Perinatal Ethical Dilemmas

Perinatal nursing has a high prevalence of ethical issues that arise with the type of care expected to be performed. These nurses have a very large role in terms of their involvement in the development of the fetus in and out of the womb, in conjunction with the wellbeing of the mother before, during and after labour. Perinatal nurses are under the leadership of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), who provide standards of practice used along with the standards of the Canadian Nurses Association (CNA) (AWHONN, 2009).

Health issues present for the patients cared for in this area of nursing vary exponentially, anywhere from hemorrhage to prevalence of morbidity and infection for both mom and baby, to appropriate adaptation towards life changes that come with pregnancy and after childbirth. Perinatal nurses are tasked with helping the family prepare for the newly arriving child by explaining best health practices and options for care (breastfeeding or formula); setting the stage for the world the baby will be born into, while identifying pre/postpartum complications and the management of high-risk pregnancies to promote best possible health outcomes for both patients involved.

With such a large role in a key developmental period the relevance of perinatal nursing has never been in question. The increasing knowledge in this area and ever evolving technological advancements in health care as a whole, perinatal nursing remains a prevalent in patient care with the need for focused attention. However, with this increased knowledge and advancements in technology comes ethical dilemmas in which nurses must face when advocating for both the fetus and the childbearing person.

Perinatal nursing is a specialty, much like any other, is plagued with various ethical dilemmas. Ethical issues faced by this particular area of nursing explored in this paper areas follows; 1) Routine opt-out HIV testing’s, these blood tests are performed during pregnancy to screen for the risk of HIV transmission from mother to baby. These patients have the opportunity to “opt-out” of the HIV testing if they so choose, however studies have shown some mothers aren’t even aware of said testing, taking away their option to decide for themselves if they want to get tested (Fields, 2011). Taking away this choice is disregarding patient autonomy and informed consent, which are two very important aspects of healthcare. Nurses try to uphold patient autonomy and informed consent as advocates of the patients on the point that “preservation of the right to autonomy is achieved through informed consent” (Fields, 2011). However, many practitioners are in favour of this as it important for the health of the baby and limits the risk of HIV transmission (through vaginal delivery, breastfeeding), which also has an effect on societal health (Fields, 2011). Societal health has a major factor in this dilemma because knowing the HIV status of the mother/baby is important to protection of the health of others as the virus can be transmitted through contact with fluids of the infected person. Furthermore, the questionable presence of coerced decision making by providing the opportunity for informed consent for prenatal HIV testing, the childbearing person may feel pressured to do so. 2) Providing care to a substance abusing mother and the fetus, where the ethical dilemma is how long should you work with the mother towards healthy living and in turn, a healthy life for her child before her condition is too damaging to the fetus and now must be dealt with in court (Tillett, 2001). This issue causes ethical distress in many nurses as they try to focus on atraumatic care, including all persons involved in the care of the fetus/newborn, which concerns the person bearing the child. Should the health of the fetus be compromised by possible relapse or refusal of terminating drug addictions by the mother, which could affect the health of the developing baby in a negative manner, and how long until legal action should be taken to protect the fetus’ bets interest? This ongoing dilemma causes stress within nurses on this assignment as they have duties to both the fetus, in terms of advocacy and health promotion, and the childbearing person, in terms of health and autonomy promotion to seek help for addiction. 3) Resuscitation of low birth weight premature newborns. Research has shown that babies born between 22-24 weeks have low birth weights, on average and only have a survival rates from 5% to 45% in best cases (Wilder, 2000). The ethical issue presented concerns the nurse with the concern of quality of life in terms of the pain and suffering of the newborn and the parents and evaluating the newborns social worth which is “measured by the degree of benefit or burden to others”, primarily the parents (Wilder, 2000). With this evaluation a decision must be made by the health care team (including the parents) if extreme resuscitation measures should be taken to preserve life if a good outcome is unlikely and that the newborn will have a long history of increased risk and presence health complications, keeping in mind the legal rights of the newborn, as well as the values and beliefs of the family.

Nursing values are what drives nurses across all areas to help determine their priorities towards their patients in respect to the care being provided. Core nursing values that are important to nurses working in this context under these ethical issues are A) providing safe, compassionate, competent and ethical care, B) promoting health and wellbeing, and C) promoting and respecting informed decision making (CNA, 2017). Providing safe, compassionate, competent and ethical care plays a hand in each one of the outlined ethical dilemmas mentioned above. In each instance the nurse involved would be keeping in mind the best possible outcomes for their patients in question while supporting them and ensuring the care being provided is safe, especially in the instance of the substance abusing mother. The nurse would be trying to provide compassionate care to the mother who may be trying to undergo the difficult process rehabilitation after a history of drug addiction, whether they are successful or not, while ensuring the safety of the fetus developing inside that person, taking an atraumatic approach. Promoting health and wellbeing is valued by all nurses as it is the essence of their career. This value can be exemplified in the event of the resuscitation of the premature newborn, where the nurse’s efforts are dedicated to the promotion of the health and wellbeing of the newborn but also taking into consideration the stress, pressures and possible sense of burden placed upon the parents and how that effects their health and wellbeing. The nursing value of promoting and respecting informed decision making is compromised in the case of the opt out HIV testing. As mentioned above, nurses usually promote patient autonomy and when these tests are being done the women aren’t always aware of the extent of the test, taking away their autonomy and choice, however is that deemed okay when it could affect the child and society in the long run? With nursing values compromised this leads to moral distress within the nurses working in this context.

There are disconnects in each case concerning the impression of the nursing role should be and what is could be in each situation. The role of the nurse in all scenarios is to act as the advocate for their patients and promoting the best possible outcomes for said patient. In the event of HIV testing the nursing role as the patient advocate stays strong and active, however the role of an educator should be enforced to ensure proper informed consent rather than assumed consent. With the possibility of substance abuse, the nurse is concerned with the mother as well as the baby and serves as an educator to promote the health of each patient and as a support system, be as it may if legal action is to be taken against the mother (i.e. the refusal for treatment, causing a maternal-fetal conflict and endangering the wellness of the fetus) the role of the nurse lessens until the decision has been made by the court system (Tillett, 2001). The ethical discussion made with the preterm baby, nurses are there to provide the prescribed care in a compassionate and safe matter, despite the strong therapeutic relationship built and the role of patient advocacy, the nurse does not have a huge role to play with this decision as it is usually decided by the parents and physician, seemingly beyond the scope of practice of the nurse involved unless it is classified as an emergency or pandemic (CAN, 2017).

There is an abundance of ethical issues present with in the realm of perinatal nursing each as unique as the last. The effects of informed consent being assumed rather than sought, risks of substance abuse on the developing fetus and resuscitation of newborns are just three instances causes moral distress in nurses. Registered nurses in this area are concerned with upholding their values as well as the health, wellbeing and autonomy of their patients. This area of nursing is very interesting as the nurses involved are part of the care of the mother and baby from before birth until after the delivery. Nurses involved in this area of nursing develop a strong rapport with their patients and playing a large role in their care and are able to be a part of one of the most intense aspects of care, labour and delivery.

Despite all the possibilities for ethical dilemmas to arise, I personally would love the opportunity to work in this specific area as a registered nurse. I would love to be part of a such a pivotal life change in the parents’ life and such a crucial developmental period for the fetus. I also feel like playing an active role in labour and delivery would be exhilarating as well. Perinatal nursing is an area in need of focused nursing attention to attend to the ethical dilemmas that may be presented to prevent the moral distress rate of the nurses in said specialty to avoid possible high turnover among nurses in this profession.