manual of high risk pregnancy and delivery 5e samplechapter

Elizabeth Stepp Gilbert, RNC-OB, MS,

FNP-BC, CNS

Director of Professional Practice

Banner Thunderbird Medical Center

Glendale, Arizona

FIFTH EDITION

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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 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.

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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

To my husband,

Robert,

and my son,

Michael,

who support me in all

my professional

and personal endeavors

Tiff any Kay Bennett, RNC-OB, MS-NL

RN Senior ManagerLabor, Delivery, and TriageBanner Th underbird Medical CenterGlendale, Arizona

Teresa K. Buchda RNC-OB, MS-NLRN Director, Women and Infant ServicesBanner Th underbird Medical CenterGlendale, Arizona

Deborah L. Davis, PhDDevelopmental Psychologist and Writer

Author of Empty Cradle, Broken Heart

Denver, ColoradoTulsa, Oklahoma

Suzanne Helzer, RNC-OB, LCCEBereavement Services/RTS Program

CoordinatorBanner Desert Medical CenterMesa, Arizona

Terance L. Kranz, RNC-OB, MSNClinical Education SpecialistBanner Del E. Webb Medical CenterSun City West, Arizona

Karen M. Marshall, RNC–OB, MSN, CNS

Clinical Nurse SpecialistBanner Th underbird Medical CenterGlendale, Arizona

Barbara Oxley, NMD, RN, BSN, IBCLC

DirectorBethany Ranch Health ClinicPhoenix, Arizona

Sheryl Parfi tt, MSN, RNCClinical Educator, ObstetricsScottsdale HeathcareScottsdale, Arizona

Mary L. Sciuto, RN, MSRN-Clinical Education SpecialistBanner Good Samaritan Medical CenterPhoenix, Arizona

Christina Tussey, MSN, CNS, RNC-OB, RNC-MN

Women and Infants Clinical Nurse Specialist

Banner Good Samaritan Medical Center Phoenix, Arizona

Amy Warengo, RN, MS-NLRN Senior ManagerAntepartum and Maternal Fetal

Medicine CenterBanner Th underbird Medical CenterGlendale, Arizona

Contributors

iv

Preface

T oday’s technologic advances make it possible to off er the woman and her family, who are experiencing a high risk pregnancy and delivery, a good chance for a positive outcome. Th e evidence-based practice

nursing and medical literature were the primary resources used in the writing of this manual such as the Cochrane Reviews, a database of systematic reviews, and evidence-based clinical guidelines such as Agency for Healthcare Research and Quality (AHRQ), National Guideline Clearinghouse (NGC), Institute for Clini-cal Systems Improvement (ICSI), and Society of Obstetricians and Gynaecologists of Canada (SOGC) as well as references from professional organizations such as AWHONN and ACOG. As nurses, nurse practitioners, and nurse-midwives, we each 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 for risk factors, they must provide preventive management using eff ective alternative and complementary therapies, and appropriately intervene when complications de-velop. Unfortunately, many women do not receive adequate prenatal care and enter the health care system only after complications occur. Because these women seek assistance from various types of facilities, nurses who practice in clinics, emergency rooms, and primary care settings must also be alert to perinatal complications and be prepared to provide immediate stabilizing care in ambulatory or other inpatient care settings.

Manual of High Risk Pregnancy & Delivery is designed as a practical reference manual to provide comprehensive information in a concise, portable, and accessible format. Clearly written text and numerous tables and boxes enhance comprehen-sion and facilitate easy retrieval of information. Th e nursing process serves as the organizational framework for discussions of both preventive and emergent care for a wide range of topics. Nursing interventions are grounded in evidence-based practice recommendations.

