RAJKUMARI AMRIT KAUR COLLEGE OF NURSING

PEER STUDY ON
LEGAL AND ETHICAL PRACTICES IN OBSTRETRICS AND STANDING ORDERS
(SUBJECT: OBSTRETRICAL NURSING)

SUBMITTED TO SUBMITTED BY

ANUGRAH MILTON PRABHDEEP KAUR

TUTOR M.Sc. (N) 1st YEAR

RAKCON RAKCON
Subject: Obstetrical and Gynecological Nursing
Topic :LEGAL AND ETHICAL PRACTICES IN OBSTRETRICS AND STANDING ORDERS
Course:MSc Nursing
Student: Prabhdeep Kaur
Group:MSc first year
Date:10/05/2023
Setting:Classroom
Time:2pm
Av aids:PPT
Teacher : Anugrah Milton

Previous knowledge
Students have acquired knowledge about legal and ethical practices in obstretrics in thier BSC
curriculum.

General objectives
To develop knowledge in students regarding ethics and practices in obstretrical nursing and
standing orders
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To INTRODUCTION PP
introduce T,
the topic to Law is a societal
the class. institution that
governs relationship
among members of
this society. In our
society, competent
adults are responsible
and accountable for
their behaviour when
other may be at risk
of harm; adults are
expected to meet
certain standards of
behaviour that
ordinary reasonable
prudent persons
would use under
similar
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circumstances.

To annouce Annoucement of the

the topic to topic
the class.
We shall discuss
about the legal and
ethical aspects in
obstretrical nursing.
LEGAL AND ETHICAL ASPECTS RELATED TO MIDWIFERY AND
OBSTETRICAL NURSING
To define What do
ethics,laws Definitions you
,regulating understand
bodies. Ethics: Ethics are the principles of conduct governing ones relationship with others. by ethics
They are basic beliefs about values of right and wrong that provide a framework for and laws?
decisions and actions.

Laws: Laws are rules of conduct or actions recognized as binding or enforced by a

controlling authority, such as the local, state or national government. They are
designed to prevent the actions of one party from infringing on the rights of another
party.

Laws and ethics are often seen as complimentary to each other, but at the same time
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they are also seen as opposite side of a coin. Midwives must follow standards and
regulations that range from the national level to the individual area of practice, such
as hospital, labor and delivery unit.

Standards of practice: National standards provide an expectation of the delivery of

care to clients. Regulations and policies at institutional levels provide care for safe
delivery. Educational programs of midwifery ensures that all new nurses/midwives
can safely deliver care within the scope of midwifery practice.

State license or registration: Practice of nursing and midwifery is regulated by state

registration 7 councils through license to practice. If a nurse/midwife moves to a
different state, she must obtain registration in that state in order to practice there.
The state license is meant to protect the consumers by ensuring that the midwife
has appropriate education and can provide safe care. Institutional policies: Policies
and regulations of an institution govern the nursing and midwifery care to clients
seeking health care in that place.

Community standards: A midwife's performance will be evaluated according to the

availability of medical and nursing knowledge that would be used in the
management of similar patients under similar circumstances by competent
midwives, given the facilities, resources and option available.
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To explain Ethical Principles F What are

the ethical the ethical
principles Beneficence: It means to act in the best interests of the patient and to balance L principles
benefits against risks. The benefits that medicine is competent to seek for patients in nursing?
are the prevention and management of disease, injury, handicap and unnecessary A
pain and suffering and the premature or unnecessary death.
S
Respect for autonomy: It means to respect the rights of individual. Respect for
autonomy enters the clinical practice by the informed consent. This process is H
usually understood to have three elements. Disclosure by the physician to the
patient's condition and its management. Understanding of that information by the
patient a voluntary decision by the patient to authorize or refuse treatment. C
Nonmaleficence: It means that a health personnel should prevent causing harm and A
is best understood as expressing the limits of beneficence. This is commonly known
as 'Primum non nocere' or first to do no harm. R
Justice: Justice signifies, to treat patients fairly and without unfair discrimination, D
there should be fairness in the distribution of benefits and risks. Medical needs, and
medical benefits should be properly weighted. S

Confidentiality: It is the basis of trust between health professionals and patient. By

acting against this principle, one destroys the patient's trust.

Informed consent: The process of obtaining permission after explaining the

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expected risk and benefit is called informed consent. Patient or individual who
requires healthcare services have right to make their own decision about the
opinions for treatment or other related issues.

Truthfulness: The fact of being realistic or true to life is called realism. It is the
basic principle of the natural moral law, and people everywhere recognize that
honesty in dealing with others is a prerequisite for societal order and well-being.
To Ethical and Legal Considerations Prior to Conception What are
elaborate the ethical
the ethical Often a couple will have difficulty conceiving. The National Center for Health and legal
and legal Statistics estimates that almost half of currently married women 15-44 years old considerati
considerati suffer from some degree of infertility, and 10% of married cou- ples fail to ons prior
ons prior to conceive after 1 year of no contraceptive use. to
conception. conception
In the last 30 years, advances in medical engineer- ing have resulted in methods of ?
reproduction without intercourse, including artificial insemination and in vitro
fertilization with embryo transfer (IVF/ET).

