecting the strong emphasis of the
libertarian concept of justice on property rights. Libertarian theories emphasize fairness of
process, rather than equality of outcomes.

The other concept of justice that has been developed is an egalitarian concept of justice.
This concept was developed to protect vulnerable and disadvantaged members of society,
who may lose out in a utilitarian distribution of scarce resources. This concept of justice
corrects for unfair outcomes in the form of undue burdens on those least able to protect
themselves.

BENEFICENCE-BASED AND AUTONOMY-BASED GYNECOLOGIC JUDGMENT AND PRACTICE

Beneficence-based and autonomy-based clinical judgments in gynecologic practice are

usually in harmony.Sometimes, beneficence-based and autonomy-based clinical judgments
are in conflict in gynecologic practice. In situations of conflict, neither beneficence nor
respect for autonomy automatically should be taken to be overriding. Instead, both ethical
principles should initially be understood as theoretically equally weighted. Thus, their
differences must be negotiated in clinical judgment and practice. The competing demands
of both principles must be balanced and negotiated in the specific clinical case to determine
which management strategies protect and promote the patient’s interests. In the technical
language of ethics, we are treating these principles as prima facie or potentially overridable,
on the basis of careful reflection and argument in the clinical setting.

The ethical and legal obligation of the physician in the matter of informed refusal is very
clear and not difficult to fulfill. In all cases, without exception, the patient should be clearly
informed about the medical risks that she is taking in her refusal. The risks to be disclosed
are those that are salient in clinical judgment: if they are important to the physician, that is,
motivating the offering or recommending of the diagnostic test or therapy, they are salient.
This discussion, especially the risks of refusal, should be thoroughly documented in the
patient’s chart. The patient does not have to sign this chart entry. It is the physician’s strict
legal obligation to make sure that the disclosure of risk and documentation of that
disclosure are comprehensive and detailed. This is all that the law requires. Preventive
ethics requires that this disclosure be followed by a recommendation that the patient

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reconsider her refusal. This preventive-ethics approach avoids the need to abandon the
patient, keeps lines of communication open, and sends a powerful signal of concern by the
physician to the patient about the medical folly of her refusal.

The process of negotiating conflict between the two principles is a function of several
factors involved in gynecologic clinical judgment: subject matter; probability of net medical
benefit; availability of reasonable alternatives; and the ability of the patient to participate in
the informed consent process. When the subject matter is primarily technical in nature,
such as the selection of an effective antibiotic regimen or intraoperative surgical technique,
clinical judgment is justifiably beneficence-based. This is because technical matters largely
concern the evidence-based benefits for aggregates of patients with a particular diagnosis
and treatment plan. Such decisions are justifiably within the gynecologist’s purview. The
individual values and beliefs of a particular patient cannot readily be taken into account in
this process. By contrast, when the patient’s basic values and beliefs are at stake, e.g. the
work-up or treatment of infertility or elective abortion, clinical judgment is justifiably
autonomy-based. This is because particular diagnostic or treatment interventions can
directly and adversely affect the basic values and beliefs of a particular patient, a matter
that only each individual patient can decide. Such decisions are justifiably within the
patient’s purview.

BENEFICENCE-BASED AND AUTONOMY-BASED OBSTETRIC JUDGMENT AND PRACTICE

The ethical principles of beneficence and respect for autonomy play a more complex role in
obstetric judgment and practice than they do in gynecologic judgment and practice. There
are obviously beneficence-based and autonomy-based obligations to the pregnant patient:
the physician’s perspective on the pregnant woman’s health-related interests provides the
basis for the physician’s beneficence-based obligations to her, whereas her own perspective
on those interests provides the basis for the physician’s autonomy-based obligations to her.
Because of an insufficiently developed central nervous system, the fetus cannot
meaningfully be said to possess values and beliefs. Thus, there is no basis for saying that a
fetus has a perspective on its interests. There can therefore be no autonomy-based
obligations to any fetus. Hence, the language of fetal rights has no meaning and therefore
no application to the fetus in obstetric clinical judgment and practice despite its popularity
in public and political discourse in the United States and other countries. Obviously, the
physician has a perspective on the fetus’s health-related interests, and the physician can
have beneficence-based obligations to the fetus, but only when the fetus is a patient.
Because of its importance for obstetric clinical judgment and practice, the ethical concept of
the fetus as a patient requires detailed consideration

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The Ethical Concept of the Fetus as a Patient

The ethical concept of the fetus as a patient is essential to obstetric clinical judgment and
practice. Developments in fetal diagnosis and management strategies to optimize fetal
outcome have become widely accepted, encouraging the development of this concept. This
concept has considerable clinical significance because, when the fetus is a patient, directive
counseling, that is, recommending a form of management, for fetal benefit is appropriate,
and when the fetus is not a patient, nondirective counseling, that is, offering but not
recommending a form of management for fetal benefit, is appropriate. However, there can
be uncertainty about when the fetus is a patient. One approach to resolving this uncertainty
would be to argue that the fetus is or is not a patient in virtue of personhood, or some other
form of independent moral status. We now show that this approach fails to resolve the
uncertainty, and we therefore defend an alternative approach that does resolve the
uncertainty.

RESPONSIBLE RESOURCE MANAGEMENT AND THE PROFESSIONAL VIRTUES

The practice of obstetrics and gynecology is coming under increasingly powerful economic
constraints, e.g. managed-care and resource-management strategies imposed by hospital
managers, used by both private and public payers and by health-care organizations to
control the cost of medical care. Two main business tools are used to achieve this goal:
creating conflicts of interests in how physicians are paid, diplomatically called “sharing
economic risk”, and increasingly strict control of clinical judgment and practice through such
means as practice guidelines, critical pathways, physician report cards, and retrospective
chart review. These business tools generate ethical challenges to obstetrician-gynecologists
that seriously threaten the virtues that define the fiduciary character of medicine as a
profession

The first virtue is self-effacement. This requires the physician not to act on the basis of
potential differences between the patient and the physician such as race, religion, national
origin, gender, sexual orientation, manners, socioeconomic status, or proficiency in speaking
English. Self-effacement prevents biases and prejudices arising from these differences that
could adversely impact on the plan of care for the patient.

