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Manual of high risk pregnancy and delivery 5e samplechapter


The only book of its kind, Manual of High Risk Pregnancy & Delivery provides a complete resource for care of this special patient and her complex needs. It helps you provide positive outcomes with …

The only book of its kind, Manual of High Risk Pregnancy & Delivery provides a complete resource for care of this special patient and her complex needs. It helps you provide positive outcomes with coverage of today's newest technology, physiologic considerations, psychologic implications, health disorders, and other complications in pregnancy. Written by noted educator and practitioner Elizabeth Stepp Gilbert, RNC, MS, FNP-BC, CNS, this book also describes how to screen for risk factors, provide preventive management, and intervene appropriately when problems arise. It's a concise, hands-on reference for both inpatient and outpatient settings!

A consistent format makes this book a practical, hands-on reference in the clinical setting, presenting problems with the following headings: incidence, etiology, physiology, pathophysiology, and medical management.

• Comprehensive coverage includes physiologic considerations, fetal assessment, perinatal screening, ethical and legal issues, health disorders during pregnancy, complications, and labor and delivery issues.

• Up-to-date content includes integrative therapy, domestic violence, multiple gestation, genetics, nutrition, culture, risk management, and all the latest screening tools.

• A section on ethical and legal considerations covers ethical decision making, legal issues, and risk management. Updated evidence-based content includes the latest AHWONN standards of practice.

• Patient safety and risk management strategies include updated approaches to improving outcomes, reducing complications, and increasing patient safety during high risk pregnancy and delivery.

• New Venous Thromboembolic Disease chapter provides current information on this increasingly common condition.

• Information on the latest assessment and monitoring devices keeps you current with today's technology. Standardized terminology and definitions from the National Institute of Child Health & Human Development (NICHD) lead to accurate and precise communication.

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  • 1. FIFTH EDITIONElizabeth Stepp Gilbert, RNC-OB, MS, FNP-BC, CNS Director of Professional Practice Banner Thunderbird Medical Center Glendale, Arizona
  • 2. Manual of High Risk Pregnancy & Delivery, 5e Gilbert  MOSBY An imprint of Elsevier 11830, Westline Industrial Drive St. Louis, Missouri 63146  Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.  All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information retrieval system, without written permission from the publisher.  Original ISBN: 978‐0‐323‐07253‐3  This edition of Manual of High Risk Pregnancy & Delivery, 5e by Elizabeth Stepp Gilbert, RNC‐OB, MS, FNP‐BC, CNS is published by an arrangement with Elsevier Inc.  Indian Reprint ISBN: 978‐81‐312‐2837‐1  First Reprinted in India 2011    Restricted South Asia Edition    This edition is for sale in Bangladesh, Bhutan, India, Maldives, Nepal,   Pakistan and Sri Lanka only.   This edition is not authorized for export outside these territories.   Circulation of this edition outside these territories is unauthorized and illegal.     Notice   Medical  Knowledge  is  constantly  changing.  Standard  safety  precautions  must  be  followed,   but  as  new  research  and  clinical  experience  broaden  our  knowledge,  changes  in  treatment   and  drug  therapy  may  become  necessary  or  appropriate.  Readers  are  advised  to  check  the   most  current  product  information  provided  by  the  manufacturer  of  each  drug  to  be   administered,  to  verify  the  recommended  dose,  the  method  and  the  duration  of   administration,  and  the  contraindications.  It  is  the  responsibility  of  the  practitioner,  relying   on  their  own  experience  and  knowledge  of  the  patient,  to  determine  dosages  and  the  best   treatment  for  each  individual  patient.  Neither  the  Publisher  nor  the  Authors  assume  any   liability for any injury and/or damage to persons or property arising from this publication.      The Publisher    Published by Elsevier, a division of Reed Elsevier India Private Limited.  Registered Office: 622, Indraprakash Building, 21 Barakhamba Road, New Delhi‐110001. Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase‐II, Gurgaon‐122 002, Haryana, India.  Printed and bound in India at Rajkamal Electric Press, Kundli. 
