Legal and ethical aspect in Midwifery

Law…..
‘’THESUM TOTAL OF RULESANDREGULATIONS BY WHICHTHESOCIETYIS GOVERNED.’’

Ethics is the systematic study of
What a persons conduct ought to be with
regard to him or herself, other human beings
and the environment,
it is the justification of what is right or good
and the study of what a person’s life and
relationship ought to be,
not necessarily what they are.
ETHICS

UNIVERSAL MORAL PRINCIPLES
Autonomy –right of the individuals to govern their own
action
Freedom- the right of freedom to exempt from control by
others to select and pursue health goals
Veracity- principle of truth telling requires professional
care givers to provide patients with accurate ,reality based
information about their health status and care or treatment
prospects
Justice – persons who are alike in morally relevant
aspects be treated alike

Non-maleficence – one is morally obliged to not harming
others
Beneficence – a person is obliged to help others to advance
their legitimate and important interests
Right – An entitlement to behave in a certain way under
certain circumstances. These can be conventional and moral
rights
Fidelity – Fulfilling one’s duties and obligations
Confidentiality – caregivers should respect a patient’s need
for privacy and use personal information only to improve care.

FUNDAMENTAL ETHICAL PRINCIPLES
OF HEALTH CARE
The Principle of Respect for Persons
The Principle of Justice
The Principle of Beneficence

INTERNATIONAL CODE OF ETHICS FOR NURSES
Nurses have four fundamental responsibilities: to promote health, to
prevent illness, to restore health and to alleviate suffering. The need
for nursing is universal.
Inherent in nursing is respect for human rights, including the right to
life, to dignity and to be treated with respect.
Nursing care is unrestricted by considerations of age, colour, creed,
culture, disability or illness, gender, nationality, politics, race or
social status.
Nurses render health services to the individual, the family and the
community and co-ordinate their services with those of related
groups.

LEGAL LIABILITY IN NURSING
• Negligence
• Malpractice
• Torts

NEGLIGENCE
• Means an act or conduct that falls below the standard of care.
• The joint commission of accreditation of health care organization
(JCAHO) defines negligence is failure to use such care as a reasonably
prudent and careful person would use under similar circumstances.
• It is an act of omission i.e. neglect to do something

NEGLIGENCE ON NURSES DUTIES THAT
LEADS IN LAWSUITS
• Failure to follow standards of care
• Failure to use equipment in a responsible manner
• Burns caused by equipment or solutions
• Falls that caused injury to patient

Leaving foreign object
in patients body

NEGLIGENCE ON NURSES DUTIES THAT
LEADS IN LAWSUITS CONT…
• Administer wrong medicine to a patient.
• Failure to exercise reasonable judgments.
• Failure to communicate
• Failure to document.
• Failure to assess and monitor.

MAL PRACTICE
• It is a negligence or carelessness by a professional person.
• It is professional misconduct, unreasonable lack of skill or
infidelity in professional duties, evil practice or illegal or
immoral conduct.

MAL PRACTICE LAW SUIT AGAINST A
NURSES
• An evidence that the nurses owed a duty to the client. e.g. : failure
to monitor the client response to treatment
• An evidence that the nurses did not carry out the duty.
• The client was injured by nurses failure.
• Forseeability not maintain e.g. falling of children from the bed in
the ward

TORTS
• A Torts is a civil wrong for which remedy is a common
law action for damages that are not liquidated and which
is not exclusively the breach of contract or trust.

1. Intentional torts:
2. Unintentional torts:
Assault
Battery
False imprisonment
Trespassing
Negligence
Mal practice
Abandonment

INTENTIONAL TORTS
• Assault and Battery – the most common suit brought against
Nurses. Assault is a threat to harm another .Battery is intentional
touching a person without permission/ consent .
• Defamation of character – Act of holding up of a person to scorn
or contempt within the community .

INTENTIONAL TORTS CONT……..
• Two types –
a) Slander – in the form of spoken words e.g. if a nurse tells a
client that his doctor is incompetent.
b) Libel – in the form of written words
Fraud:-
Purposeful, misrepresentation of self or an act that may cause
harm to a person or property. E.g.- changing the documentation
which have done or not done in the patient sheet for own means

LEGAL SAFEGUARDS IN NURSING
PRACTICE
• Licensure – Nurses possess a valid licensure issued by the State
Nursing Council or Indian Nursing Council.
• Physician order – Nurses are obligated (to follow order unless they
believe that order are not accurate
• Short Staffing – Inadequate staff may arise sometime if the Nurses is
assign to take care of more patient.

