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Chapter 12 - Intrapartum Management

from Section 3 - Professionally Responsible Clinical Practice

Published online by Cambridge University Press:  01 November 2019

Laurence B. McCullough
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
John H. Coverdale
Baylor College of Medicine, Texas
Frank A. Chervenak
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
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This chapter provides an ethical framework to guide decision making about intrapartum management.

Most women deliver their babies vaginally. Vaginal delivery is clearly safer for the pregnant patient because no invasive clinical management is involved, even when fetal monitoring takes place. This clinical reality makes assisting vaginal delivery the default in clinical judgment, placing the burden of proof on justifying cesarean delivery. As a consequence, in traditional obstetric thinking, cesarean delivery is either indicated – the burden of proof is met – or nonindicated – the burden of proof is not met. When cesarean delivery is indicated, it should be recommended. When cesarean delivery is not indicated, it should not be offered, much less recommended.

Publisher: Cambridge University Press
Print publication year: 2019

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Kalish, RB, McCullough, LB, Chervenak, FA. Decision-making about caesarean delivery. Lancet 2006; 367: 883–845.CrossRefGoogle ScholarPubMed
Nguyen, MT, McCullough, LB, Chervenak, FA. The importance of clinically and ethically fine-tuning decision-making about cesarean delivery. J Perinat Med 2017; 45: 551557.CrossRefGoogle ScholarPubMed
McCullough, LB. The professional medical ethics model of decisionmaking under conditions of uncertainty. Med Care Rev Res 2013; 70(1 Suppl): 141S–58S.CrossRefGoogle Scholar
Kon, AA. The shared decision-making continuum. JAMA 2010; 304: 903904.CrossRefGoogle ScholarPubMed
Chervenak, FA, McCullough, LB. The unlimited-rights model of obstetric ethics threatens professionalism. BJOG 2017; 124: 11441147.CrossRefGoogle ScholarPubMed
Whitney, SN, McGuire, AL, McCullough, LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med 2003; 140: 5459.CrossRefGoogle Scholar
Chervenak, FA, McCullough, LB. Clinical guides to preventing ethical conflicts between pregnant women and their physicians. Am J Obstet Gynecol 1990; 162: 303307.CrossRefGoogle ScholarPubMed
Nicolaides, KH, Chervenak, FA, McCullough, LB, et al. Evidence-based obstetric ethics and informed decision-making about invasive diagnosis after first-trimester assessment for risk of trisomy 21. Am J Obstet Gynecol 2005; 193: 322326.CrossRefGoogle ScholarPubMed
Salmeen, K, Brincat, C. Time from consent to cesarean delivery during labor. Am J Obstet Gynecol 2013; 209: 212.e16.CrossRefGoogle ScholarPubMed
Martin, JA, Hamilton, BE, Ventura, SJ, Osterman, MJK, Wilson, EC, Mathews, TJ. Births: final data for 2010. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Vital Statistics Report. August 28, 2012; 61(1): 172. Available at (accessed March 1, 2019).Google Scholar
National Institutes of Health consensus development conference statement: vaginal birth after cesarean: new insights, March 8–10, 2010. Obstet Gynecol 2010; 115: 12791295.CrossRef
Chervenak, FA, McCullough, LB. An ethical framework for the informed consent process for trial of labor after cesarean delivery. Clin Perinatol 2011; 38: 227231.CrossRefGoogle ScholarPubMed
Chervenak, FA, McCullough, LB. Preventive ethics for cesarean delivery: the time has come. Am J Obstet Gynecol 2013; 209: 166167.CrossRefGoogle ScholarPubMed
Chervenak, FA, Romero, R. Is there a role for fetal cephalocentesis in modern obstetrics? Am J Perinatol 1984; 1: 170173.CrossRefGoogle Scholar
Chasen, S, Chervenak, FA, McCullough, LB. The role of cephalocentesis in modern obstetrics. Am J Obstet Gynecol 2001; 185: 734736.CrossRefGoogle ScholarPubMed
Chervenak, FA, Isaacson, G, Campbell, S. Anomalies of the cranium and its contents. In Textbook of Ultrasound in Obstetrics and Gynecology. Boston: Little, Brown, 1993: 825852.Google Scholar
Chervenak, FA, Berkowitz, RL, Tortora, M, et al. Management of fetal hydrocephalus. Am J Obstet Gynecol 1985; 151: 933937.CrossRefGoogle ScholarPubMed
