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1. Medical and ethical issues in obstetrics
1. PRINCIPLES OF ETHICS
Beneficenceistoact in the bestinterestsof the patient,andtobalance benefitsagainstrisks.The
benefitsthatmedicine iscompetenttoseekforpatientsare the preventionandmanagementof
disease,injury,handicap,andunnecessarypainandsufferingandthe preventionof premature or
unnecessarydeath.
2. Autonomy 
Autonomymeanstorespectthe rightof the individual.Respectforautonomyentersthe clinical
practice by the informedconsent.Thisprocessusuallyunderstoodtohave 3elements,disclosure bythe
physiciantothe patient’sconditionanditsmanagement,understandingof thatinformationbythe
patientanda voluntarydecisionbythe patienttoauthorize orrefuse treatment.
3. Non maleficence 
It meansthat a healthpersonnel should preventcausingharmandisbestunderstoodasexpressingthe
limitsof beneficence.Thisiscommonlyknownas‘primumnonnocere’orfirstto do noharm.
4. Justice 
Justice signifies,totreatpatientsfairlyandwithoutunfairdiscrimination,there shouldbe fairnessinthe
distributionof benefitsandrisks.Medical needs,andmedical benefitsshouldbe properlyweighed.
5. Confidentiality 
Confidentialityisthe basisof trustbetweenhealthpersonnelandpatient.Byactingagainstthis
principle one destroysthe patienttrust.
6. PATIENT RIGHTS
The right to be treatedwithrespectanddignitywithoutreference age,marital,socio-economic,ethnic,
national,political,mental,physical orreligiousstatus. The rightto use informedchoice iscare, by
havingaccessto relevantinformationuponwhichdecisionsare based. The rightto freedomfrom
coercionindecisionmaking.
7. The rightto accept or to refuse treatment. The righttofull disclosure of financial factorsinvolvedin
hercare. The rightto knowwhowill participate inhercare and obtainadditional consultationof her
choice.
8. The rightnot to be abandoned,neglectedordischargedromcare withoutanopportunitytofind

2. otherhealthprovider. The righttoabsolute privacyexcept wherethisrightispre-emptedbylaw.
9. LEGAL AND ETHICAL PRINCIPLESIN THE PROVISION OF HEALTH SERVICES
. Informeddecisionmaking.Patientsorindividualswhorequire healthcare serviceshave righttomake
theirowndecisionaboutthe opinionsfortreatmentorotherrelatedissues.The processof obtaining
permissioniscalledinformedconsent.
10. The healthcare provider shoulddisclose the followingdetails:
The individual iscurrentlyassessedhealthstatusregardingthe general orreproductive health.
Reasonablyaccessible medical,social,andothermeansof response tothe individual’sconditions
includingpredictablesuccessrates,side effectsandrisks. The implicationsforthe individual’sgeneral,
sexual andreproductive healthandlifestyle declininganyof the optionsorsuggestions.The health
provider’sreasonedrecommendationforaparticulartreatmentoptionorsuggestion.
11. Autonomy: 
Autonomouspersonsare those who,intheirthoughts,work,andactions,are able tofollow norms
chosenof theirownwithoutexternal constraintsorcoercionbyothers.Itis to be notedthat autonomy
isnot respectforpatient’swishagainstgoodmedical judgement.Simplyput,ahealthprovidercan
refuse atreatmentoptionchosenbythe patient,if the optionisof nobenefittothe patient.
12. Surrogate decisionmakers: 
Surrogate decisionmakers[ parents,caregivers,guardians] maytake the decisionif the affected
individual’sabilitytomake a choice isdiminishedbyfactorssuchas extreme youth,mentalprocessing
difficulties,extrememedical illnessorlossof awareness.
13. 2. privacy and confidentiality
A patient’sfamily,friendorspiritual guidehas norightto medical informationregardingthe patient
unlessauthorizedbythe patients.The followingpointsof confidentialityare tobe keptin mind:health
care providersdutiestoprotectpatient’sinformationagainstunauthorizeddisclosures.Patient’srightto
knowwhattheirhealthcare providersthinkaboutthem.Healthcare provider’sdutiestoensure that
patientswhoauthorize releasesof theirconfidential healthrelatedinformationtoothers,exercise an
adequatelyinformedandfree choice.