Th e coverage of common medical and obstetric problems experienced during childbearing are presented in a layout style that includes incidence, etiology, physiology, pathophysiology, as well as the usual, expected, and intensive care management protocols for advanced nurse practitioners. Management and intervention protocols are addressed with emphases on ambulatory care prevention and inpatient high-risk care with critical care protocols, as appropriate. Psychosocial implications and family considerations are incorporated throughout. A unique, contributed chapter discusses and emphasizes how advance practice nurses can access relevant alternative and complementary therapies, which are evidence-based for high risk pregnancy and delivery care.

v

It is my conviction that with thorough, knowledgeable, and evidence-based care of the mother and fetus, neonatal morbidity and mortality can be considerably decreased, and complications for the mother can be lessened. It is my intent and hope that this text will enable health care professionals to provide optimal care for mother, fetus, and family from ambulatory, preventive, inpatient, and critical care arenas through the early postpartum period.

Elizabeth Stepp Gilbert

vi Preface

Contents

UNIT 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 Th erapies, 88

5. Integrative Th erapies in Pregnancy and Childbirth, 107

UNIT II PSYCHOLOGIC IMPLICATIONS OF A HIGH RISK PREGNANCY 6. Psychologic Adaptations, 128

7. Perinatal Death and Bereavement Care, 149

UNIT III ETHICAL DILEMMAS AND LEGAL CONSIDERATIONS IN PERINATAL NURSING 8. Ethical Decision Making, 170

9. Legal Issues and Risk Management, 181

UNIT IV HEALTH DISORDERS COMPLICATING PREGNANCY10. Diabetes, 200

11. Cardiac Disease, 243

12. Renal Disease, 258

13. Autoimmune Rheumatic Diseases, 271

14. Venous Th romboembolic Disease, 282

15. Pulmonary Disease and Respiratory Distress, 289

UNIT V COMPLICATIONS IN PREGNANCY16. 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

22. Hypertensive Disorders, 416

23. Preterm Labor and Multiple Gestation, 460

24. Premature Rupture of Membranes, 488

25. Trauma, 500

UNIT VI TERATOGENS AND SOCIAL ISSUES COMPLICATING PREGNANCY26. Sexually and Nonsexually Transmitted Genitourinary Infections, 519

27. Substance Abuse, 558

UNIT VII ALTERATIONS IN THE MECHANISM OF LABOR28. Labor Stimulation, 582

29. Dysfunctional Labor, 610

30. Prolonged Pregnancy, 660

Index, 671

viii Contents

170

Perinatal nurses are confronted daily with ethical dilemmas. Th is chapter examines the nature of values clarifi cation, 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 relevant clinical perinatal examples that commonly confront the perinatal nurse.

VALUES CLARIFICATION

Educators, psychologists, anthropologists, sociologists, and theologians have infl u-enced the defi nition of values. Th ey consider values to be attitudes, beliefs, and moral judgments that are chosen freely and thoughtfully and are prized and acted on (Albert and others, 2006; Beauchamp and Childress, 2008 ).

Process of Valuing

Th e process of valuing has three aspects: choosing, prizing, and acting.

Choosing

Choosing involves the cognitive component of valuing. Logical, critical, creative thinking and moral judgment development are included. Important elements of choosing include the following: • Choosing freely • Choosing from available alternatives • Choosing after considering the consequences of each alternative • Complements other values previously internalized

Prizing

Prizing involves the aff ective component. Th is feeling component of valuing includes the following aspects ( Beauchamp and Childress, 2008 ): • Being aware of one’s position on the matter • Expressing one’s value

8Ethical Decision Making

ETHICAL DILEMMAS AND LEGAL CONSIDERATIONS IN PERINATAL NURSING

UNI T THREE

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

Acting

Acting involves the behavioral component and results in the following ( Beauchamp and Childress, 2008 ): • Personal, professional, and academic competence • Confl ict resolution • Willingness to affi rm the choice publicly • Assimilation of the choice as part of personal behavior • Consistent repetition of the choice

MORAL JUDGMENT DEVELOPMENT

Th e moral judgment development theory complements valuing. Kohlberg (1981) contributed to the study of moral development by expanding on the work of Piaget and describing six stages of moral development.

Stages

Preconventional Level Th e child at the preconventional level is responsive to cultural rules and labels of good and bad, right and wrong. Th ese labels are considered by the child in the context of punishment, reward, or exchange of favors. Th is level is divided into two stages.