As with contraception, artificial reproduction is defended by its proponents as life

affirming while denounced by its detractors as unnatural. In addition, there has
arisen what one author called a hucksterism, or hype, surround- ing much of the
technology, particularly that of IVF/ET.

Some see this hype as an exploitation of the infertile cou- ple, especially when
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accompanied by the publicity about success rates that some centers use. Those
professionals urging caution point out that the incidence of live births (not
pregnancy) is still low with these techniques.

To discuss Artificial Insemination

the aspects
r/t artificial Artificial insemination, the depositing of sperm at the cervical os or in the uterus by What is
inseminatio mechanical means, can be accomplished by two methods. In artificial insemination artificial
n. from the husband (AIH), sperm from the client's husband is deposited within her inseminatio
reproductive tract. This is perhaps the least controversial of all of the assisted n?
reproductive methods, because it is clear who the genetic and sociologic parents
are. Some religious denominations object to masturbation as a means of sperm
collection, but this method generally is without grave ethical or legal questions.

The second method, artificial insemination from a donor (AID), is more

problematic. With AID, the woman is inseminated with the sperm from an
anonymous donor. This method separates the sociologic parent (the woman's
husband) from taking part in his offspring's conception AID has become the
preferred treatment when the husband has an absence or marked decrease in the
amount of sperm AID also is used when the husband suffers from a genetic efect or
is Rh sensitized. This procedure has decreased in recent years because of the
possibility of human immunodeficiency virus (HIV) transmission. Currently, all
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donors and each specimen are screened for HIV. As long as the husband of the
woman consents, the donor is not considered the legal father of the child. Thus, the
husband replaces the genetic father as the legal father of the child. As can be seen,
this therapeutic model places contracts among the parties ahead of genetic or
"bloodline" considerations. This model has been suggested as a model for
embryonic transfer, but there is question as to whether it fits.

Legal obligations are satisfied by written, informed consent by all parties-wife,

husband, and donor. Anonymity of all parties is recommended. It also is recom-
mended that the physician be given the right to select the donor. This
recommendation raises questions about the limits of authority for the professional,
especially because there has been some scandal in recent years when the physician
is given this right; the consent usually includes a clause removing liability from the
health professionals if the child is born with abnormalities. The question of the
child's legitimacy can be resolved by adoption.
To discuss What do u
the in In Vitro Fertilization and Embryo Transfer understand
issues by IVF and
related to IVF/ET is a procedure in which an egg or eggs are removed from a woman's ovary, what are
IVF fertilized by sperm in a laboratory dish, cultured, and then transferred back into the ethical
woman's uterus when the embryo has reached the four to six-cell stage. IVF is the considerati
only method of reproduction available for women whose fallopian tubes are ons related
damaged or missing. It also can be used for wives whose husbands have low sperm to IVF?
counts, women whose cervical mucus is no receptive to sperm, and women with
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infertility of unknown causes.

Dr. Robert G. Edward and Dr. Patrick Steptoe set the world record of performing
the first in IVF in 1978. Simultaneously, in the same year, Dr. Subhash Mukho-
padhyay of Kolkata brought glory to India by performing the first IVF in India and
Durga (Kanupriya Agrawal) was born on October 3, 1978, two months after Louise
Brown, the first test tube baby, came to the world (Kambli, 2011). These important
milestones paved the way in the development of IVF in India and the world. In
2010, there were 500 infertility clinics across the country, and approximately
20.000 babies were born in that year through this technique, with a world statistic
of 40,000 babies .

In 1984, gamete intrafallopian transfer (GIFT) was developed, this procedure

involves retrieving eggs from the woman and then transferring the eggs along with
sperm into the ampullary portion of the fallopian tubes. usually using laparoscopy.
It is the procedure of choice when there is at least one functional fallopian tube.
Data suggest that the pregnancy rate is better with GIFT than with IVF/ET alone,
perhaps due to the tim ing of implantation.

The demand for these procedures continues to grow.. In each state, fertility clinics
have been established. A variety of services are offered by these clinics:

• Artificial insemination by husband sperm or donor sperm

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• GIFT

• IVF and ET

• Intracytoplasmic sperm injection (ICSI)

⚫ Donor egg treatment

donor embryo treatment

Use of surrogate mother

The stigma regarding nonacceptance of fertility methods is not substantial

nowadays among couples and families. The charges are very low in India compared
to other countries and the success rate is also very high.Similar to medical tourism
which is flourishing in India, fertility tourism is also on the rise now. It started
gaining momentum after 1980. The government of India is encouraging the medical
fraternity to establish fertility clinics in the government sector or institutions.

