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  • Author: Laurence B. McCullough x
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The current controversy concerning patient choice cesarean delivery potentially affects all women of child-bearing age and the physicians who care for them. The purpose of this paper is to address three salient issues within the patient choice cesarean delivery controversy. First, is performing patient choice cesarean delivery consistent with good professional medical practice? Second, how should physicians respond to or counsel patients who request patient choice cesarean delivery? And, third, should patient choice cesarean delivery be routinely offered to all pregnant women?


In obstetric practice, each pregnant woman presents with a composite of maternal and fetal characteristics that can alter the risk of significant harm without cesarean intervention. The hospital’s availability of resources and the obstetrician’s training, experience, and skill level can also alter the risk of significant harm without cesarean intervention. This paper proposes a clinical ethical framework that takes these clinical and organizational factors into account, to promote a deliberative rather than simplistic approach to decision-making and counseling about cesarean delivery. The result is a clinical ethical framework that should guide the obstetrician in fine-tuning his or her evidence-based, beneficence-based analysis of specific clinical and organizational factors that can affect the strength of the beneficence-based clinical judgment about cesarean delivery. We illustrate the clinical application of this framework for three common obstetric conditions: Category II fetal heart rate tracing, prior non-classical cesarean delivery, and breech presentation.


Aim: To explore whether the Groningen Protocol is clinically necessary, scientific, and ethically justified.

Results: The Groningen Protocol is clinically unnecessary because the withdrawal of life-sustaining treatment from seriously ill infants is already ethically accepted globally without the need for the Protocol and because spina bifida, to which the Protocol has been most often applied, can be detected by ultrasound before viability, affording pregnant women the opportunity of termination of pregnancy. The Groningen Protocol is unscientific because it does not meet the accepted standards of evidence-based reasoning concerning the four clinical criteria for its application. The Groningen Protocol is unethical because it does not meet the standards of argument-based ethics in defining its four clinical criteria.

Conclusions: The Groningen Protocol is clinically unnecessary, unscientific, and unethical. Physicians should condemn its use. The Dutch Association of Paediatrics should revoke its approval and adoption of the Groningen Protocol.



Sudden severe fetal compromise during labor is usually associated with fetal bradycardia often due to sudden emergencies such as abruptio placentae, cord prolapse, disruption of the umbilical cord, shoulder dystocia, tetanic contractions or uterine rupture.

Case presentation

We report on a case of sudden severe fetal compromise due to umbilical cord prolapse in a patient with a planned home birth. Cord prolapse and thick meconium stained fluid were diagnosed at a planned home birth at the time of spontaneous rupture of fetal membranes with the cervix 3 cm dilated. An ambulance was called, and the patient was transferred by ambulance to the nearby hospital where the baby was delivered about 60 min after the diagnosis of the cord prolapse. Neonatal resuscitation was unsuccessful, and the newborn was declared dead.


Our case shows that sudden severe fetal compromise during labor and delivery can happen to even low-risk patients. When it happens at home, delay of delivery can lead to neonatal injury or death. Women who express an interest in a planned home birth must be informed of potential risks of sudden severe fetal compromise leading to neonatal injury or death when it occurs in a planned home birth and when transport to the hospital unavoidably delays timely medical interventions and delivery of the newborn.


Ethics is an essential component for the responsible clinical management of multiple gestation and decision-making about such pregnancies with pregnant women. The ethical concept of the fetus as a patient is presented as the basis for identifying a professionally responsible approach to selective termination, twin-to-twin transfusion syndrome, and to discordant beneficence-based obligations that exist when one or more fetuses are adversely affected by a fetal anomaly or complication of pregnancy. The roles for directive counseling, i.e., making evidence-based recommendations, and for non-directive counseling, i.e., offering evidence-based alternatives but making no recommendations, are described. The professional responsibility model of perinatal ethics creates a practical framework to guide the clinical judgment of perinatologists and the informed process about the clinical management of multiple pregnancies.