Ethical and legal aspects in midwifery

2. Definition
Ethics it is the principle
conduct governing one
relationship with others
they are the basic value
the govern right from
wrong
Laws are rules of conduct
or action recognised as
binding or enforced by
controlling authority

3. Ethical
principle
• Beneficence it means to acts in the best interest of the patient and balance
benefit against risk
• Respect for autonomy it means to respect individual rights
• Non maleficence it means health professional should prevent causing
harm
• Justice signifies to treat patients fairly and without unfair discrimination.
• Confidentiality it is the basis of trust between health professional and
patient
• Informed consent the process of obtaining permission after explaining
the expected risk and benefit
• Truthfulness the fact of being realistic or true to life

4. Code of ethics for nurses in India
 The nurse respect the uniqueness of the individual in the provision of
care
A nurse
• Provides care of individuals without consideration of caste, creed
religion, culture, ethnicity gender etc.
• Individualize the care considering the belief, values and cultural
sensitivity
• Appreciates the place of individual in the family and community
• Develops and promotes trustful relationship with individual
• Recognizes uniqueness of response of individual to interventions and
adapt accordingly

5. The nurse respects the rights of individuals as partner in care and help
in making informed choices –
Nurse
 Appreciates individual’s right to make decisions about their
care and therefore gives adequate and accurate information for
enabling them to make informed choices
 Respects the decisions made by individual(s) regarding their
care
 Protects public from misinformation and misinterpretations
 Advocates special provision to protect vulnerable
individuals/groups.

6. The nurse respects individual’s right to privacy, maintains
confidentiality, and shares information judiciously-
Nurse
 Respects the individual’s right to privacy of their personal information
 Maintains confidentiality of privileged information except in life
threatening situations and uses discretion in sharing information.
 Takes informed consent and maintains anonymity when information is
required for quality assurance/ academic/legal reasons
 Limits the access to all personal records written and computerized to
authorized persons only.

7. Nurse maintains competence in order to render Quality Nursing Care
• Nursing care must be provided only by registered nurse
• Nurse strives to maintain quality nursing care and upholds the standards of care
• Nurse values continuing education, initiates and utilizes all opportunities for self
development.
• Nurses values research as a means of development of nursing profession and
participates in nursing research adhering to ethical principles.

8. The nurse if obliged to practice within the framework of ethical, professional and
legal boundaries-
Nurse
• Adheres to code of ethics and code of professional conduct for nurses in India
developed by Indian Nursing Council
• Familiarizes with relevant laws and practices in accordance with the law of the
state
Nurse is obliged to work harmoniously with members of the health team –
Nurse
• Appreciates the team efforts in rendering care
• Cooperates, coordinates and collaborates with members of the health team to
meet the needs of people

9. Nurse commits to reciprocate the trust invested in nursing profession by
society
Nurse
• Demonstrates personal etiquettes in all dealings
• Demonstrates professional attributes in all dealings

10. Code of Professional Conduct for Nurses in India
Professional Responsibility and accountability –
Nurse
 Appreciates sense of self-worth and nurtures it
 Maintains standards of personal conduct reflecting credit upon the profession
 Carries out responsibilities within the framework of the professional boundaries
 Is accountable for maintaining practice standards set by Indian Nursing Council
 Is accountable for own decisions and actions
 Is compassionate
 Is responsible for continuous improvement of current practices
 Provides adequate information to individuals that allows them informed choices

11. Nursing Practice –
Nurse
• Provides care in accordance with set standards of practice
• Treats all individuals and families with human dignity in providing physical, psychological,
emotional, social and spiritual aspects of care
• Respects individuals and families in the context of traditional and cultural practices, promoting
healthy practices and discouraging harmful practices
• Presents realistic picture truthfully in all situations for facilitating autonomous decision-making by
individuals and families
• Promotes participation of individuals and significant others in the care
• Ensures safe practice
• Consults, coordinates, collaborates and follows up appropriately when individuals’ care needs
exceed the nurse’s competence

12. Communication and Interpersonal Relationships
-Nurse
• Establishes and maintains effective interpersonal relationships with individuals, families and
communities
• Upholds the dignity of team members and maintains effective interpersonal relationship with them
• Appreciates and nurtures professional role of team members
• Cooperates with other health professional to meet the needs of the individuals, families and
communities

13. Valuing Human Being
- Nurse
• Takes appropriate action to protect individuals from harmful unethical practice
• Considers relevant facts while taking conscience decisions in the best interest of individuals
• Encourages and supports individuals in their right to speak for themselves on issues affecting
their health and welfare
• Respects and supports choices made by individuals