The second virtue is self-sacrifice. This requires physicians to accept reasonable risks to
themselves. As one example, physicians manifest this virtue in their willingness to care for
patients with infectious diseases such as hepatitis, HIV infection, and tuberculosis, all of
which are a potential threat to the physician’s health. In both fee-for-service and managed
care, this virtue of self-sacrifice obligates the physician to turn away from economic self-
interest and focus on the patient’s need for relief when the two are in conflict.

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The third virtue, compassion, motivates the physician to recognize and seek to alleviate the
stress, discomfort, pain, and suffering associated with the patient’s disease and illness. Self-
effacement, self-sacrifice, and compassion provide the basis for a powerful ethical response
to the business tool of conflicts of interest by the physician.

This response is strengthened by the fourth virtue, integrity. This virtue imposes an
intellectual discipline on the physician’s clinical judgments about the patient’s problems and
how to address them. Integrity prescribes rigor in the formation of clinical judgment. Clinical
judgment is rigorous when it is based on the best available medical information or, when
such information is lacking, consensus clinical judgment and on careful thought processes of
an individual physician that can withstand peer review. Integrity is thus an antidote to the
pitfalls of bias, subjective clinical impressions, and unexamined clinical “common sense”
that can undermine evidence-based practice. Integrity provides the basis for the physician’s
ethical response to the business tool of control of clinical judgment and practice.

The professional virtue of integrity should never be compromised, while the other three
professional virtues have justified limits, based on careful reflection and argument. The task
of medical ethics is to identify both the application and the limits of these four virtues. The
concept of legitimate self-interest provides the basis for these limits. Legitimate self-interest
includes protecting the conditions for practicing medicine well, fulfilling obligations to
persons in the physician’s life other than the patient, and protecting activities outside the
practice of medicine that the physician finds deeply fulfilling.

THE ICN CODE OF ETHICS FOR NURSES

An international code of ethics for nurses was first adopted by theInternational Council of
Nurses (ICN) in 1953. It has been revisedand reaffirmed at various times since, most recently
with thisreview and revision completed in 2005. The code of ethics provides a basic manual
for the nurses in the practice situations. The ICN code was made generally for all the nurses
in all the practice situations and for all the speciality conditions.

ELEMENTS OF THE CODE

The ICN Code of Ethics for Nurses has four principal elements that
outline the standards of ethical conduct.

1. NURSES AND PEOPLE

The nurse’s primary professional responsibility is to people requiring

nursing care .In providing care, the nurse promotes an environment in which the human
rights, values, customs and spiritual beliefs of the individual ,family and community are

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respected.The nurse ensures that the individual receives sufficient informationon which to
base consent for care and related treatment.The nurse holds in confidence personal
information and uses judgement in sharing this information.The nurse shares with society
the responsibility for initiating and supporting action to meet the health and social needs of
the public, inparticular those of vulnerable populations.The nurse also shares responsibility
to sustain and protect the naturalenvironment from depletion, pollution, degradation and
destruction.

2. NURSES AND PRACTICE

The nurse carries personal responsibility and accountability fornursing practice, and for
maintaining competence by continuallearning. The nurse maintains a standard of personal
health such that theability to provide care is not compromised.The nurse uses judgement
regarding individual competence when
accepting and delegating responsibility.The nurse at all times maintains standards of
personal conductwhich reflect well on the profession and enhance public confidence.The
nurse, in providing care, ensures that use of technology andscientific advances are
compatible with the safety, dignity andrights of people.

3. NURSES AND THE PROFESSION

The nurse assumes the major role in determining and implementingacceptable standards of
clinical nursing practice, management,research and education.The nurse is active in
developing a core of research-based professionalknowledge.The nurse, acting through the
professional organisation, participatesin creating and maintaining safe, equitable social and
economicworking conditions in nursing.

4. NURSES AND CO-WORKERS

The nurse sustains a co-operative relationship with co-workers innursing and other
fields.The nurse takes appropriate action to safeguard individuals, families
and communities when their health is endangered by a co –workeror any other person.
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SUGGESTIONS FOR USE OF THE ICN CODE OF ETHICS FOR NURSES

The ICN Code of Ethics for Nurses is a guide for action based onsocial values and needs. It
will have meaning only as a living documentif applied to the realities of nursing and health
care in a changing society .To achieve its purpose the Code must be understood,
internalisedand used by nurses in all aspects of their work. It must be availableto students
and nurses throughout their study and work lives.

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INTERNATIONAL CONFEDERATION OF MIDWIVES (ICM) CODE OF ETHICS FOR MIDWIVES

“A code of ethics is not a dry dusty piece of paper; it is a living breathing

embodiment of the spirit of midwifery and we are the ones that make it not
only live, but sing and dance with the joy of life itself”

BronwinPelvin

New Zealand Midwife

Journal of NZCOM, 1992

The ICM code was specially designed for the midwifery practice. The maternity and child
health nursing is now emerging as a very peculiar and strong division in the nursing practice
areas. The ICM code provides a basic practice standard for the nurse midwives all over the
world to perform in a better way and to follow agneralised standard all over the world.

PREAMBLE
The aim of the International Confederation of Midwives (ICM) is to improve the standard of
care provided to women, babies and families throughout the world through the
development, education, and appropriate utilization of the professional midwife. In keeping
with its aim of women’s health and focus on the midwife, the ICM sets forth the following
code to guide the education, practice and research of the midwife. This code acknowledges
women as persons with human rights, seeks justice for all people and equity in access to
health care, and is based on mutual relationships of respect, trust, and the dignity of all
members of society.