Stage 1 Stage 1 is the stage of punishment and obedience. Avoidance of punishment and deference to power are ends in themselves. Th e physical consequences of an action determine whether it is good or bad. For example, the reason for doing right is to avoid punishment from those with more power.

Stage 2 Stage 2 is the stage of instrumental purpose and exchange. Right action is that which pragmatically satisfi es one’s own needs and occasionally the needs of others. Right is following 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 than out of loyalty or gratitude.

Conventional Level

At the conventional level of moral judgment development, the person considers the expectations of others and conformity as valuable in their own right, regardless of the immediate consequences. Th ere is an attitude of not only conformity but also active maintenance, support, and justifi cation of the order. Stages 3 and 4 are at this level.

Stage 3 Stage 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.

172 UNIT III : Ethical Dilemmas and Legal Considerations in Perinatal Nursing

Conformity 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 4 Stage 4 is the stage of social system and conscience maintenance. Right action is doing 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, fi xed rules, and maintenance of the social order.

Postconventional Level

Th e postconventional level is also called the autonomous or principled level. Th e indi-vidual attempts to defi ne moral values and principles that have validity and applica-tion apart from the authority of society and the individual’s identity with societal groups. Th ere are two stages at this level.

Stage 5 Stage 5 is the stage of ‘a priori’ rights and social contract or utility. Th is stage has utili-tarian overtones. Right action is defi ned in terms of standards that have been agreed on by society in terms of individual rights. Right action is described as upholding basic rights, values, and legal contracts of society even when they confl ict with con-crete rules and laws of the group.

Awareness of relativism of personal values and opinions exists, with an emphasis on reaching consensus. Right action is also a matter of personal values aside from what is constitutionally agreed on. Th ere 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 6 Stage 6 is the stage of universal ethical principles. Right action is defi ned by a deci-sion of conscience in accord with self-chosen ethical principles. Specifi c laws usually rest on these principles. When, however, laws violate these principles, acts must be in accord with principles rather than law. Principles are abstract, ethical, and universal, such as the principles of justice, reciprocity, equality, and respect for human dignity.

Qualities

In addition to the six stages of moral development, Kohlberg (1981) described six qualities of the stages of moral development: • Th e development of morality proceeds in an invariant sequence as the individual

matures and as the environment off ers 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 eff ected when cognitive disequilibrium is created by confl icting 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.


FRAMEWORK FOR ETHICS

Defi nitions

Ethics Ethics is the study of values in human conduct or the study of right conduct. It is a branch of philosophy that attempts to state and evaluate principles by which ethical dilemmas may be resolved. It is not a science with right or wrong answers but rather a systematic, critical, rational, defensible, intellectual approach to deter-mining what is best in a situation with confl icting values. Th e result will ultimately be unfavorable and pit one or more ethical principles against another (Albert and others, 2006).

Metaethics

Metaethics is the part of ethics that focuses on the extent to which ethical judgments are reasonable or justifi able.

Normative Ethics

Normative ethics is the part of ethics that raises questions about what is right or ought to be done in a situation that calls for an ethical decision.

Ethical Principles

Several basic principles help to identify values, morals, beliefs, and attitudes and to clarify ethical dilemmas ( Table 8-1 ). Ethical principles comprise the sixth stage of Kohlberg’s (1981) moral development. Th e characteristics of ethical principles follow: • Th ey suggest direction or propose certain behaviors. • Th ey serve as guides to organizing and understanding ethically relevant infor-

mation in an ethical dilemma. • Th ey propose how to resolve competing claims. • Th ey are the reasons justifying moral actions. • Th ey are universal in nature. Th ey are not absolute; they do have exceptions. • Th ey are neither rules (means) nor values (ends). • Th ey are unchangeable and discovered by human beings rather than invented.

MODEL FOR ETHICAL DECISION MAKING

Characteristics of Ethical Dilemmas

We live in an era in which technologies develop faster than we can consider conse-quences. Changes aff ect clinical practice before guidelines for use are developed and before the social and ethical impact can be considered. Recent technologic advances in endocrinology, genetics, reproductive therapy, neonatal and maternal-fetal medical care, and fetal therapy have created numerous ethical dilemmas for the recipient of care and the caregiver. Th ese dilemmas and the resultant decisions have a consider-able impact on society.