14. 3. Competentdeliveryservices:
Everyindividual hasarightto receive treatmentbyacompetenthealthcare providerwhoknowsto
handle suchsituationsquite well.Accordingtothe laws,medical negligence isshownwhenthe
following4elementsare all establishedbyacomplainingparty.A legal dutyof care must be owedbya
providertothe complainingparty.
15. Breach of the establishedlegal dutyof care mustbe shown,whichmeansahealthcare providerhas

3. failedtomeetthe legallydetermined standardsof care. Damage mustbe shown.Causationmustbe
shown.
16. 4. Safetyand efficacy ofproducts:
Healthcare providersare responsilble foranyaccidental ordeliberate use of productsthatdiffersfrom
theirapprovedpurposesormethodsof use,forinstance,the dosage level fordrugs.Lookforthe drug
contraindications,drugexpiry,damage of dilutedsterilizationsolventsetc.
17. 5. Code ofethical midwiferypractice Midwivesrights:
The rightto refuse care to patientswithwhomnomidwife- patientrelationshiphasbeenestablished.
The right to discharge patientsfromheracre,providedadequateinformationfrompatientsuponwhich
caring isbased.The rightto receive honest,relevantinformationfrompatientsuponwhichcaringis
based.The rightt receive reasonablecompensationforservicesrendered.
18. Midwivesresponsibilities:
The obligationtoserve asthe guardianof normal birth,alertto possible complications,butalwayson
guard arbitraryinterference inthe birthingprocessforthe sake of convenience orthe desire touse
humanbeingsinscientificstudiesandtraining.The obligationtohonourthe confidence of those
encounteredinthe course of midwifeypractice andtoregardeverythingseenandheardasinviolable,
rememberingalwaysthatamidwife’shighestloyaltyisowedtoherpatientandnotto herhealthcare
providers.
19. The obligationtoprovide complete,accurate andrelevantinformationtopatientssothattheycan
make informedchoicesregardingtheirhealthcare. The obligation,whenreferringapatienttoanother
healthcare provider,istoremainresponsible forthe patientuntil she iseitherdischargedorformally
tranfered.
20. The obligationnevertocommentonanothermidwife’sorotherhealthprovider’scare withoutfirst
contactingthat practitionerpersonally. The responsibilitytodevelopandutilizeasafe andefficient
mechanismformedical consultation,collaborationandreferral.
21. The obligationtopursue professionaldevelopmentthrough ongoingevaluationof knowledge and
skillsandcontinuingeducationincludingdiligentstudyof all subjectsrelevanttomidwifery.The
responsibilitytoassistotherswhowishtobecome midwivesbyhonestlyandaccuratelyevaluatingtheir
potential andcompetence andsharingmidwiferyknowledgeandskillstothe extentpossible without
violatinganothersectioninthiscode.
22. The obligationtoknowandcomplywithall legal requirementsrelatedtomidwiferypractice within
the lawto provide forthe unobstructedpractice of midwiferywithinthe state.The responsibilityto
maintainaccountabilityforall midwiferycare deliveredunderhersupervision.Assignmentand
delegationof dutiestoothermidwivesorapprenticesshouldbe proportionate totheir educational
preparationanddemonstratedproficiency The obligationtoaccuratelydocumentthe patient’shistory,

4. condition,physical progressandothervital informationobtainedduringpatientcare
23. Unprofessionalconduct:
Knowinglyorconsistentlyfailingtoaccuratelydocumentapatient’scondition,responses,progressor
otherinformationobtainedduringcare.Thisincludesfailingtomake entries,destroyingentriesor
makingfalse entriesinthe recordspertainingtomidwiferycare.Performing orattemptingtoperform
midwiferytechniquesorproceduresinwhichthe midwife isuntrainedbyexperience oreducation.
24. Failingtogive care in a reasonable andprofessional manner,includingmaintainingapatientload,
whichdoesnotallowforpersonalizedcare bythe primaryattendant. Leavinga patientintrapartum
withoutprovidingadequate care forthe motherandinfant. Delegationof midwiferycare or
responsibilitiestoapersonwholacksabilityorknowledge toperformthe functionorresponsibilityin
question.