14. Management –
Nurse
• Ensures appropriate allocation and utilization of available resources
• Participates in supervision and education of students and other formal care providers
• Uses judgment in relation to individual competence while accepting and delegating responsibility
• Facilitates conductive work culture in order to achieve institutional objectives
• Communicates effectively following appropriate channels of communication
• Participates in performance appraisal
• Participates in evaluation of nursing services
• Participates in policy decisions, following the principle of equity and accessibility of services
• Works with individuals to identify their needs and sensitizes policy makers and funding agencies
for resource allocation

15. Professional Advancement
-Nurse
• Ensures the protection of the human rights while pursuing the advancement of knowledge
• Contributes to the development of nursing practice Participates in determining and implementing quality
care
• Takes responsibility for updating own knowledge and competencies
• Contributes to core of professional knowledge by
• conducting and participating in research

16. Ethical decision and reproductive health
of women
• Ethics in gynecologic practice
• Ethics in obstetric
• Ethics and assisted reproduction
• Ultrasonography
• Genetics and ethics
• conception and young girl
• Embryonic stem cell research and ethics

17. Ethics in gynecologic practice
• beneficence-based and autonomy based-clinical judgement
• Sometimes they come in conflict.
• In such situations one should override the other
• Their difference should be negotiated in clinical judgement and practice
Ethics in obstetric
• beneficence-based and autonomy based-clinical judgement
• The health professional perspective on pregnant women interest provides the basis of
beneficence based obligation
• While the mother perspective of interests provides basis for autonomy based
obligation

18. Ethics and assisted reproduction
 It involve issues like donor insemination
 invitro fertilization, egg sharing and storing of embryos, embryo research and
surrogacy
 Donor insemination raises the issues whether the child should be told about his
genetic father or not.
 Egg sharing is also surrounded by many ethical issues.

19. Ultrasonography
• First issues is the sonologist must be competent enough
• Prenatal consent should be taken
• Strict confidentiality should be maintained
Genetics and ethics
• Result of genetic research should be provided to subject only
• Result should never be disclosed to relatives excepts in pedigree research

20. Conception and young girl
• Teenaged girl asking for contraceptives
• They don’t want their parent to know that they r taking contraceptives
Lord Fraser's ethical recommendations include
Assess whether the patients understands advice
Encourage the parent involvement
Take into account whether the patient is likely to have intercourse without
contraceptives treatment
Assess whether the physical and mental health would likely to suffer if
contraceptive advice is given or not

21. Embryonic stem cell research and ethics
• This involve many ethical issues and first and foremost is destroying life by
destroying fertilized embryo
• It raises the question when life starts
• The goal should be minimized the exploitation of human embryo at any stage of
development

22. POTENTIAL AREAS OF LITIGATION IN OBSTETRICS
Antepartum Care
•History collection:
• Recently, preconceptual care is stressed more than antenatal care, especially
when in the context of its effect on pregnancy.
• Proper history taking can be a clue for further diagnosis and management of
many cases
• Avoidance of any relevant factors can cause maternal and fetal hazards.

23. Investigations:
• One must not forget to do routine check-up, like hemoglobin, ABO, Rh
grouping, blood sugar, hepatitis B urus surface antigen (HbsAg), venereal
disease research laboratory (VDRL) and human immunodeficiency virus
(HIV).
• The HIV testing must be done only after informed consent; otherwise the
patient may sue the doctor.
• High-risk pregnancies are only picked up by thorough history taking, routine
examinations and investigations.
• High risk patients and failure of timely referral create medicolegal issues.

24. Subsequent visits:
 Antenatal screening for congenital abnormalities:
• In patients having history of congenital abnormal babies at least basic
screening is very necessary to avoid litigations.
• Other examinations like chorionic villus individual sampling, Amniocentesis
or some biochemical is very necessary depending on the individual case
• Patient counselling is very important regarding false positive or negative test
thereby avoiding legal problems.

25. Intrauterine growth retardation ( IUGR) :
• Failure of timely detection of IUGR may cause intrauterine death of fetus and the
doctor may have to face the court proceedings for this reason
Multiple pregnancy:
 It is a high-risk pregnancy involving two fetal lives.
 Management problem in such cases may cause fetal complication which will invite
legal problems
Intrauterine fetal death
• the cause of intrauterine death legal must be explored.
• As routine autopsy in India is not performed and unexplained fetal death may
impose problems of medical litigation

26. Sex selection and PNDT Act:
• In view of falling sex ratio the Indian Government promulgated Diagnostic technique
Act in 1994.
• The Act was evolved to identify genetic and congenital abnormalities related to sex.
• Unfortunately, this test was misused.
• Prenatal sex determination and selective female feticide become widespread all over
in India in spite of amendment of PNDT Act in 2002.
• The amended Act prohibits unnecessary sex determination without any disease
problem and aims at preventing selective abortions of female fetuses.
• However, still unethical practice of selective abortions is going on all over India.