PRACTICE CONT…
• Floating Nurses – nurses can inform the supervisor and request for an
orientation.
• Good Samaritan Laws – encourage health care professional to assist in
emergency situations.
• Good Rapport – Maintain open, honest, respectful relationship and
communication with patient and family members.

PRACTICE CONT…
• Standard of Care – Always better to follow standard of care to avoid
Malpractice and do not attempt beyond the level of competence.
• Standing order – Apply standing order or treatments guideline that has
been established by the physician as appropriate
• Consent for operation and other procedures
• Correct Identity – Identity or labeled should be given to the patient

PRACTICE CONT…
• Counting of sponge, Instruments & needles
• Drug Maintenance
a) Misuse of the Drugs Act 1971
b) Dangerous Drug Act 1965 & 1967.
• Professional confidence – Guarding the confidence of the patient is an
ethical duty.

PRACTICE CONT…
• Documentation – Record maintain by the nurses are not only to
provide continuity in care but it is also be use in court as evidence.
• Patient’s property – the nurses is not supposed to go through the
patient locker and belonging without permission.

GUIDELINES FOR SAFE PRACTICE
• Do’s
1) Documentation of all unusual Incidences
2) Report all unusual incidences
3) Know your job descriptions
4) Follow policies and procedures as established by the employing
agencies
5) Keep your registration updated

CONT…
6) Perform procedure within the standard scope of practice
7) Protect patient from injuring themselves
8) Remain alert and focus.
9) Maintain and established rapport with patients and family
10) Seek and clarify orders when the patient’s medical
conditions changes
11) Practice safety with physicians verbal order

CONT…
• Don’ts
1) Remove side rails from patients bed unless there is an order or hospital
policy to do so.
2) Allow patients to leave the hospital or nursing home unless there is and
order or a signed release
3) Accepts money or gifts form patients
4) Give advice that is contrary to physician orders or the nursing care plan

CONT…
5) Give medical advice to friend’s and neighbors
6) Attempt to practice medicine
7) Take medication that belongs to patients
8) Work as licensed practical/vocational nurses in a state in which
you are not licensed.

COMMON ISSUES FACED BY A MIDWIFE:
• ADMINISTERING WRONG MEDICATIONS.
• GENDER DISCRIMINATION.

COMMON ISSUES FACED BY A
MIDWIFE CONTD..
 SLEEPING OFF DURING NIGHT DUTIES
 UNTRAINED MIDWIVES

COMMON ISSUES FACED BY A
MIDWIFE CONTD..
• TELEPHONIC ORDERS FOLLOWED.
• BABIES GETTING SUFFOCATED
ACCIDENTALLY.

ESSENTIAL COMPETENCIES FOR BASIC
MIDWIFERY PRACTICE ACCORDING TO
ICM:
 COMPETENCY 1 :
MIDWIVES HAVE THE REQUISITE KNOWLEDGE AND SKILLS FROM THESOCIAL SCIENCE,
PUBLICHEALTH, AND ETHICS THAT FORM THE BASIS OF HIGH QUALITY , CULTURALLY
RELEVANT, APPROPRIATE CARE FOR WOMEN, NEWBORNANDCHILDBEARING
FAMILIES.

ESSENTIAL COMPETENCIES FOR
BASIC MIDWIFERY PRACTICE
ACCORDING TO ICM CONTD…
• BASIC KNOWLEDGE AND SKILLS :
1) RESPECT FOR LOCAL CULTURE.
2) RESOURCES FOR EMERGENCY CARE.
3) CAUSES OF MATERNAL AND NEONATAL MORTALITY AND MORBIDITY IN THE LOCAL
COMMUNITY.
4) ADVOCACY AND EMPOWERMENT STRATEGIES FOR WOMEN.
5) KNOWLEDGE OF THE COMMUNITY.
6) NATIONAL IMMUNISATION PROGRAMME.