25. Manipulatingoraffectingapatient’sdecisionbywithholdingormisrepresentinginformationin
violationof patient’srighttomake informedchoicesintheirhealthcare.Failure toreporttothe
applicable state boardorthe appropriate authorityinthe association,withinareasonable time,the
occurrence of any violationof anylegal orprofessionalcode.
26. ETHICAL DECISIONSANDREPRODUCTIVEHEALTH OF WOMEN Ethicsingynaecologicpractice
Beneficence-basedandautonomy-basedclinical judgementsingynaecologicpractice are usuallyin
harmony,like managementof rupturedectopicpregnancy.Sometimestheymaycome intoconflicts.In
such situation,one shouldnotoverride the other.Theirdifferencesmustbe negotiatedinclinical
judgementandpractice todetermine whichmanagementstrategiesprotectandpromote the patient’s
interest.
27. Ethicsin obstetricpractice 
There are obviousbeneficence-basedandautonomybasedobligationtothe pregnantpatient.Whilethe
healthprofessional’sperspective onthe pregnantwoman’sinterestprovidesthe basisof beneficence
basedobligations,herownperspective onthose interstsprovidesthe basisforautonomy- based
obligations.Becauseof insufficiencydevelopedcentral nervoussystem, the fetuscannotmeaningfully
be saidto possessvaluesandonitsinterest.Therefore,there isnoautonomybasedobligationtothe
fetus.
28. Ethics andassistedreproduction:
It involvesmanyissueslikedonorinsemination,IVF,eggsharing,freezingandstoringof embryos,
embryoresearchandsurrogacy.still manyethical issuesare involvedinIVF.Firstthere isabigquestion
whetherthe invitroembryoisa patientornot. It isappropriate tothinkthat itis a pre- viable fetusand
onlythe womancan give itthe statusof a patient.Hence pre- implantationdiagnosticcounsellingis
non- directive andcounsellingabouthow manyembryostobe transferredshouldbe
29. Donor inseminationraisesthe issue whetherthe childshouldbe toldabouthisgeneticfatherornot.

5. Egg sharingis alsosurroundedbymanyethical issues.Ethicschangesfromtime totime keepingpace
withchangingsocial values,the surrogacyissue beingexample.Itwasconsideredunethical few years
back, nowinrecentissue of Indiatoday,a lengthyarticle hasappearedsupportingsurrogacywiththe
name of the center,the photosof the physicianandnumberof happysurrogate mothers.
30. Ultrsonography:
There are manyissuesinvolvedlike competence andreferral,disclosure,confidentialityandroutine
screening.The foremostissue isthatthe sonologistmustbe competentenoughtogive adefinitive
option.Nowroutine screeningisadoptedat18-20 weeks,butpriortoscreeningthe prenatal informed
consentforsonogrammust be taken.Strictconfidentialityshouldbe maintained.
31. Geneticsandethics: 
The processof geneticresearchraisesdifficultchallengesparticularlyinthe areaof consent,community
involvementandcommercialisation.Howeveritmustbe recognizedthatmanyof these issuesare not
unique togeneticsbutratherrepresentsvariationsandnew twistsonproblemsthatarise inothertypes
of research.Resultsof geneticresearchshouldbe providedtosubjectsonlyif the testshave sufficient
clinical validity.Resultsshouldneverbe disclosedtorelatives,exceptincase of pedigree research.
32. Policiesregardingdisclosure of testresultsshouldbe includedinthe informedconsentprocess.The
genomiceraposseschallengesforthe international communityandresearchenterprises.Council for
international organizationof medical sciences[CIOMS] guidelineshouldaddressthe ethical issuesof
genetics.The goal isto care andprotect greatestsourcesof humansufferingandpremature deathand
to relieve painandsufferingcausedbythe disorder.
33. Conceptionand the younggirl:
Sometimesteenaged girlsrequestfororal contraception.Theyare alreadyinanactive sexual
relationship.Theydonotwantthat theirparentsshouldknow aboutthemtakingcontraceptives.Lord
Fraser’sethical recommendationsinclude: We shouldassesswhetherthe patient understandsadvice.