27. Abortion:
• A nurse assists in performing abortions under the Medical Termination of Pregnancy
(MTP) Act and takes care of the patients following the procedure.
• A nurse has the right to refuse to assist if the abortion is illegal.

28. Intrapartum Care
• proper intrapartum management during labour is essential for a healthy mother and a
healthy child.
• Newer methods, like use of partograph during labour, pulse oximeter or fetal
electrocardiogram (ECG) analysis can prevent birth asphyxia and appropriate
therapy minimizes litigations.

29. Cesarean section:
• Delayed decision of cesarean must be avoided as this leads to undesirable
situations, like obstructed labor causing maternal and fetal morbidity and mortality.
Difficult vaginal delivery (shoulder dystocia):
• Various clinical risk factors, like diabetes leading to big baby, etc. must be identified
to predict and prevent this condition and associated injuries, like Erb's palsy.
• In this situation, emergency obstetrics care must be provided by experienced
obstetrician, otherwise litigation problems might arise.

30. Breech presentation:
• Timely decision to be taken whether to deliver the baby with breech presentation by
vaginal route or cesarean delivery so as to avoid legal problems.
Multiple pregnancy:
• Involves enormous risk and modern concept is to be delivered by cesarean section.
Instrumental delivery (forceps/vacuum):
• High forceps must be avoided; only low forceps can be Indicated in special
circumstances to expedite the labor process.
• Ventose must be avoided in premature baby and fetal distress.
• Concerned personnel may be sued due to untoward effects, like facial palsy or
visceral injury to mother

31. Analgesia and anesthesia:
• Expert anesthetist is required to prevent medical litigations.
Emergency obstetric care:
• Every year more than, 5,00,000 women die during child birth in the world;
• Out Of which 115th, i.e. women die in India alone,
• with present situation when there is no improvement of infrastructure,
• yet doctors have the risk of facing medicolegal problems regarding emergency
obstetric care.

32. Postpartum Care
Postnatal complete perineal tear (obstetric and sphincter injuries):
• Significant dyspareunia, maternal morbidity and mortality and anal incontinence are
problem areas.
• Forceps delivery, is associated increased perineal injury.
• Patients must be counselled about the risk of anal injury when operative is contemplated,
thus avoiding litigation

33. Perinatal morbidity
• Damage Brain damage: Any neurological and psychological deficiencies can be a major
litigation issues where compensation are claimed. A health professional will be sued if is
proven in court
• Damage to bones and must viscera: this may occur during breech delivery. Health
professional must be very conscious during face, legs and arm delivery in breech.

34. Nursing care newborn:
• Newborn requires professional and specialized care.
• Failure of the neonatal nurse to meet her obligation can result in liability
employment or even civil suit.
 Failure in assessing:
• Failure in assessing and reporting has changes occurred in client's during
intrapartum for period timely
 drugs:
• Food and drug administration (FDA) recommendations of drugs should be
followed.
• The health professional must not use off license drugs.
• If damage occurs; he/she will be blamed of negligence when a licensed alternative
drug is used.

35. WAYS TO MINIMIZE MEDICOLEGAL PROBLEMS IN
MIDWIFERY
• Awareness of medicolegal problems: Health practitioner should be aware about
the changes in laws that may influence the practice.
• Code of ethics: The code of ethics for the midwife should be followed.
• Good interpersonal relationship and clear communication: The patient must not
be given false hopes/ and needs to understand what to expect from the treatment.
The health professionals must be polite and courteous showing sympathy towards
patient.
• Proper counseling: Good counseling instills enormous confidence and faith. It
helps to remove fear and misconceptions that may exist in the mind of the patient.

36. • Informed consent: After proper counseling, informed consent must be taken.
Standard health services:
• Improving infrastructure: Facilities available in the institution should be
displayed. Health authorities should set norms for the health sector as a whole.
• Quality of care: A good consultant is needed. Also, active pre and postoperative
care needed. Adequate training
• Nursing education: Improve the standard of nursing education as they came in
direct contact with patients.
• Continuing education: Regular continuing medical education and workshops
should be attended
• Audits: Morbidity and mortality audits should be regularly done. Regular meeting
of the staffs
• Second opinion/referral: Timely referral should be kept in mind.