Introduction
In an effort to increase understanding and, hence, use of the International Code of Ethics for
Midwives (1999), the ICM Board of Management commissioned the publication of this
document. The document contains:

- the Code of Ethics,

- the glossary of terms used in the Code,
- the ethical analysis of the Code,
- a brief history of the development of the Code and
- suggestions on how the midwife can use this Code in practice, education or research.

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THE CODE

I. Midwifery Relationships

a. Midwives respect a woman’s informed right of choice and promote the woman’s
acceptance of responsibility for the outcomes of her choices.
b. Midwives work with women, supporting their right to participate actively in
decisions about their care, and empowering women to speak for themselves on
issues affecting the health of women and their families in their culture/society.
c. Midwives, together with women, work with policy and funding agencies to
define women’s needs for health services and to ensure that resources are fairly
allocated considering priorities and availability.
d. Midwives support and sustain each other in their professional roles, and actively
nurture their own and others’ sense of self-worth.
e. Midwives work with other health professionals, consulting and referring as
necessary when the woman’s need for care exceeds the competencies of the
midwife.
f. Midwives recognise the human interdependence within their field of practice
and actively seek to resolve inherent conflicts.
g. The midwife has responsibilities to her or himself as a person of moral worth,
including duties of moral self-respect and the preservation of integrity.

II. Practice of Midwifery

a. Midwives provide care for women and childbearing families with respect for
cultural diversity while also working to eliminate harmful practices within those
same cultures.
b. Midwives encourage realistic expectations of childbirth by women within their
own society, with the minimum expectation that no women should be harmed
by conception or childbearing.
c. Midwives use their professional knowledge to ensure safe birthing practices in all
environments and cultures.
d. Midwives respond to the psychological, physical, emotional and spiritual needs
of women seeking health care, whatever their circumstances.
e. Midwives act as effective role models in health promotion for women
throughout their life cycle, for families and for other health professionals.
f. Midwives actively seek personal, intellectual and professional growth throughout
their midwifery career, integrating this growth into their practice.

III. The Professional Responsibilities of Midwives

a. Midwives hold in confidence client information in order to protect the right to

privacy, and use judgment in sharing this information.
b. Midwives are responsible for their decisions and actions, and are accountable for
the related outcomes in their care of women.

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 c. Midwives may refuse to participate in activities for which they hold deep moral
opposition; however, the emphasis on individual conscience should not deprive
women of essential health services.
d. Midwives understand the adverse consequences that ethical and human rights
violations have on the health of women and infants, and will work to eliminate
these violations.
e. Midwives participate in the development and implementation of health policies
that promote the health of all women and childbearing families.

IV. Advancement of Midwifery Knowledge and Practice

a. Midwives ensure that the advancement of midwifery knowledge is based on

activities that protect the rights of women as persons.
b. Midwives develop and share midwifery knowledge through a variety of
processes, such as peer review and research.
c. Midwives participate in the formal education of midwifery students and
midwives.

Ethical Analysis of the Code of Ethics

Introduction
Ethics codes are often a mix of universal ethical principles and strongly held values specific
to the “professional group”. Below is a brief analysis of the major ethical principles and
concepts that form the basis for each of the statements of the ICM International Code of
Ethics for Midwives (1999).

I. Midwifery Relationships

a. Autonomy and accountability of women; right to make choices

b. Autonomy and “human equalities” of women; empowered to speak for
herself
c. Justice/fairness in the allocation of resources
d. Respect for human dignity; viewing herself as a worthy individual
e. Competence, interdependence of health professionals, safety
f. Respect for one another
g. Moral self-respect, dignity

II. Practice of Midwifery

a. Respect for others, do good, do not harm

b. Client accountability for decisions, do not harm, safety
c. Safety; cultural relevance
d. Respect for human dignity, treat women as whole persons
e. Health promotion: attain/maintain autonomy, good/no harm, allocation of
resources

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 f. Competence in practice

III. Professional Responsibilities of Midwives

a. Confidentiality; privacy
b. Midwife accountability
c. Midwife conscience clause: autonomy and respect of human qualities of the
midwife
d. Prevent human rights violations
e. Health policy development: justice, do good

IV. Advancement of Midwifery Knowledge and Practice

a. Protect rights of women as persons

b. Midwife accountability, safety, competence
c. Professional responsibility: enhance competence of all professionals to do
good, do not harm

ETHICAL AND LEGAL ISSUES IN REPRODUCTION

Reproductive issues often involve conflicts in which a woman behaves in a way that may
cause harm to her fetus. Conflicts occurs between a mother and a fetus when the mother’s
needs, behaviors, or wishes may injure the fetus.Ethicl and
Legal issues in reproduction generates a major area as far as the nursing practice is
concerned. Now a days the area is facing a lot of issues which should be managed very
carefully.

REPRODUCTIVE TECHNOLOGY
When conceiving a child naturally is not physically not possible, technology is now capable
of assisting the couple the assisted reproductive technology has its own benefits and harms
and a lot of ethical and value based issues are concentrating around this.

Artificial insemination
It is one of the oldest terms of reproductive technology. Artificial insemination, or AI, is the
process by which sperm is placed into the reproductive tract of a female for the purpose of
impregnating the female by using means other than sexual intercourse or natural
insemination. In humans, it is used as assisted reproductive technology, using either sperm
from the woman's male partner or sperm from a sperm donor (donor sperm) in cases where
the male partner produces no sperm or the woman has no male partner (i.e., single women,
lesbians). In cases where donor sperm is used the woman is the gestational and genetic
mother of the child produced, and the sperm donor is the genetic or biological father of the
child.

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Requests by single women for artificial insemination by donor (AID) raise important ethical
issues concerning the obligations of physicians and the well-being of the children who would
be conceived. Specific objections to AID for single women can be raised, including that the
absence of a father may adversely affect the child or that a lesbian mother may influence
the child to become homosexual. A review of the relevant social science research indicates,
however, that these and other objections are not supported by the available data. In
support of AID for single women it can be argued that the life of the child who would be
produced could be expected to have value, considered in itself. Consideration of the various
aspects of the issue suggests that AID for single women is permissible in selected cases and
that the physician has a right to refuse to carry out such requests.