34. We shouldencourage the parentinvolvement. We shouldtake intoaccountwhetherthe patientis
likelytosexual intercoursewithoutcontraceptive treatment. We shouldassesswhetherthe physical,
mental healthwouldlikelyto suffer,if contraceptiveadvice isnotgiven.
35. Embryonic stemcell research and ethics:
This involvesmanyethical issuesandfirstandfore mostis,itis destroyingalife bydestroyingthe
fertilizedembryo.Thisraisesthe fundamentalquestionof whenlife starts.Doeshumanlifebeginat
gastrulation[ nextstepafterblastula] ,atneurulation[ formationof aprimitivestreak,firstsignsof
movement] oratthe momentof sentience[consciousness]?Whencanembryofirstfeelpainorfirst
suffer?.The goal shouldbe minimize the exploitationof humanembryosatanystage of development.
36. The impact of law on ethics:

6. Ethics isinvolvedwithmoral judgements,andthe law,however,concernspublicpolicy.Atone levelit
defineswhatone can/ cannot or must/ mustnot doto avoidriskof legal penalty.Ethicsencompasses
much more than law.Ethicscan determine whatisrightinthe sense thatitis good.The intentionof law
isto define whatisrightinthe sense thatit isor isnot permitted.Itcanbe safelyconcludedthatnot
onlyisdeterminingthatsomethingisunethical,neitheranecessarynora sufficientreasontomake it
illegal,butalsodeterminingthatsomethingislawfuldoesnotnecessarilymake itethical.Inmany
occasionsthe lawassistclinical decision-makingbysettingparameterswhichhelpsboththe patientand
physician.
37. MEDICO-LEGALASPECTSOFOBSTETRICS REASONSFOR OBSTETRICLITIGATION Displeasure against
medical professionaldue to Lack of communicationPoorattitude or more sobecause of a poor
outcome are causative factorsfor litigation.
38. POTENTIALAREAS OF LITIGATION IN OBSTETRICS:
Antepartumcare:Historycollection:Recently,pre-conceptional care isstressedmore thanonly
antenatal care,speciallywhenviewed inthe contextof itseffectonpregnancy.Historytakingrightfrom
the age of the patientwithrelevantcomplaintsandrelevantpastandfamilyhistorywithspecial
reference tothe obstetrical historyisveryimportant.Onlyhistorycanbe a clue forfurtherdiagnosisand
managementof manycases.Avoidance of anyrelevantfactorscause maternal andfetal hazards.
39. Diagnosis Clinical diagnosisof earlypregnancymustbe confirmedbybiochemical andif necessary
by USG.
40. Investigations
One must notforgetto do routine check-uplikeHb,ABO,Rh,grouping,bloodsugar,HbsAg,VDRLand
HIV.HIV testingmustbe done onlyafterinformedconsent;otherwisethe patientmaysue the doctor.
Highrisk pregnanciesare onlypickedupbythroughhistorytaking,routine examinationsand
investigations.Highriskpatientsandfailure of timelyreferral createsmedicolegal problems.
41. Subsequentvisits:
Antenatal screeningforcongenital abnormalitiesInpatientshavinghistoryof congenital abnormal
babiesatleastbasicscreeningsare verynecessarytoavoidlitigations.The basicscreeningismostly
done byUSG. OtherexaminationslikeCVS,amniocentesisorsome biochemical investigationsmaybe
necessarydependingonthe individual case.Patient’scounsellingisverynecessaryregardingfalse
positive andnegativetesttherebyavoidinglegal problems.
42. Intrauterine growthretardationApartfromclinicalsuspicionof IUGRmoderngadgetslike
ultrasonography,CTGandultrasonicDopplerstudytodetectthe enddiastolicflow volume-are
important.Failure of timelydetectionof IUGRmay cause intrauterine fetaldeathandthe doctormay
have to the court for thisreason.
43. Multiple pregnancy

7. It isa highriskpregnancyinvolvingtwofetal lives.Management problemissucha case may cause fetal
complicationwhichwill invite legal problems.