Th e characteristics of an ethical dilemma follow (Albert and others, 2006): • Th e choice is between equally undesirable alternatives. • Real choices exist between possible courses of action.


• Th e people involved place a signifi cantly diff erent 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 diff erent 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. • Th e choices made in an ethical dilemma have far-reaching eff ects on our percep-

tion of human beings and our defi nition of personhood, our relationships, and people and society as a whole.

• Any ethical decision involves the allocation and expenditure of resources that are fi nite.

• Ethical dilemmas are not solvable but rather resolvable. • Th ere is no right or wrong when dealing with two equally unfavorable actions.

Th eories in Ethics

Two classic schools of thought—teleology and deontology—dominate ethical theory ( Follin, 2004 ).

Table 8-1 Defi nitions of Ethical Principles

Ethical Principle Defi nition

Autonomy Being one’s own person without constraints by another’s action or psychologic and physical limitations

Benefi cence Duty to do good Confi dentiality 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 specifi c people or situations Informed consent Contains four elements: Disclosure of suffi cient information Comprehension Voluntary agreement Competency to make decision Justice Equitable distribution of risks and benefi ts Nonmalefi cence Duty to do no harm Ordering Ethical principles must be prioritized even though they

may be confl icting 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


Teleology

According to the theory of teleology, the rightness or wrongness of an action is determined by the consequences, not by whether it is inherently right or wrong. Th is approach to decision making is risk-to-benefi t-based. It is also called utilitarianism or consequentialism.

Deontology

Th e theory of deontology holds that the inherent characteristics of the decision can be judged independent of its outcome or consequences. Duty-based or rights-based approaches are examples of deontologic thoughts.

Moral Relativism

A pure application of either teleology or deontology may not be useful. Aspects of both theories are usually combined when making ethical decisions blended with moral relativism. Moral relativism adds the notion of personal interpretation. Th e application of paradigm cases, anecdotal experiences, and ethical principles to clinical problems exemplifi es relativism.

Th e root principles of ethical theory are benefi cence, justice, and autonomy (see Table 8-1). Decision making is always colored by the individual’s values, attitudes, knowledge, desires, cultural mores, experiences, and background ( Beauchamp and Childress, 2008 ).

Steps in Decision Making

Th e steps in ethical decision making are described in Box 8-1 .

Nursing Responsibility

Th e concepts central to nurses’ responsibility in participation in ethical decision making are caring, coordination, and advocacy. Th ese concepts are based on the unique relationship between the nurse and the patient. Clinical ethics, existing aside from medical ethics, incorporates the ethical problems the nurse encoun-ters in the independent and collaborative domains of practice. Nursing is owned by society and as such is an essential part of society with a responsibility to the whole.

Caring

Caring, described by Swanson (1993) , provides the fi rst mandate for nurses’ partici-pation in and assumption of ethical practice. Th e second mandate is derived from the social contract and the American Nurses Association (ANA) code for nurses ( Box 8-2 ). Th e third mandate for participation in ethical decision making is the pivotal position of nursing within the health care organization. Professional nursing practice is ethical nursing practice.

Conscience Clauses

Nurses are occasionally placed in situations where physician orders or patient requests may confl ict with their own professional ethic and moral codes. Conscience


clauses are statutory provisions that allow healthcare personnel or institutions the 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 Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) have published position statements which support patients’ rights to information and treatment that they may require or ask for, while taking into consideration a nurse’s personal code of ethics. Obstetrical units may wish to research policies within their own institutions, provide open discussions regarding conscience clauses, and develop written guidelines which will protect nurses, support staff , and patients ( Tillett, 2008 ).

PATIENT SELF-DETERMINATION ACT

A federal law, the Patient Self-Determination Act, went into eff ect in December 1991 for all health care facilities receiving federal monies. Th is act requires that all patients be informed of their rights to make decisions concerning their health care.

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 Confl icts 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.

Box 8-1 Steps in Ethical Decision Making


ADVANCE DIRECTIVE

An 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 of aspects 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 can appoint another person to make those decisions. A living will can direct the physician to provide, withhold, or withdraw life-sustaining care.