 COMPETENCY 2 :
“ MIDWIVES PROVIDE HIGH QUALITY, CULTURALLY COMPETENT HEALTH
EDUCATION AND SERVICES TO ALL IN THE COMMUNITY IN ORDER TO PROMOTE
HEALTHYFAMILYLIFE, PLANNED PREGNANCIES AND POSITIVEPARENTING.”

• BASIC KNOWLEDGE OF :
1) GROWTH AND DEVELOPMENT RELATED TO SEXUALITY , SEXUAL DEVELOPMENT AND
SEXUAL ACTIVITY.
2) CONTRACEPTION AND REPRODUCTION, SEXUALLY TRANSMITTED INFECTIONS.
3) HEALTH HISTORY , FAMILY HISTORY AND GENETIC HISTORY.

 COMPETENCY 3 :
“ MIDWIVES PROVIDE HIGH QUALITY ANTENATAL CARE TO MAXIMISE THE HEALTH
DURING PREGNANCY AND THAT INCLUDES EARLYDETECTIONAND TREATMENT OR
REFERRALOF SELECTEDCOMPLICATIONS.”

1) MENSTRUAL CYCLE AND PROCESS OF CONCEPTION.
2) SIGNS AND SYMPTOMS OF PREGNANCY.
3) DATING PREGNANCY BY MENSTRUAL HISTORY .
4) FUNDAL GROWTH PATTERNS.
5) PHYSICAL EXAMINATION FOR ANTENATAL VISITS.

6) DETERMINE FOETAL WELL BEING DURING PREGNANCY.
7) PREPARATION OF LABOUR, BIRTH , PARENTING.
8) INDICATORS OF LABOUR ONSET , BREAST FEEDING.
9) EFFECTS OF SMOKING, ALCOHOL.

 COMPETENCY 4 :
“ MIDWIVES PROVIDE HIGH QUALITY , CULTURALLY SENSITIVE CARE DURING LABOUR,
CONDUCT A CLEANANDSAFEDELIVERY AND HANDLE SELECTED EMERGENCY
SITUATIONS TO MAXIMIZE THE HEALTH OF WOMEN AND THEIR NEWBORN.”

1) PHYSIOLOGY OF LABOUR.
2) ANATOMY AND PELVIS OF SKULL.
3) NORMAL PROGRESSION OF LABOUR AND USE OF PARTOGRAPH.
4) ASSES FOETAL AND MATERNAL WELLBEING DURING LABOUR.

5) MECHANISM OF LABOUR.
6) PHYSICAL CARE OF NEW BORN : BREATHING , WARMTH, FEEDING.
7) INDICATIONS FOR OPERATIVE DELIVERY.

 COMPETENCY 5 :
“ MIDWIVES PROVIDE COMPREHENSIVE , HIGH QUALITY,
CULTURALLY SENSITIVE POSTNATAL CAREFOR WOMEN.”

ESSENTIAL COMPETENCIES FOR BASIC
MIDWIFERY PRACTICE ACCORDING TO
ICM CONTD…
1) NORMAL PROCESS OF INVOLUTION AND HEALING.
2) LACTATION AND BREAST COMPLICATIONS.
3) MATERNAL NUTRITION , REST AND ACTIVITY.
4) INFANT NUTRITIONAL NEEDS.
5) PARENT- INFANT BONDING.

 COMPETENCY 6 :
“ MIDWIVES PROVIDE HIGH QUALITY, COMPREHENSIVE CAREFORTHEESSENTIALLY
HEALTHYINFANTFROM BIRTH TO TWO MONTHS OF AGE”.

1)BASIC NEEDS OF NEW BORN.
2)APGAR SCORE ASSESSMENT.
3)NORMAL NEWBORN AND INFANT GROWTH AND DEVELOPMENT.
4) NORMAL VARIATIONS IN THE NEWBORN LIKE MOULDING,
MONGOLIAN SPOT.
5) IMMUNISATION NEEDS.
6) RECORD FINDINGS .

THE PREGNANT PATIENT BILL OF RIGHTS :
• THE PREGNANT PATIENT HAS THE RIGHT TO:
 PRIOR TO THE ADMINISTRATION OF ANY DRUGOR PROCEDURETO BE INFORMED BY
THE HEALTH PROFESSIONAL CARING FOR HER OF ANY EFFECTS , RISKS OR HAZARDS TO
HERSELF OR HER FOETUS, OR NEWBORN.