44. Intrauterine fetal death 
The cause of IUFD mustbe explored.Asroutine autopsyinIndiaisnotperformedandunexplainedfetal
death;may impose problemsof medical litigation
45. Sex selectionandPNDTact Inviewof the fallingsex ratiothe Indiangovernmentpromulgated
Prenatal DiagnosticTechniqueActin1994. This testbythisact wasevolvedtoidentifygeneticand
congenital abnormalitiesinrelationtsex. Unfortunatelythistestwasmisused.Prenatal sex
determinationandselectivefemale feticide becamewidespreadalloverinIndiainspite of the
amendmentof PNDTact in2002, the amendedact prohibitsunnecessarysex determinationwithoutany
disease problemandaimsat preventingselective abortionsof female foetuses.However,stillunethical
practice of selectiveabortionsisgoingalloverIndia.
46. Intrapartum care 
Properintrapartummanagementduringlaborisessential forahealthymotherandahealthychild.In
majorityof the mothersthere isspontaneousonsetof labor.Injudiciousadministrationof oxytocicswas
the primaryreasondisciplinaryactionin33 percentof cases.Randomisedcontrolledtrial of EFMand
auscultationof fetal heartrate foundthatan increasedincidenceof caesareandeliveryanddecreased
neonatal seizuresinthe EFMgroupbut no effectoncerebral palsyorperinatal death.Newermethods
like pulse oximeterorfetal electrocardiogramanalysiscanpreventbirthasphyxiaand therebyminimize
litigations.
47. Caesareansection: 
With the adventof CPA;there isan increasedincidenceof caesareansection.The WHOglobal study
2005 revealedthathighrate of caesareansectiondoesnotcontribute toan improvedpregnancy
outcome,ratherisassociatedwithincreasedmaternalmorbidityandmortalitywithhigherincidenceof
newbornillnessdue tolowbirthweight. Delayeddecisionof CSmustbe avoidedasthismay leadto
undesirablesituationslike obstructedlaborcausingmaternal andfetal morbidityandmortality.
48. Difficultvaginal delivery:
ShoulderdystociaVariousclinical riskfactorslike diabetesleadingtobigbabyetc;must be identifiedto
predictandpreventthiscondtionandassociatedinjurieslike erb’spalsy.Butif we afce suchsituationsin
emergencyobstetriccare itmust be tackledbyexperiencedobstetricianotherwiselitigationproblem
are there.
. Perinatal morbidity Braindamage
Anyneurological andpsychological deficienciesis the majorlitigationissue where compensationsare
claimed.A healthprofessionalwill be suedif itcanbe provedinthe court that braindamage has

8. occurredduringintrapartumperioddue tonegligence of the healthprofessional.
Damage to bonesand viscera
This mayoccur speciallyduringbreechdelivery.Healthprofessional mustbe veryconsciousduringface,
legsandarm deliveryinbreech. Analgesiaandanaesthesia:Expertanaesthetistisrequired;toprevent
medical litigations.
. Drugs in pregnancyand lactation
Though onlya small groupof drugs are knowntobe harmful to the fetus;butit isa wise precautionto
avoidvastmajorityof drugs; if not genuinelyindicated,ie if there islessevidence of fetal safety.FDA
recommendationof drugshouldbe followed.The healthprofessional mustnotuse off- license drugs.If
damage occurs; he will be blamedof negligence whenalicensedalternative drugisused.
Ethical issuesin surrogacy: 
Surrogacy ispossible byAIDandIVF,where achildisborne in anothermother’swomb.A ladywithout
uterusbutfunctioningovariescanhave achildwiththe helpof a surrogate mother.Accordingto
fertilizationact1990, the carrying motheristhe motherinlaw.Geneticmothercan getlegal parenthood
by legal proceduresonly.Surrogacyforconvenience only;whenthe womenisphysicallycapable of
bearinga childisethicallyunacceptable.
HIV- positive womenand pregnancy In an overwhelmingnumberof cases,childrenof HIV positive
womenacquire the infectionbeforeoraroundthe time of birthor throughbreastmilk.The riskof
vertical transmissioncanbe potentiallyreducedtolessthan2% by the judicioususe of combinationanti
retro viral therapyduringpregnancyandlabour,deliverybycaesareansectionandavoidance of
breastfeeding.The legalstandardof care in prenatal care and childbirthisentitledtoanHIV positive
womenif she decidestocontinue the pregnancy.Neitherthe womannorherchildshouldsufferany
discriminationontheirHIV status.