  • 3. To my husband, Robert, and my son, Michael, who support me in all my professionaland personal endeavors
  • 4. ContributorsTiffany Kay Bennett, RNC-OB, Barbara Oxley, NMD, RN, BSN, MS-NL IBCLCRN Senior Manager DirectorLabor, Delivery, and Triage Bethany Ranch Health ClinicBanner Thunderbird Medical Center Phoenix, ArizonaGlendale, Arizona Sheryl Parfitt, MSN, RNCTeresa K. Buchda RNC-OB, MS-NL Clinical Educator, ObstetricsRN Director, Women and Infant Services Scottsdale HeathcareBanner Thunderbird Medical Center Scottsdale, ArizonaGlendale, Arizona Mary L. Sciuto, RN, MSDeborah L. Davis, PhD RN-Clinical Education SpecialistDevelopmental Psychologist and Writer Banner Good Samaritan Medical Center Author of Empty Cradle, Broken Heart Phoenix, ArizonaDenver, ColoradoTulsa, Oklahoma Christina Tussey, MSN, CNS, RNC-OB, RNC-MNSuzanne Helzer, RNC-OB, LCCE Women and Infants Clinical NurseBereavement Services/RTS Program Specialist Coordinator Banner Good Samaritan Medical CenterBanner Desert Medical Center Phoenix, ArizonaMesa, Arizona Amy Warengo, RN, MS-NLTerance L. Kranz, RNC-OB, MSN RN Senior ManagerClinical Education Specialist Antepartum and Maternal FetalBanner Del E. Webb Medical Center Medicine CenterSun City West, Arizona Banner Thunderbird Medical Center Glendale, ArizonaKaren M. Marshall, RNC–OB, MSN, CNSClinical Nurse SpecialistBanner Thunderbird Medical CenterGlendale, Arizonaiv
  • 5. Preface T oday’s technologic advances make it possible to offer the woman and her family, who are experiencing a high risk pregnancy and delivery, a good chance for a positive outcome. The evidence-based practicenursing and medical literature were the primary resources used in the writing ofthis manual such as the Cochrane Reviews, a database of systematic reviews, andevidence-based clinical guidelines such as Agency for Healthcare Research andQuality (AHRQ), National Guideline Clearinghouse (NGC), Institute for Clini-cal Systems Improvement (ICSI), and Society of Obstetricians and Gynaecologistsof Canada (SOGC) as well as references from professional organizations such asAWHONN and ACOG. As nurses, nurse practitioners, and nurse-midwives, weeach have a responsibility to keep our practices up-to-date and evidence-based.Nurses play a key role in ensuring that women and their fetuses receive the best pos-sible care. Perinatal nurses in all obstetric facilities must know about screening forrisk factors, they must provide preventive management using effective alternativeand complementary therapies, and appropriately intervene when complications de-velop. Unfortunately, many women do not receive adequate prenatal care and enterthe health care system only after complications occur. Because these women seekassistance from various types of facilities, nurses who practice in clinics, emergencyrooms, and primary care settings must also be alert to perinatal complications andbe prepared to provide immediate stabilizing care in ambulatory or other inpatientcare settings. Manual of High Risk Pregnancy & Delivery is designed as a practical referencemanual to provide comprehensive information in a concise, portable, and accessibleformat. Clearly written text and numerous tables and boxes enhance comprehen-sion and facilitate easy retrieval of information. The nursing process serves as theorganizational framework for discussions of both preventive and emergent care for awide range of topics. Nursing interventions are grounded in evidence-based practicerecommendations. The coverage of common medical and obstetric problems experienced duringchildbearing are presented in a layout style that includes incidence, etiology, physiology,pathophysiology, as well as the usual, expected, and intensive care managementprotocols for advanced nurse practitioners. Management and intervention protocolsare addressed with emphases on ambulatory care prevention and inpatient high-risk care with critical care protocols, as appropriate. Psychosocial implications andfamily considerations are incorporated throughout. A unique, contributed chapterdiscusses and emphasizes how advance practice nurses can access relevant alternativeand complementary therapies, which are evidence-based for high risk pregnancy anddelivery care. v