Indian Society for Assisted Reproduction (ISAR) organizes conferences at national

and international levels in the country. ISAR 2014: The 19th annual conference of
the Indian Society for Assisted Reproduction will be held in Ahmedabad, Gujarat,
with the theme "Basics, Recent and the Future of Infertility Management."

While these procedures move ahead clinically, there has been no federally funded
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research in humans since 1975 because of a de facto moratorium. Congress first

imposed a temporary moratorium on fetal research on July 12, 1974. This was lifted
technically on August 8, 1975, when regulations were issued by what was then the
Department of Health, Education, and Welfare. These regulations required all
proposals dealing with IVF and fetal research to be reviewed by a national Ethics
Advisory Board (EAB) in addition to the usual review by peer and Institutional
Review Board for scientific merit. The EAB was duly but slowly constructed. It
examined the topic of IVF thoroughly, concluding that although the controversy
was legitimate, IVF/ET was acceptable from an ethical standpoint (Holmes, 1988,
Medical Ethics Advisor, 1994), However, at subsequent public hearings and
presentations to Congress, the response was overwhelmingly negative, so a de facto
moratorium set in.

In India, ICMR has laid guidelines on the ethical aspects of ART. It has drafted the
Assisted Reproductive Technology (Regulation) Bill 2010.

Assisted Reproductive Technology (Regulation) Bill 2010

The ART Bill 2010 includes guidelines on the following aspects:

Authorities or institutions authorized to regulate the practice of ART in India of the

procedures for registration and Delineation complaints

Duties and responsibilities of ART centers/clinics

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Regulation of research on human materials such as embryo

⚫ Rights and duties of patients, donors, surrogate mothers,or sperms and children

⚫ Offences and penalties if violation of bill occurs Because of various legal and
ethical issues confronted by ART practices, National Guidelines (Government of
India) has been drafted with an expert committee. It gives guidelines for the
following procedures:

⚫ Alternative strategies for reversal of sterilization

• Minimal infrastructure facilities recommended to start IRTclinic/center

Qualifications and experiences required for ART members of the team various
ART procedures

Criteria for selection of couples for ART procedures What is the

criteria for
• Fertility centers at various levels selection
for ART
Code of ART practices procedures
?
• Procedures for licensing the centers
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• Duties and responsibilities of the clinics/centers

Role and functions of sperm donor, oocytes donor, and surrogate mother

Pharmacotherapy

To explain ⚫ Legal and ethical issues What are

the legal the ethical
and ethical Over the years, the ethical and legal concerns have changed. The current concerns issues r/t
issues of regarding IVF/ET can be E summarized as follows: IVF?
IVF.
Moral status of the fetus: The human embryo is entitled to profound respect, but
this respect does not necessarily encompass the full array of legal and moral rights
attributed to a person. Mainstream ethicists and theologians generally concur that
IVF/ET is not prob lematic as long as the EAB's guidelines are followed.
Conservative theologians, however, believe that any tampering with the procreative
process is unnatural and should not be attempted. Thus, the use of human embryos
for research remains a problem .

⚫ Safety and efficacy: During the late 1970s, there was only limited
understanding about the risks involved with this procedure. As data have been
collected, there is a good (but not conclusive) indication that there are no patterns
of abnormality or short-term risks either in laboratory research with animals or in
clinical experience with humans. Until further research is conducted, however, this
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concern will remain.

The slippery slope: This concern relates to the fear that research procedures
performed on nonhuman mammalian species might be performed on human
embryos with the results possibly leading to undesir- able clinical applications.
Some ethicists are concerned about extending the procedure to unmarried people,
such as surrogate mothers and third-party donors. They see the basic relationship
between husband and wife and the institution of marriage as being threatened.
These were the same concerns that artificial insemination generated decades ago.

• Funding and cost: There is general acknowledgment that the procedure is costly.
Although some believe that it is ethical to federally fund research projects relating
to IVF, it should have a low national priority, because there are many other national
health problems that are far more pressing. Those who oppose the procedure say
that efforts would be better spent finding and preventing the causes of infertility
and tubal obstruction.

To explain Surrogate Motherhood What are

issues the issues
related to Surrogate motherhood involves the contractual hiring of a woman to bear another r/t
surrogate couple's child. The father's sperm may be used to impregnate the surrogate, or, in surrogate
motherhoo surrogate ET the surrogate is implanted with the genetic parent's embryo. When the motherhoo
d. fetus is born, the surrogate mother relinquishes her rights to the newborn to the d?
couple as per the terms of a contract.
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Some people view this as another instance of collab- orative reproduction, such as
AID and IVF, saying these methods are no different ethically and legally from adop
tion, which separates conception and gestation from child rearing . However,
ethical and legal issues remain.