In the case of a pregnant woman, however, the advance directive does not allow her to make decisions in advance that may aff ect fetal survival or quality of life. For example, if a pregnant woman is involved in a motor vehicle accident and sustains a head injury that permanently aff ects her cardiorespiratory center, she may be kept on life-sustaining care despite instructions in her living will to the contrary. If sustaining her on life support can successfully maintain the pregnancy, which shows no evidence of fetal compromise, her living will requesting no life support will be disregarded. In

• 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.

Box 8-2 American Nurses Association Code of Ethics

From American Nurses Association: Code of ethics for nurses with interpretive statements , Silver Springs, MD, 2001, American Nurses Publishing. Retrieved from www.nursingworld.org/ethics/chcode.htm.


such situations it has been determined that postponement of maternal death does less harm to her when balanced against the fetal right to survive.

ETHICS COMMITTEE

Most tertiary institutions have a review board or ethics committee in place for situa-tions in which individuals/families need assistance in dealing with diffi cult decisions regarding what is right or fair care or when ethical decisions collide with legal and moral obligations of the institution. Th ese committees are usually multidisciplinary and composed of physicians and nurses from the various settings where many of the dilemmas arise, along with allied health care professionals such as an administrator, a member of the clergy, a social services representative, an attorney or risk management representative, and an ethicist (who actually may be one of the professionals previ-ously listed) ( Beauchamp and Childress, 2008 ). A layperson may be asked to serve on 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 process of ethical decision making. Th ere typically is also some time set aside to educate the members and for them to become accustomed as a group to the processes they will follow. Th e main functions of the committee are: • To develop and revise ethical policies and procedures such as informed consent,

confi dentiality, and advance directives • To assist with diffi cult ethical decisions related to health care It is recommended that there be a process in place for handling emergency situations and specifi ed people who must serve on the board to make decisions. Th e family should always be invited to provide input and to attend some part of the session when possible and when desired.

CLINICAL EXAMPLES OF ETHICAL DILEMMAS

Some clinical examples of ethical dilemmas that perinatal nurses face are listed in Box 8-3 .

CONCLUSION

Th e list of perinatal ethical decisions is much longer than that given in Box 8-3 . Some dilemmas are everyday issues. Others are likely to be encountered infrequently and then only in select tertiary perinatal centers. However, it is impossible to work in perinatal nursing and not become involved in ethical dilemmas or participate in ethical decision making. Th e nurse must not only examine issues in light of the level of participation she or he is willing to have but also facilitate an environment in which colleagues and patients can participate in ethical decisions. Th e nurse functions as educator, sup-port person, counselor, administrator, researcher, and care provider. Nurses spend more time with patients than any other health care team members do. As a result, nurses must take an active and assertive role in the development of ethical guidelines for areas of perinatal practice ( Follin, 2004; Beauchamp and Childress, 2008 ).


BIBLIOGRAPHY Albert 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 http://www.nursingworld.org/Main

MenuCategories/EthicsStandards/CodeofEthicsforNurses.aspx.

Association of Women’s Health, Obstetric, and Neonatal Nurses : Position statement: access to health care

issues , Washington, DC , 2005 , AWHONN .

• 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 infant

Box 8-3 Clinical Examples of Perinatal Ethical Dilemmas


Association 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 , 2000 b , AWHONN .

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College of Obstetricians and Gynecologists’ position on patient-choice surgery , Bioethics

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applications , ed 2 , Philadelphia , 2001 , Saunders .

Follin S , editor: Nurse’s legal handbook , ed 5 , Philadelphia , 2004 , Lippincott Williams & Wilkins .

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Obstet Gynecol 20 ( 2 ) : 116 – 119 , 2008 .

Kohlberg L : Essays on moral development. Vol I, Th e philosophy of moral development; Vol II, Th e psychology

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Lupton M : Termination of pregnancy by telemedicine: an ethicist’s viewpoint , Br J Obstet Gynecol

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1993 .

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22 ( 3 ) : 179 – 180 , 2008 .

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