  • 6. vi Preface It is my conviction that with thorough, knowledgeable, and evidence-basedcare of the mother and fetus, neonatal morbidity and mortality can be considerablydecreased, and complications for the mother can be lessened. It is my intent andhope that this text will enable health care professionals to provide optimal care formother, fetus, and family from ambulatory, preventive, inpatient, and critical carearenas through the early postpartum period. Elizabeth Stepp Gilbert
  • 7. ContentsUNIT I PHYSIOLOGIC CONSIDERATIONS, ASSESSMENTS, AND INTEGRATIVE THERAPIES 1. Physiologic and Nutritional Adaptations to Pregnancy, 1 2. General Nursing Assessment of the High Risk Expectant Family, 25 3. Assessment of Fetal Well-Being, 43 4. Perinatal Screening, Diagnoses, and Fetal Therapies, 88 5. Integrative Therapies in Pregnancy and Childbirth, 107UNIT II PSYCHOLOGIC IMPLICATIONS OF A HIGH RISK PREGNANCY 6. Psychologic Adaptations, 128 7. Perinatal Death and Bereavement Care, 149UNIT III ETHICAL DILEMMAS AND LEGAL CONSIDERATIONS IN PERINATAL NURSING 8. Ethical Decision Making, 170 9. Legal Issues and Risk Management, 181UNIT IV HEALTH DISORDERS COMPLICATING PREGNANCY 10. Diabetes, 200 11. Cardiac Disease, 243 12. Renal Disease, 258 13. Autoimmune Rheumatic Diseases, 271 14. Venous Thromboembolic Disease, 282 15. Pulmonary Disease and Respiratory Distress, 289UNIT V COMPLICATIONS IN PREGNANCY 16. Spontaneous Abortion, 311 17. Ectopic Pregnancy, 331 18. Gestational Trophoblastic Disease, 351 19. Placental Abnormalities, 364 20. Disseminated Intravascular Coagulation, 395 21. Hemolytic Incompatibility, 402 vii
  • 8. viii Contents 22. Hypertensive Disorders, 416 23. Preterm Labor and Multiple Gestation, 460 24. Premature Rupture of Membranes, 488 25. Trauma, 500UNIT VI TERATOGENS AND SOCIAL ISSUES COMPLICATING PREGNANCY 26. Sexually and Nonsexually Transmitted Genitourinary Infections, 519 27. Substance Abuse, 558UNIT VII ALTERATIONS IN THE MECHANISM OF LABOR 28. Labor Stimulation, 582 29. Dysfunctional Labor, 610 30. Prolonged Pregnancy, 660 Index, 671
  • 9. U N I T TH R E E ETHICAL DILEMMAS AND LEGAL CONSIDERATIONS IN PERINATAL NURSING 8 Ethical Decision Making P erinatal nurses are confronted daily with ethical dilemmas. This chapter examines the nature of values clarification, introduces a framework for ethics, provides a model for ethical decision making, outlines the indi-vidual nurse’s responsibility for participation and involvement, and lists the relevantclinical perinatal examples that commonly confront the perinatal nurse.VALUES CLARIFICATIONEducators, psychologists, anthropologists, sociologists, and theologians have influ-enced the definition of values. They consider values to be attitudes, beliefs, and moraljudgments that are chosen freely and thoughtfully and are prized and acted on(Albert and others, 2006; Beauchamp and Childress, 2008).Process of ValuingThe process of valuing has three aspects: choosing, prizing, and acting. ChoosingChoosing involves the cognitive component of valuing. Logical, critical, creativethinking and moral judgment development are included. Important elements ofchoosing include the following: • Choosing freely • Choosing from available alternatives • Choosing after considering the consequences of each alternative • Complements other values previously internalized PrizingPrizing involves the affective component. This feeling component of valuing includesthe following aspects (Beauchamp and Childress, 2008): • Being aware of one’s position on the matter • Expressing one’s value170
  • 10. CHAPTER 8 : Ethical Decision Making 171 • Experiencing positive self-esteem as a result of the expression of the value • Communicating and sending clear messages about the value • Empathetic listening • Feeling pride and happiness with the choice ActingActing involves the behavioral component and results in the following (Beauchampand Childress, 2008): • Personal, professional, and academic competence • Conflict resolution • Willingness to affirm the choice publicly • Assimilation of the choice as part of personal behavior • Consistent repetition of the choiceMORAL JUDGMENT DEVELOPMENTThe moral judgment development theory complements valuing. Kohlberg (1981)contributed to the study of moral development by expanding on the work of Piagetand describing six stages of moral development.Stages Preconventional