Raimondi, AJ, Soare, P. Intellectual development in shunted hydrocephalic children. Am J Dis Child 1974; 127: 664.Google ScholarPubMed
McCullough, DC, Balzer-Martin, LA. Current prognosis in overt neonatal hydrocephalus. J Neurosurg 1982; 57: 378.CrossRefGoogle ScholarPubMed
Sutton, LN, Bruce, DA, Schut, L. Hydranencephaly versus maximal hydrocephalus: an important clinical distinction. Neurosurgery 1980; 6: 35.CrossRefGoogle Scholar
Lorber, J. The results of early treatment on extreme hydrocephalus. Med Child Neurol (Suppl) 1968; 16: 21.Google Scholar
Chervenak, FA, McCullough, LB. An ethically justified, clinically comprehensive management strategy for third-trimester pregnancies complicated by fetal anomalies. Obstet Gynecol 1990; 75: 311316.Google ScholarPubMed
Chervenak, FA, McCullough, LB. Justified limits on refusing intervention. Hastings Cent Rep 1991; 21: 1218.CrossRefGoogle ScholarPubMed
Brett, AS, McCullough, LB. When patients request specific interventions: defining the limits of the physician’s obligation. N Engl J Med 1986; 315: 13471351.CrossRefGoogle ScholarPubMed
Brett, AS, McCullough, LB. Addressing requests by patients for non-beneficial interventions. JAMA 2012; 307: 149150.CrossRefGoogle Scholar
McCullough, LB. Was bioethics founded on historical and conceptual mistakes about medical paternalism? Bioethics 2011; 25: 6674.CrossRefGoogle ScholarPubMed
Annas, GJ. Protecting the liberty of pregnant patients. N Engl J Med 1987; 316: 12131214.CrossRefGoogle ScholarPubMed
Minkoff, H, Marshal, MF, Liashenko, J. The fetus and the “potential child,” and the ethical obligations of obstetricians. Obstet Gynecol 2014; 123: 11001103.CrossRefGoogle Scholar
DeSisto, MJ, Harding, CM, McCormick, RV, et al. The Maine and Vermont three-decade studies of serious mental illness.I. Matched comparison of cross-sectional outcome. Brit J Psychiatry 1995; 167: 331338.CrossRefGoogle ScholarPubMed
Howard, LM, Kumar, C, Leese, M, et al. The general fertility rate in women with psychotic disorders. Am J Psychiatry 2002; 159: 991997.CrossRefGoogle ScholarPubMed
Miller, LJ, Finnerty, M. Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders. Psychiatr Serv 1996; 47: 502506.Google ScholarPubMed
Teplin, LA, McClelland, GM, Abram, KM, et al. Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey. Arch Gen Psychiatry 2005; 62: 911921.CrossRefGoogle ScholarPubMed
McCullough, LB, Coverdale, JH, Chervenak, FA. Ethical challenges of decision making with pregnant patients who have schizophrenia. Am J Obstet Gynecol 2002; 187: 696702.CrossRefGoogle ScholarPubMed
McCullough, LB, Coverdale, J, Bayer, T, Chervenak, FA. Ethically justified guidelines for family planning interventions to prevent pregnancy in female patients with chronic mental illness. Am J Obstet Gynecol 1992; 167: 1925.CrossRefGoogle ScholarPubMed
Miller, LJ. Psychotic denial of pregnancy: phenomenology and clinical management. Hosp Community Psychiatry 1990; 41: 1233–1137.Google ScholarPubMed
Webb, R, Abel, K, Pickles, A, Appleby, L. Mortality in offspring of parents with psychotic disorders: a critical review and meta-analysis. Am J Psychiatry 2005; 162: 10451056.CrossRefGoogle ScholarPubMed
Jablensky, AV, Morgan, V, Zubrick, SR, Bower, C, Yellachich, L-A. Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. Am J Psychiatry 2005; 62: 7991.CrossRefGoogle Scholar
Schneid-Kofman, N, Sheiner, E, Levy, A. Psychiatric illness and adverse pregnancy outcome. Int J Gynecol Obstet 2008; 101: 5256.CrossRefGoogle ScholarPubMed
Spielvogel, A, Wile, J. Treatment and outcomes of psychotic patients during pregnancy and childbirth. Birth 1992; 19: 131137.CrossRefGoogle ScholarPubMed
Coverdale, JH, McCullough, LB, Chervenak, FA. Assisted and surrogate decision making for pregnant patients who have schizophrenia. Schizophr Bull 2004; 30: 659664.CrossRefGoogle ScholarPubMed
Babbitt, KE, Bailey, KJ, Coverdale, JH, Chervenak, FA, McCullough, LB. Professionally responsible management of patients with major mental disorders. Am J Obstet Gynecol 2014; 210: 2731.CrossRefGoogle ScholarPubMed
American College of Obstetricians and Gynecologists.Use of psychiatric medications during pregnancy and lactation. ACOG Pract Bull 2008; 111: 10011020.