In vitrofertilisation

In vitrofertilisation (IVF) is a process by which egg cells are fertilised by sperm outside the
body: in vitro. IVF is a major treatment in infertility when other methods of assisted
reproductive technology have failed. The process involves hormonally controlling the
ovulatory process, removing ova (eggs) from the woman's ovaries and letting spermfertilise
them in a fluid medium. The fertilised egg (zygote) is then transferred to the patient's uterus
with the intent to establish a successful pregnancy. The first successful birth of a "test tube
baby", Louise Brown, occurred in 1978

Ethical Issues

In a few cases, laboratory mix-ups (misidentified gametes, transfer of wrong embryos) have
occurred, leading to legal action against the IVF provider and complex paternity suits. The
Human Fertilisation and Embryology Authority (HFEA )for example, requires clinics to use a
double witnessing system, where the identity of specimens is checked by two people at
each point at which specimens are transferred. Alternatively, technological solutions are
gaining favour, to reduce the manpower cost of manual double witnessing, and to further
reduce the risk of human error.

Another concern is that people will screen in or out for particular traits, using
preimplantation genetic diagnosis. Some medical ethicists have been very critical of this
approach. Jacob Appel wrote that "intentionally culling out blind or deaf embryos might
prevent considerable future suffering, while a policy that allowed deaf or blind parents to
select for such traits intentionally would be far more troublesome."

Pregnancy past menopause

Although menopause is a natural barrier to further conception, IVF has allowed women to
be pregnant in their fifties and sixties. Women whose uterus has been appropriately
prepared receive embryos that originated from an egg of an egg donor. Therefore, although

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these women do not have a genetic link with the child, they have an emotional link through
pregnancy and childbirth. In many cases the genetic father of the child is the woman's
partner. Even after menopause the uterus is fully capable of carrying out a pregnancy.

Same-sex couples, single and unmarried parents

Ethical concerns include reproductive rights, the welfare of offspring, nondiscrimination

against unmarried individuals, homosexual, and professional autonomy.

Catholic objections

The Catholic Church opposes all kinds of in vitrofertilisation because, as with contraception,
it separates the procreative purpose of the marriage act from its unitive purpose:

Legal status

Government agencies in China passed bans on the use of IVF in 2003 by unmarried women
or by couples with certain infectious diseases. Sunni Muslim nations generally allow IVF
between married couples when conducted with their own respective sperm and eggs, but
not with donor eggs from other couples. But Iran, which is Shi'a Muslim, has a more
complex scheme. Iran bars sperm donation but allows donation of both fertilised and
unfertilised eggs. Fertilised eggs are donated from married couples to other married
couples, while unfertilised eggs are donated in the context of mut'ah or temporary marriage
to the father

WHAT ARE THE ETHICAL ISSUES REGARDING HUMAN CLONING?

The possibility of human cloning has long fired the popular imagination, including in the
world of popular entertainment. For many others, cloning implied overtones of human
immortality or of assembly-line eugenics. The high failure rates (more than 90 per cent) and
high morbidity of animal cloning strongly suggests its inapplicability to humans.
Furthermore, cloned animals seem to suffer high deformity and disability rates. Dolly herself
was finally put down in 2003, at the age of just six and a half years, even though many sheep
live more than 10 years. She had developed a progressive lung disease, which is usually
found in older sheep, as well as premature arthritis

Ethical Issues regarding Human Reproductive Cloning

•Technical and medical safety

•Undermining the concept of reproduction and family

• Ambiguous relations of a cloned child with the progenitor

15
•Confusing personal identity and harming the psychological development of a clone

•Concerns about eugenics

•Contrary to Human Dignity

• Promoting trends towards designer babies and humanenhancement

Human cloning elaborated by UNESCO. In Section C of the Declaration, “Research on the

Human Genome”, it is stated “Practices which are contrary to human dignity, such as
reproductive cloning of human beings, shall not be permitted…”. After careful consideration,
several countries have formulated opinions and regulations on human

IS RESEARCH CLONING DIFFERENT FROM REPRODUCTIVE CLONING?

Meanwhile, biomedical researchers have focused their attention since Dolly’s birth on
experimental, so-called “therapeutic” cloning, centering on the use of the cloning technique
to obtain embryonic stem cells for research and potential therapeutic purposes. Since the
notion “therapeutic” suggests possible beneficial applications of cloning, which at the
present time seem completely unjustified, it is more appropriate to change this positive
connotation and use a more neutral wording, viz. research cloning. In the case of
reproductive cloning, the aim of somatic cell nuclear transfer is to create an embryo carrying
the same genetic information as the progenitor and to implant this embryo into a womb to
generate a pregnancy, and from there to produce a baby. The goal of research cloning,
however, is to create an embryo in the same manner as for reproductive cloning, not to
produce a child but in order to derive embryonic stem cells which contain the same genetic
characteristics as the progenitor.

ETHICAL ISSUES

 What are the pros and cons of using unused embryos for medical research?
 Is there anything wrong with disposal of unused embryos …leaving them on the
counter to unthaw and degenerate?
 What if the surrogate decides to maintain her privacy?
 What if the surrogate and the spouse violate the abstention clause?
 What if the surrogate decides to keep the baby?
 What if the surrogate with genetic ties demands to visit her child?
 Is there anything wrong with a surrogate giving her unused embryos to someone
else?
 Who should make a decision to unthaw frozen embryos?
 Is handing over a child after delivery for a fee “baby-selling”?
 Do women participate in surrogacy to save their marriage?
 Is it wrong for a surrogate to abort?

16
Donor anonymity

In 2004, the Human Fertilisation and Embryology Authority (Disclosure of Donor

Information) Regulations 2004/1511, enabled donor-conceived children to access the
identity of their sperm, egg or embryo donor upon reaching the age of 18.