LevelThe child at the preconventional level is responsive to cultural rules and labels of goodand bad, right and wrong. These labels are considered by the child in the context ofpunishment, reward, or exchange of favors. This level is divided into two stages. Stage 1Stage 1 is the stage of punishment and obedience. Avoidance of punishment anddeference to power are ends in themselves. The physical consequences of an actiondetermine whether it is good or bad. For example, the reason for doing right is toavoid punishment from those with more power. Stage 2Stage 2 is the stage of instrumental purpose and exchange. Right action is that whichpragmatically satisfies one’s own needs and occasionally the needs of others. Right isfollowing the rules because it is in the immediate interest. Right is also what is fair,equal, a deal, or an agreement. Reciprocity is given for the actual reward rather thanout of loyalty or gratitude. Conventional LevelAt the conventional level of moral judgment development, the person considers theexpectations of others and conformity as valuable in their own right, regardless of theimmediate consequences. There is an attitude of not only conformity but also activemaintenance, support, and justification of the order. Stages 3 and 4 are at this level. Stage 3Stage 3 is the stage of mutual interpersonal expectations, relationships, and conform-ity. Good behavior is that which pleases and helps others and is approved by them.
  • 11. 172 UNIT III : Ethical Dilemmas and Legal Considerations in Perinatal NursingConformity to stereotypes is common. Behavior is frequently judged by intention,as in meaning well. Right behavior is being nice and living up to what is expected. Stage 4Stage 4 is the stage of social system and conscience maintenance. Right action isdoing one’s duty in a group, showing respect for authority, and upholding the pre-scribed social order for its own sake. Orientation is toward authority, fixed rules, andmaintenance of the social order. Postconventional LevelThe postconventional level is also called the autonomous or principled level. The indi-vidual attempts to define moral values and principles that have validity and applica-tion apart from the authority of society and the individual’s identity with societalgroups. There are two stages at this level. Stage 5Stage 5 is the stage of ‘a priori’ rights and social contract or utility. This stage has utili-tarian overtones. Right action is defined in terms of standards that have been agreedon by society in terms of individual rights. Right action is described as upholdingbasic rights, values, and legal contracts of society even when they conflict with con-crete rules and laws of the group. Awareness of relativism of personal values and opinions exists, with an emphasis onreaching consensus. Right action is also a matter of personal values aside from what isconstitutionally agreed on. There is an emphasis on the legal point of view, with the possi-bility of changing law in terms of rational consideration of societal utility (Douglas, 2001). Stage 6Stage 6 is the stage of universal ethical principles. Right action is defined by a deci-sion of conscience in accord with self-chosen ethical principles. Specific laws usuallyrest on these principles. When, however, laws violate these principles, acts must be inaccord with principles rather than law. Principles are abstract, ethical, and universal,such as the principles of justice, reciprocity, equality, and respect for human dignity.QualitiesIn addition to the six stages of moral development, Kohlberg (1981) described sixqualities of the stages of moral development: • The development of morality proceeds in an invariant sequence as the individual matures and as the environment offers the necessary stimulation and opportuni- ties to learn. • Subjects cannot comprehend moral reasoning at a level more than one stage beyond their development. • Subjects are cognitively attracted to reasoning one level above their own pre- dominant level. • Movement through stages is effected when cognitive disequilibrium is created by conflicting values. • Although the time it takes to move through the stages varies, the sequence is always the same. • Movement to higher stages of moral development is advantageous for the indi- vidual and society.