THE PREGNANT PATIENT BILL OF
RIGHTS CONTD…
 TO BE INFORMED ABOUT THE ALTERNATIVETHERAPIESSUCH AS AVAILABLE CHILD
BIRTH EDUCATION CLASSES FOR PHYSICAL AND MENTAL PREPARATION TO COPE WITH
STRESS OF PREGNANCY AND THEREBY REDUCING NEED FOR DRUGS.

RIGHTS CONTD…
 TO BE INFORMED PRIOR IF CAESAREAN BIRTH IS ANTICIPATED.
TO BE INFORMED PRIOR TO THE ADMINISTRATION OF
ANY PROCEDURE WHETHER THAT PROCEDURE IS FOR HER
OR HER BABY’S BENEFIT.

 TO KNOW THE NAME AND QUALIFICATIONS OF THE INDIVIDUAL
ADMINISTERING A MEDICATION OR PROCEDURE TO HER DURING
LABOUR AND BIRTH.
TO BE INFORMED OF THE BRAND/GENERIC NAME OF THE
DRUG SO THAT SHE MAY INFORM THE HEALTH
PROFESSIONAL OF ANY PAST ALLERGY.

RIGHTS CONTD…
TO BE ACCOMPANIED DURING THE STRESS OF LABOUR AND BIRTH BY SOMEONE SHE
CARES FOR AND TO WHOM SHE LOOKS FOREMOTIONALCOMFORT AND
ENCOURAGEMENT.

 TO HAVEHER BABY CAREDFOR AT HER BEDSIDE IF HER BABY IS
NORMAL AND TO FEED HER BABY ACCORDING TO HER BABY’S
NEEDS.
TO BE INFORMED IF THERE IS ANY KNOWN OR INDICATEDASPECT
OF HER OR HER BABY’S CARE WHICH MAY CAUSE HER OR HER
BABY LATER DIFFICULTY OR PROBLEMS.

RIGHTS CONTD…
• TO HAVE HER AND HER BABY’S HOSPITAL MEDICAL RECORDS COMPLETE ACCURATE
AND LEGIBLE.

• RIGHT TO PRIVACY :
 The right of a person to keep her or her property free from public
scrutiny .
 Only those responsible for her care should examine her or discuss her
case.

GUIDELINES FOR ANTENATAL CARE AND
SKILLED ATTENDANCE AT BIRTH BY ANMs
AND LHVs:
• GOOD RECORD KEEPING ASSIST IN BETTER CASE MANAGEMENT AND FOLLOW UP.
• ENSURE IRON FOLIC ACID SUPPLIMENTATION TO EARLY PREGNANT WOMEN.

• DO NOT GIVE A PREGNANT WOMAN ANY MEDICATION DURING
THE FIRST TRIMESTER UNLESS INDICATED.
• ADEQUATE REST AND DIET.
• RECOGNISE THAT EVERY PREGNANCY MAY BE AT RISK.

• MAKE SURE THAT SERVICES ARE AVAILABLE TO MANAGE
OBSTETRIC EMERGENCIES WHEN THEY OCCUR.

• REFER THE WOMAN TO THE MEDICAL OFFICER IF HER
OBSTETRIC HISTORY REVEALS ANY OF THE FOLLOWING :
1) PREVIOUS STILLBIRTH OR NEONATAL LOSS.
2) HISTORY OF THREE OR MORE SPONTANEOUS CONSECUTIVE ABORTIONS.
3) PREVIOUS LOWBIRTH WEIGHT BABIES.
4) PREVIOUS HYPERTENSION.
5) PREVIOUS SURGERY ON THE REPRODUCTIVE TRACT.

LEGAL AND ETHICAL CONSIDERATIONS IN
VARIOUS ASPECTS:
• INFORMED CONSENT :
The policy protects the client’s right to autonomy and self determination by specifying that no
action may be taken without that person’s prior understanding and freely given consent.