There is the issue of "hiring" the surrogate mother. The mother typically receives a
fee for carrying the child. Although this may seem fair for the surrogate mother's
efforts, some find the idea of payment for producing a child repugnant and morally
offensive. Children are reduced to commodities to be bought and sold. Some have
suggested that mothers who need money may "sell" themselves as surrogates to
keep their own families together. There also is the stress of the complex
relationship involving a stranger in such an intimate context, which may be
entangling and dis- turbing to the parties. For example, the surrogate may
experience depression when giving up the child, or the couple may continue the
relationship with the mother out of misplaced feelings of indebtedness. The lineage
of the children may become confused, and the fabric of the marriage may be
damaged. However, it has been argued that although these concerns are legitimate,
they must be balanced against the deep desires of the infertile couple to have
children (Annas, 1988b; Raymond, 1990).

Legal concerns surround the contractual arrangements. It had been maintained that
a well-drawn contract would obviate some of the difficulties in the three-way
relation ship. However, this was not true for the Baby C case liti gated in California
in 1990, wherein the surrogate mother abrogated the well-drawn contract with the
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parents by charging them with neglect during pregnancy and bonding to the
newborn she carried. The surrogate mother is suing for shared custody of the child.
In the Baby C case and in the famed Baby M case, it is evident that well-drawn
contracts can be contested, causing a great deal of stress for all parties, including
the infant . Some critics also are concerned about cases in which neither party
wants a child born with impairments or in which the surrogate is reluctant to
surrender the new- born. The legality of such contracts remains a controversial
issue, because the courts are still battling the extent to which these contracts are
binding.

Issues of the surrogate mother's right to privacy and freedom of choice come into
play. Because of these and other complexities, Great Britain has made it a criminal
offense for third parties to benefit from commercial surrogacy. However, voluntary
surrogacy is still legal. Because of the legal climate and hostile public and medical
sentiment surrounding surrogacy, the method is essentially banned in that country.
Researchers caution that the use of a surrogate mother, even for a short time; the
inconvenience of synchronizing the donor and recipient menstrual cycles; and the
medical risks to the donor make this method less appealing to many

To Amniocentesis What is
elaborate amniocente
the issue Amniocentesis has been available for more than a decade. Ethical and legal issues sis and
related to surrounding this procedure involve errors of omission or commission. For example, issues r/t to
amnicentes if a woman who is a candidate for the test because of age (older than 35 years)
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is. produces a child with a chromosomal anomaly or has a history of genetic disease it?
and is not made aware of the test, the healthcare professional may be liable if she
produces a defective newborn. Risks and benefits of the tests also must be
explained to the client, and an informed consent must be obtained. If the mother has
the test, is told that her fetus is normal, and then subsequently produces a defective
newborn, the healthcare professional and the laboratory performing the test could
be held accountable. If the healthcare professional has personal beliefs about the
efficacy of the test, opinions about whether the woman should abort if the test
shows a defective fetus, or moral, ethical, or religious objections to the test, the
healthcare profes- sional nevertheless has the obligation to inform the cli- ent about
the test and refer her elsewhere.

To
elucidate Ethical and Legal Considerations in Abortion
the ethical What I
and legal The current conflict between the prochoice and the profetus groups has rekindled sabortion
considerati the fires that have raged around he topic of abortion. Nurses must understand their and the
ons in own ethical position on this matter if they are to render qual ity care to their clients. ethical and
abortions. Because the nurse is involved in counseling clients about abortions from a variety legal issues
of standpoints, a brief review of the ethical and legal consid erations is given in the r/t to it?
following sections.

Ethical Considerations
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The ethics involved in the abortion issue revolve around terminating the life of a
fetus by removing it from its life support system. It has been argued that given a
choice, humans would choose health and lack of suffering for themselves.
Furthermore, the argument continues, humans do not have the right to inflict the
tragic con- sequences of detectable diseases on a fetus. By aborting a defective
fetus, "nothingness" results rather than the pain of living with an abnormality. The
damaged fetus can be replaced with a normal one in a subsequent preg- nancy.
Although this line of reasoning supports aborting damaged fetuses, it does not
address the ethics of abort- ing healthy (or unplanned) products of conception. It
also raises the issue of who determines what is normal or healthy.

Prochoice advocates take the position that the mother has the ultimate responsibility
and freedom of choice about what happens to her body. Prochoice is not pro-
abortion. Prochoice advocates stress using abortion only as a last resort. They
uphold the responsible use of con- traception, amniocentesis to determine fetal
defects, and adoption whenever possible. Prolife advocates believe that the fetus is
human from the time of conception and that to destroy human life is murder and,
hence, indefensible morally.