  • 12. CHAPTER 8 : Ethical Decision Making 173FRAMEWORK FOR ETHICSDefinitions EthicsEthics is the study of values in human conduct or the study of right conduct. Itis a branch of philosophy that attempts to state and evaluate principles by whichethical dilemmas may be resolved. It is not a science with right or wrong answersbut rather a systematic, critical, rational, defensible, intellectual approach to deter-mining what is best in a situation with conflicting values. The result will ultimatelybe unfavorable and pit one or more ethical principles against another (Albert andothers, 2006). MetaethicsMetaethics is the part of ethics that focuses on the extent to which ethical judgmentsare reasonable or justifiable. Normative EthicsNormative ethics is the part of ethics that raises questions about what is right orought to be done in a situation that calls for an ethical decision. Ethical PrinciplesSeveral basic principles help to identify values, morals, beliefs, and attitudes and toclarify ethical dilemmas (Table 8-1). Ethical principles comprise the sixth stage ofKohlberg’s (1981) moral development. The characteristics of ethical principles follow: • They suggest direction or propose certain behaviors. • They serve as guides to organizing and understanding ethically relevant infor- mation in an ethical dilemma. • They propose how to resolve competing claims. • They are the reasons justifying moral actions. • They are universal in nature. They are not absolute; they do have exceptions. • They are neither rules (means) nor values (ends). • They are unchangeable and discovered by human beings rather than invented.MODEL FOR ETHICAL DECISION MAKINGCharacteristics of Ethical DilemmasWe live in an era in which technologies develop faster than we can consider conse-quences. Changes affect clinical practice before guidelines for use are developed andbefore the social and ethical impact can be considered. Recent technologic advancesin endocrinology, genetics, reproductive therapy, neonatal and maternal-fetal medicalcare, and fetal therapy have created numerous ethical dilemmas for the recipient ofcare and the caregiver. These dilemmas and the resultant decisions have a consider-able impact on society. The characteristics of an ethical dilemma follow (Albert and others, 2006): • The choice is between equally undesirable alternatives. • Real choices exist between possible courses of action.
  • 13. 174 UNIT III : Ethical Dilemmas and Legal Considerations in Perinatal NursingTable 8-1 Definitions of Ethical Principles Ethical Principle Definition Autonomy Being one’s own person without constraints by another’s action or psychologic and physical limitations Beneficence Duty to do good Confidentiality Holding information entrusted in context of special relationships as private Fidelity Duty to keep one’s promise or word Finality May override demands of law and custom Generality Must not refer to specific people or situations Informed consent Contains four elements: Disclosure of sufficient information Comprehension Voluntary agreement Competency to make decision Justice Equitable distribution of risks and benefits Nonmaleficence Duty to do no harm Ordering Ethical principles must be prioritized even though they may be conflicting Publicity Principles must be known and recognized by all Reparation Duty to make up for a wrong Universality Same principle must hold for everyone, regardless of time, place, or people involved Utility Greatest good or least harm for the greatest number Veracity Duty to tell the truth • The people involved place a significantly different value judgment on possible actions or the consequences. • Data alone do not help to resolve the dilemma. • “Answers” to the dilemma come from a number of different disciplines, such as psychology, sociology, and theology. • Actions taken in an ethical dilemma result in unfavorable outcomes or consti- tute a breach of one’s duty to another individual. • The choices made in an ethical dilemma have far-reaching effects on our percep- tion of human beings and our definition of personhood, our relationships, and people and society as a whole. • Any ethical decision involves the allocation and expenditure of resources that are finite. • Ethical dilemmas are not solvable but rather resolvable. • There is no right or wrong when dealing with two equally unfavorable actions.Theories in EthicsTwo classic schools of thought—teleology and deontology—dominate ethical theory(Follin, 2004).