The Regulations were implemented on 1 April 2005 and any donor who donated sperm,
eggs or embryos from that date onwards is, by law, identifiable. Since that date, any person
born as a result of donation is entitled to request and receive the donor’s name and last
known address, once they reach the age of 18

SURROGATE MOTHER

Surrogate mothers are women who agree to carry and give birth to a child or children to be
raised by another couple or person. Arrangements with surrogate mothers are often made
by couples with fertility problems, and laws dictating the legality of this practice vary from
one country to the next. But beyond the legal and medical considerations, which can be very
complex, there are complex ethical issues that should be considered prior to entering a
surrogate mother agreement.
Gestational Mother Attachment

In a surrogate mother arrangement, the gestational mother is the woman who carries the
baby to term. One common objection raised by critics of surrogate motherhood, according
to "Surrogate Motherhood: International Perspectives" by Rachel Cook, Shelley Day Sclater
and Felicity Kaganas, is a belief that the gestational mother inevitably develops a
relationship with the child she carries, and relinquishing the child after this can be difficult
and emotionally taxing. However, the authors paint this as a misconception, stressing that
most surrogate mothers take deliberate steps throughout the process to mentally and
emotionally prepare themselves, as well as emotionally detach themselves from the infants
they carry.
Gestational Mother Involvement

The gestational mother in a surrogacy arrangement is unquestionably an important part of

the child's background and, depending on the manner of surrogacy chosen, may be
genetically linked to the child. However, since the gestational mother will not be the child's
primary caretaker, and since typical surrogate mother arrangements involve full parental
rights being transferred to another party, there will naturally be questions about the extent
to which the gestational mother should be involved in the child's life. Such arrangements
are often decided in advance and specified in legal contracts between the surrogate mother
and the intended parents or parent. In some arrangements, the identities of the two parties
are never revealed to one another. In others, the gestational mother may be granted legal
visitation rights. There are plenty of other types of arrangements, with no rules dictating

17
right or wrong. But it is important for this arrangement to be thought out, agreed upon and
perhaps established in legal terms prior to beginning the surrogacy.
Child Identity

An issue closely related to gestational mother involvement, as well as to special

considerations of adoption, is how the identity of the child will be affected by the surrogacy.
Some parents may choose to never tell their child about the surrogate arrangement. Others
may tell the child as soon as they're old enough to understand. Others still may wait until
the child turns 18. In any circumstance, knowledge or lack thereof regarding the surrogate
arrangement may have an effect on the child's self-identity. Right and wrong in this case are
also not well-defined, though the decision is worthy of careful thought and gentle handling.
Compensation

In some surrogacy arrangements, often when the aspiring parents do not know the
gestational mother personally, the gestational mother is financially compensated for her
services. It is not uncommon for the aspiring parents to pay for related medical expenses
and even things such as meals, housing and maternity wear throughout the pregnancy, but
some couples with the means to do so may pay what amounts to a fee to the gestational
mother. Ethical criticisms of this practice, according to Cook, Sclater and Kaganas, include
the view that this is a luxury available only to the wealthy and that it amounts to pregnancy-
for-hire. Some critics also say that this presents an opportunity for wealthy, fertile couples
to choose surrogacy rather than endure the strain involved in pregnancy.

Ethics of Surrogacy: Infertile People Should Adopt

Opposing viewpoints of surrogate parenthood argue, with all the unfortunate babies being
born today in this world, isn't it the duty of the infertile couples out there to adopt them,
instead of bringing more children, science babies at that, into this already overcrowded and
difficult world?
There are several reasons why an infertile couple may choose surrogacy over adoption.
Often, there simply isn't a choice.

AdoptionLimitations
In order to adopt a child in the United States, intended parents must jump through
enormous hoops. There are interviews with social workers, home studies, and a long list of
requirements. One of those requirements, in most situations, is age. This means that older
intended parents are less likely to be given the approval to adopt.

Infertility is commonly diagnosed in the late 30's to early 40's. So an intended mother, who
is say, 38 when she tries to begin a family, and spends the next five years seeking treatment
might be 43 by the time she has come to the point where adoption is a serious option. At
that point, she is interviewed by an adoption agency and told that there is a 5 year waiting

18
list. This puts her too old to be able to adopt, according to the rules and regulations in her
area. 

AdoptionRisks
Unlike in surrogacy, adoptive mothers have legal rights. In most cases, they have the ability
to change their minds after they give birth and decide to keep the baby. This does not
happen in surrogacy.

A set of intended parents can become attached to an adoptive mother and baby, spending
months of their time with her, going to doctor's appointments in some cases, paying for her
cost of living, decorating a nursery for the upcoming birth, having a baby shower, watching
the birth of their supposed child only to have the mother decide at the last minute that she
doesn't want to put the baby up for adoption. 

Adoption Costs
Adoptive parents often pay for the medical and living expenses of the biological mother who
"may" be giving up her baby to them. They also pay the legal fees. 
These collective fees are paid even if the biological mother ends up keeping the baby. Often,
these fees equal an inexpensive surrogacy. 

Add in a failed adoption or two and the costs are completely in line with a typical surrogacy.
So those arguments against surrogacy but for adoption who say that surrogacy is more
expensive are not correct. Just uninformed. 

Abortion

Abortion is the most difficult and controversial moral topic in today’s society. Many people
view abortion as a murder of unborn children. On the other hand, some people view it as
freedom for women. We need to listen to both sides, even if that is difficult to do. Both
sides have negative and positive moral insights, even if ultimately these insights are
outweighed by the insights of the other side.

There are two principal morals we need to consider; first, the moral status of the fetus. Is
the fetus a person? At what age in its development does it becomes a person? Conception?
First trimester? Birth? Secondly, the right of the pregnant woman, does the pregnant
woman have the right to decide if she is going to carry the baby to term or not?
As we consider these difficult issues, it is imperative to distinguish two other questions. Is
abortion morally wrong or should abortion be illegal? These are distinct issues because not
everything that is immoral is necessarily illegal.