Legal Considerations
To explain Indian Medical Termination of Pregnancy (MTP) Act What are
the legal the lagal
aspects of Strict abortion laws are made by the countries to prevent the misuse of induced aspects r/t
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r/t abortions. In India, the abortion law came under the Medical Termination of abortions?
abortions. Pregnancy Act and it clearly states that only qualified doctors under specific
conditions can execute the act of abortion. The hospital or clinic where the abortion
is to be performed should be approved by the government.

The MTP Act was passed in 1971 and was implemented 1972 onwards and was
amended once in 1975.

Grounds for Abortion as per the Indian MTP Act

The MTP Act emphasizes that pregnancy can be terminated strictly on the
following conditions:

. When the pregnancy does not exceed 12 weeks

When the pregnancy is more than 12 weeks, but less than 20 weeks; two registered
practitioners' consultation is needed before termination When the pregnancy, if
continued, can cause the mother to have physical or mental risk

On therapeutic grounds . When the fetus has serious or life-threatening physical or

mental defects (eugenic grounds).

 When pregnancy has occurred as a result of rape (social ground)

⚫ Failure of contraceptive device used by a couple Consent of the following kinds

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is required before a legal abortion by an approved practitioner can be conducted on

a pregnant female:

. Husband's consent is not required if the woman is married.

. When the woman is unmarried and is above 18 years, her consent is valid.

Guardian should give consent when she is below 18 years.

If mentally unstable, guardian should give the consent.

Qualifications for Conducting MTP

⚫ A registered medical practitioner

⚫ A qualified doctor who has had experience in assisting MTP

⚫ A house surgeon who has had a posting for 6 months in obstetrics and
gynecology department

A doctor who has a degree or diploma in obstetrics and gynecology

⚫ A doctor who has had 3 years of practice in obstetrics and gynecology before the
MTP Act was enforced
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. A doctor who has a minimum of 1 year experience in obstetrics and gynecology

after the MTP act enforced (Government of India, Medical Termination of
Pregnancy Act 1971)

Reaffirmation of Women's Rights

At the center of the debate about abortion is the issue of women's rights. Ethicists
point out that abortion must remain a moral decision for the mother unless sexual
inequality is to be governmentally institutionalized.
To Ethical and Legal Considerations for the Fetus, Sick Newborn, and What are
elucidate the the
the ethical Mother ethical and
and legal legal
Perhaps the areas in perinatology and neonatology that are most fraught with
considerati considerati
dissension, discussion, debate, and ethical and legal dilemmas are the areas of
ons for ons for
neonatal intensive care and fetal research and treatment. Ironically, many of the
fetus,sick fetus,sick
problems in this area are a result of the technologi- cal advances developed in the
newborn,m newborn,m
field of neonatology and perinatology. Fetuses that would have naturally aborted or
other. other?
been stillborn 5 years ago now often can be sustained in utero until they are almost
full term. Infants who had no chance of survival a decade ago now may look
forward to a relatively healthy and productive life.

As technology and expertise continue to increase, there will be more attempts to

save fetuses at earlier and earlier stages, even those with severe conditions. In many
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of these cases, the "saved" newborn may be severely phys- ically or mentally
handicapped. Heroic efforts are made by health professionals to prolong life, when
it is questionable whether it is in the best interest of the newborn or family. Health
providers and parents are often faced with these ethical and moral dilemmas
because of federal regulations and guidelines.

The Fetus

The fetus has rights from the time of conception and can Es be a beneficiary of a
trust and inherit property. Although not legally considered a person until born, the
rights cs of the fetus have been upheld in courts. For example, a woman was
ordered to have a cesarean section by the courts because of fetal distress. The
woman had refused the procedure and was adamant about leaving the hospital.
After conferring with her, the legal staff of the hos- pital procured a court order for
the woman to undergo the cesarean section. This was the first time a woman had
been legally coerced into surgery. In another case, the courts ordered a mother who
was a Witness to have a blood transfusion to save the life of her fetus must.

Fetal Research
Although federal funding for fetal research remains a con- troversial issue, many
advocates believe the research has great potential for preventing costly diseases.
However, many states have made fetal research illegal, especially when the fetus is
an abortus or is still in utero. The ethics of fetal tissue transplants are hotly debated.
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Several difficult questions have been raised regarding the rights of the mother
versus the rights of the fetus:

Does the woman have the right to determine what will be done with fetal remains?

⚫ Does a woman who plans an abortion have the right to allow experimentation in
utero?

• Can an aborted fetus be kept alive for experimental purposes?

Federal guidelines require that fetal research be designed to meet the needs of the
fetus, be of minimal risk, and have the potential to develop important medical
knowledge. These global guidelines allow for wide interpretation. Experts agree
that we are on the threshold of great discoveries. However, with this progress will
come even more difficult decisions for expectant parents and those who care for
them.