  • 14. CHAPTER 8 : Ethical Decision Making 175 TeleologyAccording to the theory of teleology, the rightness or wrongness of an action isdetermined by the consequences, not by whether it is inherently right or wrong. Thisapproach to decision making is risk-to-benefit-based. It is also called utilitarianismor consequentialism. DeontologyThe theory of deontology holds that the inherent characteristics of the decision canbe judged independent of its outcome or consequences. Duty-based or rights-basedapproaches are examples of deontologic thoughts. Moral RelativismA pure application of either teleology or deontology may not be useful. Aspects ofboth theories are usually combined when making ethical decisions blended withmoral relativism. Moral relativism adds the notion of personal interpretation. Theapplication of paradigm cases, anecdotal experiences, and ethical principles to clinicalproblems exemplifies relativism. The root principles of ethical theory are beneficence, justice, and autonomy (seeTable 8-1). Decision making is always colored by the individual’s values, attitudes,knowledge, desires, cultural mores, experiences, and background (Beauchamp andChildress, 2008).Steps in Decision MakingThe steps in ethical decision making are described in Box 8-1.Nursing ResponsibilityThe concepts central to nurses’ responsibility in participation in ethical decisionmaking are caring, coordination, and advocacy. These concepts are based on theunique relationship between the nurse and the patient. Clinical ethics, existingaside from medical ethics, incorporates the ethical problems the nurse encoun-ters in the independent and collaborative domains of practice. Nursing is ownedby society and as such is an essential part of society with a responsibility to thewhole. CaringCaring, described by Swanson (1993), provides the first mandate for nurses’ partici-pation in and assumption of ethical practice. The second mandate is derived from thesocial contract and the American Nurses Association (ANA) code for nurses (Box8-2). The third mandate for participation in ethical decision making is the pivotalposition of nursing within the health care organization. Professional nursing practiceis ethical nursing practice. Conscience ClausesNurses are occasionally placed in situations where physician orders or patientrequests may conflict with their own professional ethic and moral codes. Conscience
  • 15. 176 UNIT III : Ethical Dilemmas and Legal Considerations in Perinatal Nursing Box 8-1 Steps in Ethical Decision Making Identify the Problem • Who are the people involved? • How are they interrelated? • What is involved? Identify the Values, Issues, or Ethical Dilemmas, and Make a Concise Statement of the Problem and Conflicts in Values • State your values and ethical position related to the case. • Generate alternatives for resolving the dilemma or dilemmas. Examine and Categorize the Alternatives • List alternatives. • Identify those consistent and those inconsistent with your own values and ethics. Predict the Possible Consequences for Those Acceptable Alternatives • Identify physical, psychologic, social, spiritual, and short- and long-range consequences. • Identify those consequences consistent with your values and ethics. Prioritize Acceptable Alternatives • Develop a plan of action. • Implement the plan. • Evaluate the action taken.clauses are statutory provisions that allow healthcare personnel or institutionsthe right to refuse provision of medical care because of religious or moral beliefs.Unfortunately, many of these clauses do not take into consideration the respon-sibilities of healthcare providers to the general public or their own colleagues.Because of this, professional organizations such as the ANA and the Associationof Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) have publishedposition statements which support patients’ rights to information and treatmentthat they may require or ask for, while taking into consideration a nurse’s personalcode of ethics. Obstetrical units may wish to research policies within their owninstitutions, provide open discussions regarding conscience clauses, and developwritten guidelines which will protect nurses, support staff, and patients (Tillett,2008).PATIENT SELF-DETERMINATION ACTA federal law, the Patient Self-Determination Act, went into effect in December1991 for all health care facilities receiving federal monies. This act requiresthat all patients be informed of their rights to make decisions concerning theirhealth care.
