Ethical Dilemmas in L&D Nursing

CEG · Dec 6, 2009

For me personally, my biggest ethical issue is patients who are undergoing procedures like induction or c-section for no good reason setting them up for additional risk. It's tough to educate your patients when it could be at the expense of your job. Physicians don't take too kindly to patient education when they have all of their patients coming in for induction at 39 +0 or scheduled section for "suspected macrosomia."

ladytraviler · Dec 7, 2009

For me one of the biggest issue is just because we can, does that mean we should? I know I will get flamed for this but will go ahead anyway. Just because we can save 22 to 24 weekers does that mean we should? What will the quality of life be? What will the health issues be? When is to young to survive?

I know of 24 weekers who are fine with minor problems. I also know of some that will never have a quality of life. When did God ceed the power of life to man? What will happen to the little one when one parent, or both, can't deal with the health problems after begging that every thing be done for little johnny? Society pays for these infants. When is enough enough?

rn/writer, RN · Dec 7, 2009

If you want an ethical dilemma that comes up fairly often, you don't have to look any further than circumcision. This is a topic that nurses are often asked about, probably much more so than the docs. In this forum, we have had some heated discussions about circumcision including this one that ran over 100 pages.

https://allnurses.com/ob-gyn-nursing/the-circumcision-discussion-195222.html

There are two parts to this dilemma.

The first is what you personally think/believe about the procedure itself. And the second is what you tell your patients.

Here is part of the position taken by the American Academy of Pediatrics:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

Some nurses feel so strongly that babies should not be routinely circumcised that they find themselves unable to provide impartial information.

This may not be as morally intense a debate as other issues that occur in L&D, but it could still make for an interesting paper because people feel so strongly about it and because it comes up often enough to create a real challenge for some nurses.

If you would, let us know what you choose.

Work in Progress · Dec 7, 2009

Thank you. These are all excellent ideas. I have thought about doing the circumcision issue and patient education. I don't think I would be able to write a very objective paper, however because I am still extremely irked by my mother-in-law insisting that we circumcise our son. He is seven months old now and she STILL is bringing up why we should have circed him. Ugh. Anyhow, I am going to think all of these over and I am still open to more suggestions! I really don't know how I am going to stretch this paper to 10 pages based on the criteria given. Please tell me that nursing school will actually end someday. Sometimes it doesn't feel like it ever will.

rn/writer, RN · Dec 7, 2009

Thank you. These are all excellent ideas. I have thought about doing the circumcision issue and patient education. I don't think I would be able to write a very objective paper, however because I am still extremely irked by my mother-in-law insisting that we circumcise our son. He is seven months old now and she STILL is bringing up why we should have circed him. Ugh. Anyhow, I am going to think all of these over and I am still open to more suggestions! I really don't know how I am going to stretch this paper to 10 pages based on the criteria given. Please tell me that nursing school will actually end someday. Sometimes it doesn't feel like it ever will.

This is a first-hand example of the kinds of internal wrestling matches that nurses can face.

I'm sure you'll come up with something good. And, yes, nursing school does eventually end. And most students actually live to tell about it.

CEG · Dec 7, 2009

Thank you. These are all excellent ideas. I have thought about doing the circumcision issue and patient education. I don't think I would be able to write a very objective paper, however because I am still extremely irked by my mother-in-law insisting that we circumcise our son. He is seven months old now and she STILL is bringing up why we should have circed him. Ugh. Anyhow, I am going to think all of these over and I am still open to more suggestions! I really don't know how I am going to stretch this paper to 10 pages based on the criteria given. Please tell me that nursing school will actually end someday. Sometimes it doesn't feel like it ever will.

If you are anything like me, if you choose the right topic you will find that 10 pages is not enough. Some of these topics are soooooo thought provoking. Find something you are passionate about.

littleneoRN · Dec 8, 2009

If you look back at some recent threads on this site, there is a lot of discussion about interventions during the birth process and nurses' feelings about them. Sometimes doctors and patients make decisions for interventions such as pitocin, artificial rupture of membranes, c-section, etc. that the nurse doesn't feel is in the best interest of the patient. Sometimes this is related to physician convenience, such as doing a c-section on a mom who is progressing slowly so she doesn't end up delivering in the middle of the night when the OB would prefer to be sleeping. He/she may tell parents the c-section is for failure to progress, but is it truly failure to progress or just failure to progress fast enough for physician convenience? The ethical dilemma then for your paper would be, does the nurse speak up an educate the patient on the risks and benefits or just go along with the plan?

rbytsdy · Dec 10, 2009

Women tend to lose all their rights when they become pregnant. I'm not talking about abortion rights at all. I'm talking about the right to make choices that she feels are in the best interest of her and her baby.