37. • Documentation and record keeping:
 History,
physical examination
drug allergies
chronic medication
plan of management
date and time of investigations done
operative and investigative notes
 record of discussion with relatives
note to be take of patients not following instruction

38. Risk management:
• Risk management involves limiting health risk to the patient and also reduce legal
risks to the care provider
• It should not primarily be about avoiding or mitigating claims but rather a for
improving the quality of care.
Public awareness program and health education.

39. MOTHER AND CHILDTRACKING SYSTEM
• Mother and child tracking system (MCTS) is a technology-enabled application
which will monitoring of universal access to maternal and child health services
by all pregnant women and children
• The system is developed jointly by the Ministry of Health and Family Welfare
and National Info Center and it was launched by the Government of India in
December 2009 in collaboration with states/union territories.
• It is an innovative application of the information technology directed towards
improving efficiency of maternal and child health services.
• MCTS is designed to capture and track all pregnant women right from conception
up to 42 days postpartum and
• all newborn up to five years of age to ensure that pregnant woman and children
receive 'full' set of medical services thereby contributing to the reduction of
maternal, infant and child mortality and achieving the goals laid down in the
National Rural Health Mission as well as Millennium Development Goals.

40. Objectives
The broad objectives of the program through the software are:
• To reduce infant mortality rate (IMR)
• To improve the nutritional level of the child
• To ensure completion of immunization in children by tracking the proper
growth of the individual child
• To reduce mother mortality rate (MMR) and reduce total fertility rate (TFR)

41. Purposes
It serves two purposes.
• It facilitates the service provider at the grass roots level in delivering services
to women and children according to their specific needs.
• At the same time, MCTS supports the health and family welfare manager
and policy maker in measuring and monitoring the maternal and child
health services in term of needs effectiveness and capacity, efficiency and
evaluation up to what extent the increase in efficiency in the delivery of
maternal and child health services have contributed to the in maternal, infant
and child mortality.
• In this way, MCTS facilitates justification of investments in health and
family welfare services delivery system.

42. Services offered
 Registration Of pregnant women:
• when a pregnant woman comes to any health facility/sub-center and gets herself
registered and receives first antenatal care (ANC) service
• then she is registered for getting the full health services.
ANC, delivery and postnatal care (PNC) services:
• During the pregnancy period, MCTS records four ANC services given to a pregnant
woman
• captures delivery details, like date of delivery, place of delivery and its outcome and
then PNC Service.
• Workplan for the auxiliary nursing and midwifery (ANM)/accredited social health
activists (ASHA) is generated so that no woman is left without services.

43. Registration of children for immunization:
• In order to give 30 immunizations to every child, he she is registered in MCTS
application.
Immunization services to children:
• Immunization is given to every child as per the schedule and work plan is generated
to be consumed by ANM/ASHA from the MCTS application so that no child is left
Unstructured supplementary service data (USSD) technology to update the service
live on the MCTS portal
• Data is updated through USSD by the ANMs on real time basis on the MCTS portal
from the remotest part of the country.

44. Integration with other applications
• like public financial management system (PFMS), mobile device reporting (MDR),
mother and child tracking facilitation center (MCTFC), Mobile Academy, Kilkari,
etc.
• Integrated with:
l. PFMS to make the DBT based JSY payments to the beneficiary.
2. MCTFC to access the quality of service being delivered in the field.
3. Kilkari Services, a dedicated interactive voice response system (IVRS) platform to
educate beneficiary about the pregnancy and child care.

45. Initiatives taken by Government of India for their Effective Operationalization
• Call center established in ministry of health and family welfare (MoHFW) for
verification of data is entered in MCTS. Another call center is being established at
national institute of health and family welfare (NIFHW), New Delhi.
• Facility of communicating monthly Work Plan to ANMs/ASHAs through SMS in
English and Hindi has been operationalized.
• SMS alerts to beneficiaries about services due have also been started.
• SMS related to mother and child registration status and telephonic verification status
are sent daily to senior officials, like State Health Secretary, managing director of
national rural health mission (NRHM) Regional Director, State Coordinators,
District Collector, District Program Manager, etc.

46. • States/union territories have been asked to constitute State and District e-Mission
Teams to regularly monitor the progress of implementation.
• States/union territories have been asked to nominate the District and Block Program
Manager (NRHM) as the Nodal Office r for MCTS at district and block levels.
• Working group on technology options and business processes reengineering
constituted to assess field difficulties along with the proposed solutions.

47. Outcomes and expectationOutcomes and Expectations
• MCTS is expected to contribute significantly towards universal access of all
pregnant women and children to maternal and child health services thereby
facilitating and accelerating reduction in maternal, infant and child mortality.
• MCTS is being implemented all over the country. Once fully scaled up, MCTS will
be accessible throughout the country. It will be accessible to the entire population of
the country, irrespective of the region, caste, living status, etc.