 Inability to make diagnosis
 Inacurate diagnosis
 False negative
 Termination
 Failure to give advice
 Wrong advice
PROBLEMS
ENCOUNTERED

Legal issues can be there in:
 Fetal anomalies:
 Overlooked or missed
 Some are not detected
 Vaginal bleeding
 Placenta praevia
 IUGR, prematurity, wrong dates
 Fetal death
 Ectopic Pregnancy
 Fetal biophysical profile
ULTRASONOGRAPHY IN
OBSTETRICS

• DURING LABOUR :
1) MOTIVATE THE WOMAN AND HER FAMILY TO HAVE A CLEAN AND
SAFE DELIVERY.
2) PROMOTE INSTITUTIONAL
DELIVERY.
3) MAINTAIN A PARTOGRAPH FOR RECOGNIZING THE NEED FOR ACTION AT
APPROPRIATE TIME AND ENSURE TIMELY REFERRAL.
4) KEEP A CHECK FOR PPH.

ESSENTIAL NEW BORN CARE:
 CARE OF THE UMBILICAL CORD INVOLVES ENSURING A CLEAN CORD CUT , A CLEAN
CORD TIE, AND A CLEAN CORD STUMP.
 KEEP THE NEONATAL BABIES
WARM.
BREAST MILK KEEPS BABIES WELL-FED AND HEALTHY.

• MATERNAL-FOETAL CONFLICT :
 In some instances women refuse interventions on behalf of the fetus.
 The American College Of Obstetricians and gynecologists ( ACOG) Committee on
ethics support that “ Every reasonable effort should be made to protect the fetus,
but the pregnant woman’s autonomy should be respected.
 Caregivers should rely on education, counseling for such cases.

• INTRA UTERINE FOETAL SURGERY :
 It’s a surgery that involves opening of the uterus during the second
trimester , treating the fetus and replacing it in the uterus.
 The risks to the fetus is substantial and the mother is committed to
caesarean births, its experimental nature should be explained well.

• INVITROFERTILISATION,EMBRYOTRANSFER,SURROGACY:
 Problems of religious objections with artificial
conception.
 The problem of who will assume financial and moral
responsibility for a child born with a congenital defect
.
 The issue of candidate selection, the rights of the
surrogate mother should also be considered.

• THE MEDICAL TERMINATION OF PREGNANCY RULES,
2003 :
1) Composition and tenure of district level committee :
 members would be : gynaecologists/surgeon/anaesthetist and other members of the local medical
profession, non governmental organization, and panchayati raj institution of the district.
 one of the members should be a woman .
 Tenure shall be 2 years.

2) EXPERIENCE AND TRAINING :
 Registered medical practitioner.
 Experience in the practice of obstetrics and gynaecology for not less than 3 years.
 If registerd in a State Medical Register:
I. Completed atleast six months of house surgency in gynaecology and obstetrics.
II. Assisted a registerd medical practitioner in the performance of 25 cases of MTP of which five
have been performed independently .

• Bennet V Ruth & Brown K Linda, “Myle’s text Book for Midwives, ELBS, Churchill Livingstone
• Buckley Kathleen and Kulb Nancy W, “ High Risk Maternity Nursing Manual” Edn, Williams &
Wilkin, 1993, Philadelphia.
• D.C Dutta, “Text book of Gynaecology” ,Vth edn, New Central Agency (p) Calcutta, 2001.
• FIGO Committee for the Study of Ethical Aspects of Human Reproduction. Recommendations of
Ethical Issues in Obstetrics and Gynecology. London: International Federation of Gynecology and
Obstetrics, 1997.
• Bergeron, Veronique, 2007, “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): 478–87.
• Lyerly, Anne Drapkin, et al, 2009, “Risk and the pregnant body”, Hastings Center Report39(6): 34–
42.
• Van Bogaert, Louis-Jacques, 2006, “Rights of and duties to non-consenting patients: informed
refusal in the developing world”, Developing World Bioethics 6(1): 13–22.
BIBLIOGRAPHY-

http://www.slideshare.net/fullscreen/deepthyphilipthomas/medical-and-ethical-issues-in-
obstetrics/1
http://www.slideshare.net/fullscreen/VasanthaKumari4/common-drugs-used-in-obstetric-
emergencies/1
http://www.slideshare.net/fullscreen/phant0m0o0o/3medico-legal-and-ethical-issues/1
http://www.slideshare.net/fullscreen/Sciblack/medicolegal-aspects-of-pregnancy-delivery-
and-abortion/1
BIBLIOGRAPHY-

Legal and ethical aspect in Midwifery

Legal and ethical aspect in Midwifery

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