  • 16. CHAPTER 8 : Ethical Decision Making 177 Box 8-2 American Nurses Association Code of Ethics • The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual unrestricted by consideration of social or economic status, personal attributes, or nature of the health problems. • The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. • The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. • The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum care. • The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. • The nurse participates in establishing, maintaining health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. • The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. • The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. • The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.From American Nurses Association: Code of ethics for nurses with interpretive statements, Silver Springs,MD, 2001, American Nurses Publishing. Retrieved from DIRECTIVEAn advance directive, also known as a living will or a durable power of attorney,recognizes the patient’s right to control decisions relating to acceptance or refusal ofaspects of his or her own medical care. When the patient has decision-making capac-ity, that control can be exercised by formulating an advance directive. If the patient loses decision-making capacity, a durable power of attorney canappoint another person to make those decisions. A living will can direct the physicianto provide, withhold, or withdraw life-sustaining care. In the case of a pregnant woman, however, the advance directive does not allowher to make decisions in advance that may affect fetal survival or quality of life. Forexample, if a pregnant woman is involved in a motor vehicle accident and sustains ahead injury that permanently affects her cardiorespiratory center, she may be kept onlife-sustaining care despite instructions in her living will to the contrary. If sustainingher on life support can successfully maintain the pregnancy, which shows no evidenceof fetal compromise, her living will requesting no life support will be disregarded. In
  • 17. 178 UNIT III : Ethical Dilemmas and Legal Considerations in Perinatal Nursingsuch situations it has been determined that postponement of maternal death doesless harm to her when balanced against the fetal right to survive.ETHICS COMMITTEEMost tertiary institutions have a review board or ethics committee in place for situa-tions in which individuals/families need assistance in dealing with difficult decisionsregarding what is right or fair care or when ethical decisions collide with legal andmoral obligations of the institution. These committees are usually multidisciplinaryand composed of physicians and nurses from the various settings where many of thedilemmas arise, along with allied health care professionals such as an administrator, amember of the clergy, a social services representative, an attorney or risk managementrepresentative, and an ethicist (who actually may be one of the professionals previ-ously listed) (Beauchamp and Childress, 2008). A layperson may be asked to serveon the committee as well. In the beginning of the formation of a board, there are usually some require-ments for the prospective members to receive formalized education in the processof ethical decision making. There typically is also some time set aside to educate themembers and for them to become accustomed as a group to the processes they willfollow. The main functions of the committee are: • To develop and revise ethical policies and procedures such as informed consent, confidentiality, and advance directives • To assist with difficult ethical decisions related to health careIt is recommended that there be a process in place for handling emergency situationsand specified people who must serve on the board to make decisions. The familyshould always be invited to provide input and to attend some part of the session whenpossible and when desired.CLINICAL EXAMPLES OF ETHICAL DILEMMASSome clinical examples of ethical dilemmas that perinatal nurses face are listed inBox 8-3.CONCLUSIONThe list of perinatal ethical decisions is much longer than that given in Box 8-3. Somedilemmas are everyday issues. Others are likely to be encountered infrequently and thenonly in select tertiary perinatal centers. However, it is impossible to work in perinatalnursing and not become involved in ethical dilemmas or participate in ethical decisionmaking. The nurse must not only examine issues in light of the level of participationshe or he is willing to have but also facilitate an environment in which colleaguesand patients can participate in ethical decisions. The nurse functions as educator, sup-port person, counselor, administrator, researcher, and care provider. Nurses spend moretime with patients than any other health care team members do. As a result, nursesmust take an active and assertive role in the development of ethical guidelines for areasof perinatal practice (Follin, 2004; Beauchamp and Childress, 2008).