Ryding, EL, Wijma, B, Wijma, K. Posttraumatic stress reactions after emergency cesarean section. Acta Obstet Gynecol Scand 1997; 76: 856861.CrossRefGoogle ScholarPubMed
Giacino, JT, Katz, DI, Schiff, ND, Whyte, J, et al. Practice guideline update recommendations summary: disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology 2018; 91: 450460.CrossRefGoogle ScholarPubMed
Russell, JA, Epstein, LG, MD, Greer, DM, Kirschen, M, et al., on behalf of the Brain Death Working Group. AAN Position Statement. Brain death, the determination of brain death, and member guidance for brain death accommodation requests. Neurology 2019; 92: 15.CrossRefGoogle Scholar
Esmaeilzadeh, M, Dictus, C, Kayvanpour, E, et al. One life ends, another begins: management of a brain-dead pregnant mother – a systematic review. BMC Medicine 2010; 8: 74.CrossRefGoogle ScholarPubMed
American College of Obstetricians and Gynecologists. ACOG Committee Opinion Number 761. Cesarean delivery on maternal request. Obstet Gynecol 2019; 133: e.7377.CrossRef
Chervenak, FA, McCullough, LB. An ethically justified algorithm for offering, recommending, and performing cesarean delivery and its application in managed care practice. Obstet Gynecol 1996; 87: 302305.CrossRefGoogle ScholarPubMed
Kingwani, P. Risk Management – An Analytical Study. IOSR Journal of Business and Management. February 2014, 8389. Available at (accessed July 31, 2019).
Sheen, JJ, Wright, JD, Goffman, D, et al. Maternal age and risk for adverse outcomes. Am J Obstet Gynecol 2018; 219: 390.e115.CrossRefGoogle ScholarPubMed
Tita, ATN, Jablonski, KA, Bailit, JL, et al. Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity. Am J Obstet Gynecol 2018; 219: 296.e18.CrossRefGoogle ScholarPubMed
Johnson, JK, Miller, SH, Horowitz, SD. Systems-based practice: improving the safety and quality of patient care by recognizing and improving the systems in which we work. In Henriksen, K, Battles, JB, Keyes, MA, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Research and Quality (US); August 2008. Available at (accessed January 13, 2019).Google Scholar
Grünebaum, A, McCullough, LB, Sapra, KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006–2009. Am J Obstet Gynecol 2014; 211: 390.e1–7.CrossRefGoogle ScholarPubMed
Grünebaum, A, McCullough, LB, Sapra, KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol 2013; 209: 323.e16.CrossRefGoogle ScholarPubMed
Grünebaum, A, McCullough, LB, Brent, RL, Arabin, B, Levene, MI, Chervenak, FA. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol 2015; 212: 350.e1–6.CrossRefGoogle ScholarPubMed
Wax, JR, Lucas, FL, Lamont, M, Cartin, A, Blackstone, J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010; 203: 243.e18.CrossRefGoogle ScholarPubMed
Snowden, JM, Tilden, EL, Snyder, J, Quigley, B, Caughey, AB, Cheng, YW. Planned out-of-hospital birth and birth outcomes. N Engl J Med 2015; 373: 26422653.CrossRefGoogle ScholarPubMed
American Academy of Pediatrics: Policy Statement Planned Home Birth. Pediatrics 2013; 131: 10161020.CrossRef
Gigerenzer, G, Galesic, M. Why do single event probabilities confuse patients? statements of frequency are better for communicating risk. BMJ; 2012; 344: e245.CrossRefGoogle Scholar
Publications Committee, Society for Maternal-Fetal Medicine. Placenta accreta. Am J Obstet Gynecol 2010; 203: 430439.CrossRef
ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010; 116: 450463.CrossRef
Rasmussen, SA, Jamieson, DJ, Uyeki, TM. Effects of influenza on pregnant women and infants. Am J Obstet Gynecol 2012; 207: S38.CrossRefGoogle ScholarPubMed
Farr, A, Chervenak, FA, McCullough, LB, Baergen, RN, Grünebaum, A. Human placentophagy: a review. Am J Obstet Gynecol 2017; 218: 401.e1–11.Google ScholarPubMed
Ecker, J. Minkoff home birth: what are physicians’ ethical obligations when patient choices may carry increased risk? Obstet Gynecol 2011; 117: 11791182.CrossRefGoogle ScholarPubMed
Minkoff, H, Ecker, J. A reconsideration of home birth in the United States. J Clin Ethics 2013; 24: 207214.Google ScholarPubMed
Chervenak, FA, McCullough, LB. The unlimited-rights model of obstetric ethics threatens professionalism. BJOG 2017; 124: 11441147.CrossRefGoogle ScholarPubMed

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