Another argument that is usually advanced against abortion is the fact that the fetus is an

19
innocent person. It is morally wrong to end the life of an innocent person; therefore, it is
morally wrong to end the life of a fetus. Much of the debate in regard to abortion has been
centered on whether the fetus is a person or not. If the fetus is a person then it has the right
that belongs to persons, including the right to life

Is the Fetus a Person with Rights?:

Much debate about the legality of abortion involves debating the legal status of the fetus. If
the fetus is a person, anti-choice activists argue, then abortion is murder and should be
illegal. Even if the fetus is a person, though, abortion may justified as necessary to women’s
bodily autonomy — but that wouldn’t mean that abortion is automatically ethical. Perhaps
the state can’t force women to carry pregnancies to term, but it could argue that it is the
most ethical choice.

Does the Woman have Ethical Obligations to the Fetus?:

If a woman consented to sex and/or didn’t properly use contraception, then she knew that
pregnancy might result. Being pregnant means having a new life growing inside. Whether
the fetus is a person or not, and whether the state takes a position on abortion or not, it’s
arguable that a woman has some sort of ethical obligation to the fetus. Perhaps this
obligation isn’t strong enough to eliminate abortion as an option, but it may be enough to
limit when abortion can be ethically chosen.

Does Abortion Treat the Fetus in an Unethical, Callous Way?:

Most debates on the ethics of abortion focus on whether the fetus is a person. Even if it is
not a person, however, this doesn’t mean that it can’t have any moral standing. Many
people object to abortions later in pregnancy because they intuitively feel that there is
something too human about a fetus which looks so much like a baby. Anti-choice activists
rely heavily upon this and they have a point. Perhaps the ability to kill something which
looks like a baby is one which we should avoid.

Ethics of Personal, Bodily Autonomy:

It’s arguable that a right to abortion is a right to control one’s body and the death of the
fetus is a unavoidable consequence of choosing not to continue a pregnancy. That people
have some ethical claim to personal, bodily autonomy must be regarded as fundamental to
the conception of any ethical, democratic, and free society. Given that autonomy exists as
an ethical necessity, the question becomes how far that autonomy extends. Can the state
really force a woman to carry a pregnancy to term?

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Is it Ethical to Force a Woman to Carry a Pregnancy to Term?:

If legalized abortion is eliminated, then the law will be used to force women to carry
pregnancies to term — using their bodies to provide a place where a fetus can develop into
a baby. This is the ideal of anti-choice activists, but would it be ethical? Not permitting
women a choice over being pregnant and reproducing is not compatible with justice in a
free, democratic state. Even if the fetus is a person and abortion unethical, it shouldn’t be
prevented through unethical means.

Ethics and the Consequences of Sexual Activity:

Pregnancy almost invariably occurs as a consequence of sexual activity; thus, questions

about the ethics of abortion must include questions about the ethics of sex itself. Some
argue, or at least seem to assume, that sexual activity must carry consequences, one of
which may be pregnancy. It is therefore unethical to try to prevent those consequences —
whether through abortion or contraception. Modern sexual liberty, however, is often
focused on freeing sex from traditional consequences.

Does the Woman have Ethical Obligations to the Father?:

Pregnancy can only occur with the participation of a man who is equally as responsible for
the existence of the fetus as the woman. Should women give fathers any say in deciding
whether the pregnancy is carried to term? If men have an ethical obligation to support a
child after birth, don’t they have an ethical claim on whether a child is born? Ideally, fathers
would be consulted, but not every relationship is ideal and men don’t run the same physical
risks as a pregnant woman.

Is it Ethical to Give Birth to an Unwanted Child?:

While anti-choice activists like to hype supposed examples of women having abortions to
keep their careers alive, it’s far more common that women have abortions because they feel
unable to properly care for the child. Even if it were ethical to force women to carry
pregnancies to term, it would not be ethical to force the birth of children who are unwanted
and cannot be cared for. Women who choose to abort when they cannot be good mothers
are making the most ethical choice open to them.

Political vs. Religious Debates over the Ethics of Abortion:

There are both political and religious dimensions to ethical debates over abortion. Perhaps
the most significant error which people make is to confuse the two, acting as though a
decision on the religious front should necessitate a particular decision on the political front
(or vice-versa). So long as we accept the existence of a secular sphere where religious

21
leaders have no authority and religious doctrines cannot be the basis for law, we must also
accept that civil law may be at odds with religious beliefs

STANDARDS OF NURSING PRACTICE

The international organizations in the field of nursing has adopted certain standards in the
professional practice situations. The international professional organizations of midwives
such as The ANA , AWHONN have their own written manuals for the standards which the
nurses are expected to implement in their practice situations. In India since the nursing as
an emerging profession now a days we are adopting these standards into our practice
situations in a modified form which is suited for the Indian situations. In midwifery practice
mainly the ANA standards and the AWHONN standards are adapted.

STANDARDS OF MATERNAL AND CHILD HEALTH NURSING PRACTICE BY ANA

Standard 1

The nurse helps the children and parents to attain and maintain optimum health

Standard 2

The nurse assists the families to achieve and maintain a balance between the personal
growth needs of the individual family members and the optimum family functioning.

Standard 3

The nurse intervenes with vulnerable clients and families at risk to prevent potential
developmental and health problems.

Standard 4

The nurse promote an environment free of hazards to reproduction , growth and

development, wellness and recovery from the illness.

Standard 5

The nurse detects changes in health status and deviations from the optimum development

Standard 6

22
The nurse carries out appropriate interventions and treatment to facilitate the survival and
recovery from the illness.

Standard 7

The nurse assists the client and families to understand and cope with developmental and
traumatic situations during illness , childbearing , childrearing and childhood.

Standard 8

The nurse actively persues strategies to enhance acces to and use of adequate health care
services.

Standard 9

The nurse improves the maternal and child health practices through the evaluation of
practice ,education and research.