Here is an interesting case about a mom whose baby was removed by child protective services in NJ after she refused a c-section: http://lawlibrary.rutgers.edu/courts/appellate/a4627-06.opn.html

The c-section was actually unnecessary. The baby was born lady partslly and in good health (even at 35 weeks gestation) but the hospital was upset that she refused to sign a consent form for a c-section just in case (the c-s rate at the hospital is approaching 50%)

When I was laboring with my first baby, the doctor came in (after I'd been at the hospital for a whole 9 hours) and told me that I had a 5% chance of a lady partsl delivery because my pelvis was too small. After my c-section, the doctor said I had an oval shaped pelvis and would probably never birth lady partslly and advised that I schedule c-sections from now on. My 2nd baby was born lady partslly with no complications whatsoever. I am so grateful for my beautiful health children but that doctor just wanted to get me over with so he lied to me. He had no basis for his 5% statistic and was willing to subject me to the risks of surgery without bothering to tell me what it meant for my future health and my future births. It's funny how you cannot consent someone for a procedure after they have been given narcotics and you can only skip consenting someone in a life threatening emergency. I was completely doped up on drugs, not consented and there was no life threatening emergency. If that wasn't bad enough, when I began searching for a new provider to have a lady partsl birth the second time, there were several hospitals that refused to allow me to birth there unless I agreed to a repeat c-section. Since when can a hospital set policy to prohibit me from have a normal lady partsl birth? It's actually pretty scary but about 30% of hospitals have policies in place prohibiting women from having a lady partsl birth after a cesarean. Obviously, there is a lot of question about the risk but there are risks with repeat c-sections as well. Why can hospitals decide this?

littleneoRN · Dec 10, 2009

I definitely support VBAC in most situations, but I also think it is ok for hospitals to refuse to do VBACs. Not because I think it's a bad idea, but because I don't think all hospitals have the safety resources necessary to make this a safe, good thing for women. Although many women have successful VBACs, there is that chance of uterine rupture. The hospital needs to have the appropriate surgical team immediately available, and many small hospitals can't provide that. I would rather tham say they don't do VBACs and give me the opportunity to find another facility than to not have a policy but also not have the right resources. It's kind of like a hospital saying they won't deliver preterm mom's (if they can avoid it by transporting the mom out safely beforehand) because they don't have the appropriate resources if the baby needs significant intervention. And it wouldn't be so bad to sign a consent for a CS just-in-case if we could truly trust our providers to be honest and in mom and baby's best interest about when the CS is necessary.

rbytsdy · Dec 10, 2009

That makes a VBAC a good ethical dilemma then because if you refuse a VBAC by saying you can't handle it then you are not equipped to handle ANY birth. There is not such thing as a risk free birth. Any birth can have an emergency and women should be told up front that a hospital cannot handle obstetrical emergencies.

I called some hospitals about VBAC and asked what they do in the case of a cord prolapse or a placental abruption. The risk of a cord prolapse is about the same as the risk of uterine rupture in a VBAC mom who is not give induction drugs or pitocin. I was told they call anesthesia. I asked if anesthesia came and I was told, yes, they run right over. Then I asked why they couldn't handle a VBAC. I was told it was because of the "known" vs the "unknown" risk. I'd actually think the "unknown" risk would be harder to handle. I finally got the nurse to admit that the anesthesiologists just didn't want to deal with VBAC moms and the potential risk but they are okay with running in and saving the say when something unexpected happens in an otherwise healthy mom.

It still boils down to whether or not a hospital has a right to tell a woman she must have surgery (and how well are moms counseled on the risks of surgery vs the risks of VBAC) vs delivering the way nature intended. Is there any other situation where a person would be forced into surgery and not given the opportunity to refuse???

littleneoRN · Dec 12, 2009

Sort of a similar concept to home births. They say it's ok for low-risk moms. But we don't KNOW nothing will happen. But that doesn't mean we say it's ok for a high-risk mom to deliver at home just because problems also occur unexpectedly in low risk women.

Not to open a home-birth can of worms. Just sayin...