  • 18. CHAPTER 8 : Ethical Decision Making 179 Box 8-3 Clinical Examples of Perinatal Ethical Dilemmas • Voluntary pregnancy termination • Second trimester abortions • Selective reduction in multiple gestation • Emergency contraception • Previable termination of pregnancy for maternal reasons • Termination of pregnancy by telemedicine (Lupton, 2008) • Harvesting of fetal organs or tissue • In vitro fertilization and decisions for disposal of remaining fertilized ova • In vitro fertilization with multiple eggs • In vitro fertilization in mothers with advanced maternal age • Allocation of resources in pregnancies complicated by substance abuse and other antisocial behaviors • Allocation of resources in pregnancy care during previable period • Fetal surgery • Treatment of genetic disorders or fetal abnormalities found on prenatal screening • Routine use of electronic fetal monitoring (EFM) for cesarean delivery indication in cases of previous cesarean delivery • Routine use of electronic fetal monitoring (EFM) on low-risk intrapartum patients • Equal access to prenatal care • Health care rights • Maternal rights versus fetal rights • Extraordinary medical treatment for pregnancy complications • Court-ordered cesarean section • Using organs from an anencephalic infant • Genetic engineering/gender selection • Cloning • Surrogate motherhood • Mandatory drug testing • Sanctity of life versus quality of life for extremely premature or severely disabled infantBIBLIOGRAPHYAlbert R and others: Clinical ethics: a practical approach to ethical decisions in clinical medicine, ed 6, New York, 2006, McGraw-Hill.American College of Obstetricians and Gynecologists: Position statement: ethical decision making in obstetrics and gynecology, Washington, DC, 2007, ACOG.American College of Obstetricians and Gynecologists: Position statement: the limits of conscientious refusal in reproductive medicine, Washington, DC, 2007, ACOG.American College of Obstetricians and Gynecologists: Position statement: surgery and patient choice, Washington, DC, 2008, ACOG.American Nurses Association: Code of ethics for nurses with interpretive statements, Silver Springs, MD, 2001, American Nurses Publishing. Retrieved from MenuCategories/EthicsStandards/CodeofEthicsforNurses.aspx.Association of Women’s Health, Obstetric, and Neonatal Nurses: Position statement: access to health care issues, Washington, DC, 2005, AWHONN.
  • 19. 180 UNIT III : Ethical Dilemmas and Legal Considerations in Perinatal NursingAssociation of Women’s Health, Obstetric, and Neonatal Nurses: Position statement: role of the registered nurse in support of patients as related to genetic testing, Washington, DC, 1998, AWHONN.Association of Women’s Health, Obstetric, and Neonatal Nurses: Position statement: nurses’ rights and responsibilities related to abortion and sterilization, Washington, DC, 1999, AWHONN.Association of Women’s Health, Obstetric, and Neonatal Nurses: Position statement: fetal assessment, Washington, DC, 2000a, AWHONN.Association of Women’s Health, Obstetric, and Neonatal Nurses: Position statement: pregnancy discrimination act, Washington, DC, 2000b, AWHONN.Beauchamp T, Childress T: Principles of biomedical ethics, ed 6, New York, 2008, Oxford University Press.Bendikson K, Racowsky C: Gender selection, UpToDate, 2008. Retrieved from V: The ethics of cesarean section on maternal request: a feminist critique of the American College of Obstetricians and Gynecologists’ position on patient-choice surgery, Bioethics 21(9):478–487, 2007.Douglas M: Ethics in nursing practice. In Brent N, editor: Nurses and the law: a guide to principles and applications, ed 2, Philadelphia, 2001, Saunders.Follin S, editor: Nurse’s legal handbook, ed 5, Philadelphia, 2004, Lippincott Williams & Wilkins.Kalish RB, McCullough LB, Chervenak FA: Patient choice cesarean delivery: ethical issues, Curr Opin Obstet Gynecol 20(2):116–119, 2008.Kohlberg L: Essays on moral development. Vol I, The philosophy of moral development; Vol II, The psychology of moral development: moral stages the life cycle; Vol III, Education and moral development: moral stages and practice, San Francisco, 1981, Harper & Row.Lupton M: Termination of pregnancy by telemedicine: an ethicist’s viewpoint, Br J Obstet Gynecol 115:1071–1073, 2008.Swanson K: Nursing as informed caring for the well-being of others, Image J Nurs Sch 25(4):352–357, 1993.Tillett J: “Conscience” clauses: the rights and responsibilities of a nurse, J Perinatal Neonatal Nurs 22(3):179–180, 2008.