ASSOCIATION OF WOMEN’S HEALTH, OBSTETRIC AND NEONATALNURSES(AWHONN)

NURSING PRACTICE STANDARDS

Standard 1

Comprehensive nursing care of women and newborn focus on individuals, families and
communities achieve their optimum health potential. This is best achieved within the
framework of the nursing process.

Standard 2

Health education for the individual, family and community is an integral part of the
comprehensive nursing practice and care. Such education encourages the participation in
and shared responsibility for health promotion, maintenance and restoration

Standard 3

Written policies, procedures and protocols clarify the scope of nursing practice and
delineate the qualifications of the personnel authorized to provide the care to women and
newborns within the healthcare settings.

Standard 4

23
Comprehensive nursing care for women and newborns is provided by nurse who are
clinically comprehentand accountable for professional actions and legal responsibilities
inherent to the nursing role.

Standard 5

Nursing care for women and newborn is conducted in practice settings that have qualified
nursing staff in sufficient numbers to meet the patient care needs

Standard 6

Ethical principles guide the process of decision making for nurses caring for women and
newborns at all times and especiallt when personal and professional values conflict with
those of patients, families, colleagues or practice settings.

Standard 7

Nurses caring for women and newborns utilize research findings, conduct nursing research,
and evaluate nursing practice to improve outcomes of care.

Standard 8

Quality and appropriateness of patient care and evaluated through a planned assessment
program using specific, identified clinical indicators.

STANDING ORDERS

Standing orders are those orders which a nurse could be carried out in emergency situations
in the absence of a physician. The nurse midwife should expand the range of knowledge to
be a perfect health care professional and to implement the standing orders by identifying
the situations correctly. The nurse practitioner must pocess a detailed knowledge regarding
the disease process and the drug peculiarities before administering the drug.

Core Section of Patient Group Directions

Introduction

Patient group direction supersedes Midwives Standing Orders. This patient group direction
states which medicines may be supplied and administered by midwives within the Borders
General Hospital NHS Trust.

24
 Midwives may, under the Medicines Act 1968, supply all medical products on the
General Sale List and Pharmacy List and administer a small range of Prescription Only
Medicines.

The formulary contains monographs for all products within the patient group directions and
should be used in conjunction with the information in the core section of the patient group
direction.

Clinical Decision Making

Patientswhomayreceivemidwivesformularymedicines

This patient group direction should be used for the supply and/or administration of
the agreed medicines to ante-partum, intra-partum or post-partum mothers within the
Borders General Hospital NHS Trust. The medicines may only be used within individual
product monograph recommendations and contra-indications.

Consent

If the patient does not wish to receive treatment with a formulary item, and no
alternative is listed, medical help should be sought to find a suitable therapy. Patient
Information Leaflets may be supplied if available.

Contra-indications

No product in this formulary should be used without consideration of the possible

consequences to the patient. Formulary products should not be used if the patient has
previously had or suspected an adverse reaction to the product, or if a contra-indication for
that patient occurs in the monograph. In these cases the patient should be referred to a
doctor.

Precautions

The products listed in this formulary should be used only for the specific condition specified
in the monograph.

Formulary items should not be used for the treatment of patients who have known, or
suspected hypersensitivity to any product or any of its ingredients.

In the event that an adverse reaction occurs, use of the product should be stopped and
medical help sought immediately.

Facilities for treating anaphylaxis should always be available.

25
Designated staff authorised to administer midwives formulary products

Authorised Staff

The following staff who are employed by the Borders General Hospital NHS Trust are
authorised to administer Midwives Formulary products without individual medical
prescription for conditions specified in the product monograph.

Registered Midwife

In addition the following requirements are necessary:

 To be professionally accountable
 To have received adequate training and be competent
 To be familiar with contra-indications to the product
 To have access to the current group protocols for the administration of
Medicines in the Midwives Formulary
 To be trained to identify anaphylaxis
 To have immediate access to appropriate equipment and drugs to treat
anaphylaxis and have access to the current protocol and guidelines for its
management
 To maintain their own professional level of competence and knowledge.

Head of Midwifery/Midwife Managers will be responsible for:

 Ensuring that there are patient group directions for the administration of
medicines in the midwifery formulary
 Ensuring that midwives administering products have received adequate
training and follow the patient group directions for the administration of
products in the midwifery formulary.

The midwife will be given a copy of the patient group directions which she/he will sign along
with the line manager and Pharmacist.

Treatment Available

Product, Dose, Route and Frequency

See individual product monograph and summary table

Adverse Reactions

See individual product monographs

Follow-up Treatment

Patients should be observed for any sign of adverse drug reaction

26
Documentation

Out-patient settings

The supply of medicines must be documented in the woman’s case notes, eg an immediate
discharge letter should be completed and filed (B77).

In-patients

All medicines must be prescribed on the Obstetric Medicine Chart for Self
Medication/Borders General Hospital NHS Medicine Chart and documented in the case
notes, according to policies and procedures relating to the department. The name of the
prescribing midwife must be printed legibly and signed.

FurtherPoints

Manufacturer and patient information leaflets for any product in the formulary should be
read and advice taken from them.

The recommendations for storage and handling of any product in the formulary must be
followed.

Concurrent Medication

See individual product monograph for the details of each medications.

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

APERIENT Ispaghula Husk 3.5g one sachet in water, once only

PROPHYLAXIS FOR Ranitidine tablet 150mg at 22.00 on night

MENDELSON’S SYNDROME before theatre, repeated two hours before

IN ELECTIVE LSCS theatre. Sodium Citrate 0.3M 30ml orally once only
immediately prior to transfer to Theatre

27
I.V. THERAPY Compound Sodium Lactate 1 litrei.v. over
8-12 hours, to a maximum of two litres

Heparin 10iu/ml 5ml instilled into i.v. cannula

when required every 4-8 hours

LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to

cannulation once only

Amethocaine gel 4% 1g under occlusive dressing 45

minutes prior to venouscannulation once only

NIGHT SEDATION Temazepam10mg as a single dose up to 2.00am in

the morning.