Fetal Therapy
Advances in technology have resulted in the ability to drain spinal fluid from the
brain of a fetus (cephalocentesis), catheterize the fetus in utero, remove its lower
body from the uterus to repair a urinary tract obstruction, transfuse the fetus in
utero, repair gastroschisis, and surgically repair skeletal defects. Although these are
certainly milestones in the area of therapy, investigators generally advise caution
and note the experimental nature of many of the treatments . Those who take a
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more conservative approach state that the only anatomic malformations that
warrant consideration are those that interfere with fetal organ development and that
if alleviated, would allow normal fetal development to proceed.

The Committee on Bioethics of the American Academy of Pediatrics (1990) points

out that the woman and her fetus are being viewed more often as two treatable
entities. They caution, however, that while some fetal diagnostic procedures and
treatments in utero, such as amniocentesis and intrauterine transfusion of the fetus,
have become stan- dard practices of proven efficacy, other fetal interventions, such
as shunt diversions for hydrocephalus or obstructive uropathy, are considered
research procedures and are not standard medical practice.

Thus, their use is equivocal at this time. In their opinion, these interventions should
be registered with the international registry that has been established to record
experience with these experimental interventions. In general, this opinion is held by
a majority of practitioners in the field, but others want to push the frontiers of
research in the interest of future "common good".

Ethical and legal questions and possible conflicts can emerge as these treatments
are used more frequently. What happens if a physician feels he or she can help a
fetus, but the mother refuses consent, or the surgical consent is ambiguous? If a
court orders the mother to submit to fetal treatment, does this invade her right to
privacy and her own body integrity? Could she be charged with fetal abuse if she
refuses treatment? Is the risk-to-benefit ratio favor- able enough to cause this costly
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therapy to be a national priority? Finally, who will be required to pay for these
experimental procedures? Health insurance often refuses coverage in
"experimental" conditions. Answers to these questions are not easy, and solutions
are becoming more difficult as technology improves.

The Sick Newborn

Ethical and legal questions and conflicts also emerge for the sick newborn. How
much should a newborn have to suffer for the sake of life? More importantly, which
should be regarded more highly-the sanctity of life or the quality of life? Doctors,
nurses, and parents will continue to face these dilemmas as infant mortality rates
continue to decline. Approximately 3% of all children born in the United States
have a major malformation at birth. Many more show problems of developmental
ori- gin with time. In India, birth defect prevalence varies from 61 to 69.9/1000 live
births. Clearly, medicine is advancing in its effort to save lives, but the long-range
outcomes may be questionable.

Effects of Invasive Procedures

Some of the procedures deemed necessary for a sick newborn can have an
iatrogenic effect, resulting in another disease or defect. For example, prolonged use
of ventilators can scar respiratory passages. Oxygen therapy, if it is given at too
high a concentration, can cause varying degrees of vision impairment. Newborns
are subjected to numerous needle punctures, tubes down their throats, and catheters
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into their hearts, bladders,and other orifices. Healthcare providers often view the
newborn's suffering as justifiable, something that must be endured to make the
newborn better in the long term. The newborn clearly has no choice, unlike adults
health who have the option of refusing treatment. Therefore, labeli the decision
about what is reasonable treatment for newborns is more difficult.

There is a growing consensus among providers and ethicists that society must come
to terms with several difficult questions in the next few years:

⚫ Should the lives of certain newborns be saved only to have those lead lives of
pain, disability, and deprivation?

Should the newborn who would not otherwise survive without major intervention
be left to die? If so, who makes the decision?

What is the family's role in these decisions? How much power should the family
have in decision making?

What kind of care does one deny or give a newborn to allow death with comfort
and dignity?
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To Baby Doe Regulations What is

elaborate baby doe
on Baby On October 11, 1983, a baby with multiple neural tube defects was born in Port regulations
Doe Jefferson, New York. After consulting with physicians and their Roman Catholic ?
Regulation priest. the parents chose conservative medical rather than surgical treatment to
s. reduce the chance of infection rather than correct the defects.

The American Academy of Pediatrics developed guidelines for the composition

and duties of such a committee, regarding them as viable alternatives to hotlines
and squads of investigators.

On May 15, 1985, the latest Baby Doe regulation went into effect as the Child
Abuse Amendments of 1985 to Public Law 98-457-the Child Abuse Prevention and
Treatment Act (Murray, 1985). Included in this amendment are the following
definitions:

⚫ Medical neglect: Withholding of medically indicated treatment from a disabled

infant with a life-threatening condition.

 Withholding medically indicated treatment: Failure to respond to the

infant's life-threatening conditions by providing treatment (including
appropriate nutrition, hydration, and medication) which, in the treating
physician's (or physicians') reasonable medical judgment, will most likely be
effective in ameliorating or correcting all such conditions.
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Withholding medical treatment is not neglect under three conditions:

The infant is chronically and irreversibly comatose. The provision of such

treatment would merely pro- long dying, not be effective in ameliorating or cor-
recting all of the infant's life-threatening conditions, or otherwise be futile in terms
of the survival of the infant.