DINOPROSTONE VAGINAL GEL As per induction of labourguidelines.

FOLIC ACID Folic acid 400microgram tablet once daily, until 12-
14 weeks gestation.

DEMULCENT COUGH Simple linctus 5ml once only

PREPARATION

ANTISPASMODIC Peppermint water 10ml in plenty of water, once

only.

ANTI –D IMMUNOGLOBULIN

Anti-D immunoglobulin may be given to all non-sensitised Rh D negative women within 72

hours of a sensitising event in the following circumstances

Prior to 20 weeks gestation Anti-D 250iu by i.m. injection

 Threatened miscarriage after 12 weeks gestation

 Spontaneous miscarriage after 12 weeks gestation
 Ectopic pregnancy

28
  Therapeutic termination of pregnancy – medical and surgical
 Following sensitising events such as amniocentesis
 Incomplete miscarriage requiring E.R.P.O.C.

After 20 weeks gestatation Anti- D 500i.u. by i.m. injection

 Antepartum haemorrhage
 External cephalic version
 Intrauterine death
 Invasive prenatal diagnostic and intrauterine procedures
 Blunt abdominal trauma

Routine Ante-natal Anti-D prophylaxis

Anti-D 500i.u. by i.m. injection at 28 and 34 weeks gestation

INTRAPARTUM

ANALGESIA Entonox inhalation as required

Diamorphinei.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 Cyclizine50mg 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

PROPHYLAXSIS FOR Ranitidine tablet 150mg every 6 MENDELSON’S

SYNDROME Sodium Citrate 0.3M 30ml prior to Theatre

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

Syntometrine 1ml i.m. with anterior
shoulder at delivery

29
I.V. THERAPY Compound Sodium Lactate 1 litrei.v. every 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 under occlusive dressing 45
minutes prior to venous cannulation once only

LAXATIVES Glycerine Suppository 1 or 2 per rectum

or

Docusate sodium 90mg microenema as required

EPISIOTOMY Lignocaine 1% 10ml by perineal infiltration

PAEDIATRICS

The following may be administered to babies after delivery without reference to Paediatric
staff:

Oxygen by facemask

Phytomenadione 1mg by i.m. injection

POSTPARTUM

EPISIOTOMY REPAIR Lignocaine 1% by perineal infiltration to a maximum

of 20ml

ANALGESIA
NSAID ANALGESIC Only one NSAID should be prescribed at any one time

Cesarean Section for first 24 hours:

Anaesthetist 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 Section after first 24 hours:

30
Ibuprofen tablet or syrup 400mg or 600mg three times a day.
Diclofenac tablet or suppository 50mg three times a day (to a maximum of 150mg in 24
hours by any route).

PARACETAMOL BASEDANALGESIC

Only one paracetamol based analgesicshould 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 Cyclizine50mg 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

Lactulose 10ml orally twice daily

Glycerine suppository 1 or 2 per rectum as required

I.V. THERAPY Compound Sodium Lactate 1 litre i.v. every 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 under occlusive dressing 45

minutes prior to venous cannulation once only

31
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.
If symptomatic refer to SHO.

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

PREPARATION

ANTISPASMODIC Peppermint water 10ml in plenty of water, once

only.

EMERGENCY PRESCRIPTIONS

The following can be administered FOLLOWING AND ONLY WITH reference to medical staff,
provided that all are entered correctly in the casenotes/drug or i.v. prescription sheet,
signed by the initiating midwife and countersigned by the duty SHO as soon as practicable

OXYGEN Oxygen6 litres/minute by face mask

TREATMENT OF Glucagon 1mg i.m. or i.v.

SEVERE
HYPOGLYCAEMIA Hypostop gel orally as required

ANTEPARTUM Compound Sodium Lactate 500-1000ml stat IV

HAEMORRHAGE

32
POSTPARTUM Syntometrine 1ml I.M
HAEMORRHAGE
Oxytocin 10i.u by i.m. or i.v. injection
Oxytocin 40i.u. in 1 litre Compound Sodium Lactate at
a rate of up to 250ml/hour

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 CONCLUSION
Maternity nursing is now a days emerging as the most considerable regions in the field of
nursing. In our country also it is developing into an independent practice area while
considering the other areas of nursing are not yet approached to the level of an
independent professional practice area. So the nurse midwives should have a thorough
understanding and independent and interdependent wide range of thought in the field of
ethical considerations, professional standards and standing orders for a nurse midwife
should be taken into account before planning the actions and implementing them because
the nurse midwife is answerable legally towards any unwanted outcome of the intervention.
So it is the responsibility of the nurse to gain adequate knowledge and skill in the
professional practice areas.

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 BIBLIOGRAPHY

 Lowdermilk& Perry ‘MATERNITY AND WOMWEN’S HEALTHCARE’8 THedn Mosby

publications . Pp 11-12
 Adele Pilletteri ‘MATERNAL AND CHILD HEALTH NURSING CARE OF CHILD BEARING
AND CHILD REAEING FAMILY’ 2NDedn. J. B Lippincott company Pp 20-22
 Murrey&Mc Kinney ‘FOUNDATIONDS OF MATERNAL, NEWBORN AND WOMEN’S
HEALTH NURSING’ 5THedn Saunders publication Pp 37-51
 GiaGanguly Mukherjee ‘MEDICOLEGAL ASPECTS IN OBSTETRICS AND GYNECOLOGY’
2NDednJaypee brothers publications New DelhiPp1-20
 Illyasa R Foster & Jon Lasser ‘PROFESSIONAL ETHICS IN MIDWIFERY PRACTICE’
1STedn Jones and Bartilett publishers Pp9-37
 http://books.google.co.in/books/about/Ethics_in_Midwifery.html
 http://www.facebook.com/pages/Professional-Ethics-in-Midwifery-Practice
 http://midwiferytoday.com/articles/interncode.asp

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