- The provision of such treatment would be virtually futile in terms of the

survival of the infant and the treatment itself under such circumstances would be
inhumane.

Reasonable medical judgments: Medical judgment that would be made by a

reasonably prudent physician about the case and the treatment possibilities with
respect to the medical treatment involved.

However, the amendment has had minimal impact on medical and ethical decision
making, because the trend is toward aggressive treatment of nonlethal conditions
and the narrowing of parents' and physicians' discretion on treatment decisions (the
"best interest of the infant" standard).
To explain
ethical The Mother
aspects
One controversial legal and ethical issue surrounding the mother is whether
related to
pregnant women should be compelled by law to receive medical or surgical
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mother. treatment for benefit of the fetus.

Several cases of unusual circumstances have focused on these issues. In one case,
the ethical question revolved around the appropriateness of using life support
systems On the mother for a short period to improve substantially.

the outcome of the fetus. It has been noted that the use of the mother's body to serve
the interest of her fetus would be permissible if the mother had given prior consent
or signed an anatomic donation card. Without the mother's consent, permission
must be obtained from next of kin.Such cases inevitably create controversy and
conflicting opinions between relatives and the health- care providers. They raise
questions about the limits of benevolence, authority, and the right of the client to
bodily integrity. In the present climate, this opinion would not be held by the
majority of clients, health personnel. and ethicists.

To explain Midwife/Obstetrical Nurse's Responsibility What are

the the
responsibit The midwife/obstetrical nurse working in maternal and perinatal care have a responsibili
y of responsibility to the woman and fetus or newborn. An understanding of one's own ties of
obstretrical values and beliefs together with knowledge of the standards of care, scope of obstretical
nurse. practice, and legal regulations aids in effective decision making. nurses?
The obstetrical nurse has certain obligations to the woman. He or she must have the
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knowledge and expertise to use the equipment necessary for the woman's care,
particularly fetal monitors. He or she should be familiar with the guidelines for
monitoring developed by the National Council of Nurses and Midwives. The obstet
rical nurse must be proficient in reading the monitor accurately, making appropriate
notations, and reporting complications to the physician immediately. Monitoring
tapes should be appropriately stored, because often they are important evidence in
the event of a medical malpractice suit.

The importance of the obstetrical nurse recording promptly and accurately his or
her observations, treatments, procedures, medicines, and any other appropriate
information cannot be stressed enough. Many weak mal- practice cases come to
court because of errors or omissions in charting and recording.

Another important area of responsibility is to observe the newborn and mother

carefully after delivery and report and record any signs of a complication or prob
lem. Midwives/obstetrical nurses can be held liable in the event of maternal or
newborn complications. It is extremely important that they are knowledgeable
regarding their appropriate responsibilities and care.

To define STANDING ORDERS What are

standing standing
orders . Definition orders?
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Standing Orders are orders in which the nurse may act to carry out specific orders
for a patient who presents with symptoms or needs addressed in the standing
orders. They must be in written form and signed and dated by the Licensed
Independent Practitioner.

 The legislation sets out the powers and processes for receipt, investigation,
determination and resolution of complaints.

 Appropriate mechanisms must be in place to effectively manage issues of

competence, health and conduct. The mechanisms must ensure natural justice

 The detail in the legislation will depend on the judicial system and cultural
context in place in any country. Very prescriptive legislation may restrict the
development of a flexible and responsive midwifery workforce.

 The midwifery regulatory body has policy and processes to manage

complaints in relation to competence, conduct or health impairment in a timely
manner.

 • Complaint processes enable anyone to make a complaint about a midwife

(consumer/service user, other health professional, employer, another midwife
regulator can initiate a complaint).
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To explain List of standing orders What are

the list of the various
standing • The Expert Advisory Group Meeting held on 140.10.2004 as a follow up the standing
orders . meeting held on the 19th of July 2004 was to suggest recommendations on various orders r/t
issues which needed policy decisions related to the use of selected life saving drugs obstretrics?
and interventions in obstetric emergencies by Staff Nurses LHVS and ANMS.

⚫ Administration of Inj. Oxytocin and Misoprostol

It was decided that Tab. Misoprostol would be used as prophylaxis against PPH, in
all deliveries, as a part of active management of the third stage of labour.

Tab. Misoprostol should be given, sublingually or orally, 600mg (3 tablets of 200

mg each), immediately after the delivery of the baby.

If a woman bleeds for more than 10 minutes after deliver, she should be given 10U
Inj. Oxytocin preferably by the IV route (when the ANM is trained to give the
same).

 Administration of IV infusions to treat shock

It was universally felt that the administration of IV infusions was a life saving
procedure. As haemorrhage was the commonest cause of maternal mortality, the
administration of 3ml of fluid for every ml of blood lost could keep the woman
alive during the time it took to transport her to the nearest CHC/FRU where blood
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transfusion facility was available.

As of now, the ANMs are neither trained nor allowed by the regulatory authorities
to establish an IV line. After the discussion, it was decided that:If the ANM is
trained to give IV infusion, she should administer wherever feasible, even at home.

The ANM should start infusion with Ringer Lactate or Dextrose Saline.

If an IV infusion was being started incases of PPH, it was recommended the IV

fluid should be augmented with 20U of Oxytocin for every 500 ml bottle of fluid.
This could be continued throughout transportation.However, the logistics and
feasibility of the ANM be able to carry IV infusion sets and IV fluids to homes
need to explored, and ensured.

 Administration of Inj. Magnesium sulphate for prevention and management of

Eclampsia

Inj. MGSO4 is the drug of choice for controlling eclamptic fits.The first does
should be given by the ANM/staff nurse/Medical Officer at the PHC.The woman
should immediately be referred to a CHC/FRU and not a PHC. This is because in
these cases termination of pregnancy will be required, and a PHC may not be
equipped for the same.

This first dose should be given as a 50% solution (this preparation is available in
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the market). 8cc need to be given to make total dose of 4 gms.

 Removal of retained products of conception:

For incomplete abortion, if bleeding continues, the ANM and staff nurse can
perform only digital evacuation of products of conception. However the staff nurse
can use MVA under the supervision of the Medical Officer.

 Repair of vaginal and perineal tears:

• Scientific evidence proved that superficial tears do not require any repair, because
the outcome was the same whether or not such a tear was sutured. The ANM
should be able to recognize a superficial tear, and should be able to distinguish it
from deeper tears. She should simply apply pad and pressure on the tear.For second
and third degree tears which require repair, the ANM should refer the woman to a
higher facility.

 Manual removal of placenta (MRP):

MRP should be carried out only by the Medical Officer in a health facility
(PHC/CHC) setting.

• If the placenta was partially separated (as could be diagnosed by the presence of
vaginal bleeding), the ANM should try and see if a part of the placenta could be
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seen coming out from the os. Then she could assist the removal of the placenta.

• The ANM should be trained in the active management of the third stage of labour.

 Administration of antibiotics:

The indications for which antibiotic therapy is recommended are:

- Premature rupture of membranes

- Prolonged labour

- Anything requiring manual intervention

- UTI

• Puerperal sepsis. There should be instructions for the ANM that after starting the
woman on antibiotics, she should inform the PHC Medical Officer

 Administration of antihypertensive:

There was a universal consensus that only the Medical Officer should be allowed to
administer anti- hypertensives to a woman with hypertension in pregnancy.
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RESEARCH ARTICLE

Medico-legal aspects of abortion in Europe

JOURNAL:European Journal of Gynaecology and reproductive health

YEAR:2019 june

Objective: The practice of abortion in a particular country reflects culture,

economic status, religion and the law. Various aspects of abortion in Europe
- laws, rates and practices - are presented.

Results: Abortion is completely prohibited in Ireland and Malta. In Poland it

is permitted only to save the woman's life or protect her physical health. On
the grounds of protecting the woman's mental health it is also permitted in
Northern Ireland, Portugal, Spain and Switzerland. On socioeconomic
grounds abortion is permitted in Finland, Great Britain and Hungary. In the
other European countries it is permitted on demand. Eastern Europe has the
highest abortion rate (Romania 78/1000 women aged 15-44), and Western
Europe has the lowest (The Netherlands 6.5/1000); the disparity may be
attributable to differences in availability and use of effective contraceptives.
Within the first 12 weeks of gestation, vacuum aspiration has replaced
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dilatation and curettage, as the most commonly used method to perform

abortion. More recently, medical abortion (mifepristone with
prostaglandins) in early pregnancy has been used in several European
countries.

Conclusions: Reduction of the need for induced abortion and prevention of

unsafe abortion through the provision of appropriate legislation and good
family planning services should be an integral part of health care in every
country. SUMMARY

We discussed the
basic
defination,principles
of ethice,ethical
considerations prior
to conception,ethical
considerations related
to pregnacy,

abortions ,legality
and new rules and
regulations .
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CONCLUSION

Nurses working in
maternity and
perinatal care have
obligations to the
woman and the fetus
or newborn. A thor-
ough knowledge
base, careful
observation and
monitoring, and
accurate recording
and reporting are
essential.
BIBLIOGRAPHY

1. Raman AV, Maternity Nursing, Wolwer Kluwer, pg675-652

2. Sharma S,Textbook of midwifery and reproductive health nursing,CBS

Publishers,pg 568-573

3. Basavanthappa BT,Textbook of midwifery and reproductive health

nursing,jaypee brothers, pg 702-712
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4. May K A,Comprehensive Maternity Nursing,Lippincott Company,pg 345-

356

5. FIGO guidelines;(article reviewed on may.2023 ;from

www.figoguidelines.com)
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