The assessment process reveals a critical juncture in the credentialing of a North American fetal surgery consultant, specifically concerning operative principles, instrumentation, and energy device safety. This scenario is professionally challenging because it demands a rigorous evaluation of a candidate’s practical skills and theoretical knowledge in a high-stakes, technically demanding field where patient safety is paramount. Errors in judgment or application of principles can have catastrophic consequences for both the fetus and the mother. Careful judgment is required to ensure the consultant possesses not only the technical proficiency but also the ethical understanding and adherence to safety protocols mandated by North American regulatory bodies and professional surgical standards. The best approach involves a comprehensive review of the candidate’s documented operative experience, including detailed case logs with outcomes, peer-reviewed publications demonstrating innovation or refinement of techniques, and direct observation or simulation of complex procedures. This approach is correct because it aligns with the principles of evidence-based practice and competency assessment. Regulatory bodies and credentialing committees in North America emphasize a multi-faceted evaluation that includes demonstrated surgical skill, understanding of anatomical nuances, mastery of specialized instrumentation, and a thorough grasp of energy device physics and safety parameters to minimize collateral tissue damage. Ethical obligations to patient welfare and the principle of “do no harm” are intrinsically linked to possessing and applying this comprehensive knowledge and skill set. An approach that relies solely on a written examination without practical assessment or peer validation is professionally unacceptable. This fails to adequately gauge the candidate’s ability to translate theoretical knowledge into safe and effective clinical practice, a core requirement for operative competence. It also neglects the ethical imperative to ensure a surgeon can manage the complexities and potential complications inherent in fetal surgery. Another unacceptable approach is to prioritize the candidate’s experience with a broad range of surgical procedures over specialized fetal surgery expertise. While general surgical experience is valuable, fetal surgery requires highly specific skills, knowledge of unique instrumentation, and an understanding of the delicate fetal environment. Focusing on breadth rather than depth in this context represents a failure to meet the specialized credentialing requirements and poses a significant risk to patients. Furthermore, an approach that accepts self-reported proficiency with energy devices without objective verification or documented training is also professionally unsound. Energy devices, while essential, carry inherent risks. A consultant must demonstrate a clear understanding of their safe application, including appropriate settings, tissue interaction, and troubleshooting, to prevent iatrogenic injury. This lack of objective verification violates the ethical duty to ensure competence and patient safety. Professionals should employ a decision-making framework that begins with clearly defined credentialing criteria based on established best practices and regulatory guidelines. This framework should incorporate a blend of objective assessments (e.g., simulation, direct observation), subjective evaluations (e.g., peer review, case log analysis), and a thorough review of the candidate’s educational and experiential background. Continuous learning and adaptation to new technologies and techniques must also be considered. The ultimate goal is to ensure that only those individuals who have demonstrated the highest level of competence and ethical commitment are granted credentials to perform complex procedures, thereby safeguarding patient well-being.

This scenario is professionally challenging because it requires a fetal surgeon to balance the immediate, life-saving needs of a fetus with the long-term implications for the child and the family, all while navigating complex ethical considerations and the evolving landscape of fetal interventions. The decision-making process must be rigorous, evidence-based, and deeply rooted in patient autonomy and beneficence. Careful judgment is required to assess not only the technical feasibility of the surgery but also the potential risks, benefits, and the overall quality of life post-intervention, considering the limited data available for novel procedures. The best approach involves a comprehensive, multidisciplinary risk assessment that prioritizes informed consent and shared decision-making. This entails a thorough evaluation of the fetal condition, the potential surgical outcomes, the known and unknown risks of the procedure, and the expected long-term prognosis. Crucially, this assessment must be communicated transparently to the expectant parents, ensuring they understand the uncertainties and have the opportunity to ask questions and express their values and preferences. This aligns with the ethical principles of beneficence (acting in the best interest of the patient) and non-maleficence (avoiding harm), as well as the regulatory imperative for robust informed consent processes that empower patients to make autonomous decisions. An incorrect approach would be to proceed with surgery based solely on the technical possibility or a perceived high likelihood of success without a thorough exploration of all potential risks and uncertainties with the parents. This fails to uphold the principle of informed consent, as the parents would not be adequately equipped to make a truly autonomous decision. Another incorrect approach would be to rely solely on the opinions of a limited surgical team without engaging other specialists, such as neonatologists, genetic counselors, and pediatric subspecialists. This oversight neglects the holistic care needs of the child and can lead to suboptimal post-operative management and a failure to address potential co-morbidities. Finally, an approach that prioritizes the novelty of the procedure or institutional prestige over the individualized needs and well-being of the patient and family would be ethically indefensible, as it deviates from the core tenet of patient-centered care. Professionals should employ a structured decision-making framework that begins with a thorough diagnostic workup, followed by a comprehensive risk-benefit analysis involving a multidisciplinary team. This analysis should be translated into clear, understandable language for the expectant parents, facilitating a shared decision-making process. Regular communication, ongoing reassessment of the fetal and maternal condition, and a commitment to transparency throughout the entire process are paramount.

This scenario is professionally challenging because it requires balancing the integrity of a high-stakes credentialing process with the need for fair and consistent application of policies. The consultant’s desire to expedite the process due to a critical patient case creates a conflict between immediate patient needs and established procedural safeguards designed to ensure competence and patient safety. Careful judgment is required to navigate this tension without compromising the credentialing standards. The best professional approach involves adhering strictly to the established blueprint weighting, scoring, and retake policies, even in urgent situations. This means the consultant must complete the standard credentialing process, including any required retakes, as outlined by the Elite North American Fetal Surgery Consultant Credentialing body. This approach is correct because it upholds the integrity and validity of the credentialing program. Regulatory frameworks for medical credentialing, while not explicitly detailed in the prompt, universally emphasize standardized, objective evaluation to ensure that all practitioners meet a defined level of competence before being granted privileges. Deviating from these policies, even for a compelling reason, risks undermining the credibility of the credentialing process and could set a dangerous precedent. Ethically, this approach prioritizes patient safety by ensuring that all consultants, regardless of urgency, have demonstrably met the required standards. An incorrect approach would be to bypass or significantly alter the standard retake policy due to the urgent patient case. This fails to acknowledge the purpose of the retake policy, which is to ensure mastery of essential knowledge and skills that may not have been adequately demonstrated in the initial attempt. Allowing an exception undermines the objective scoring and weighting mechanisms designed to identify potential gaps in competence. This could lead to a situation where a consultant is credentialed without fully meeting the established standards, posing a direct risk to future patients. Another incorrect approach would be to rely solely on the consultant’s reputation or the urgency of the current case to grant provisional credentialing without adherence to the retake policy. While reputation and urgency are important considerations in healthcare, they cannot substitute for a formal, objective assessment of competence as defined by the credentialing blueprint. This approach disregards the structured evaluation process and the specific weighting and scoring criteria that are in place to ensure a consistent and reliable assessment of a consultant’s qualifications. A final incorrect approach would be to seek a waiver for the retake requirement from a superior without a formal, documented process for such waivers, or without ensuring that the waiver process itself adheres to the spirit of the original credentialing policies. This bypasses the established governance of the credentialing program and introduces subjectivity that can lead to inconsistencies and potential bias. It fails to provide a transparent and defensible rationale for deviating from the established policies. Professionals should employ a decision-making framework that prioritizes adherence to established policies and procedures, especially in credentialing. This involves understanding the rationale behind each policy, assessing the potential risks of deviation, and seeking to resolve conflicts through established channels for policy review or exception requests, ensuring that any exceptions are rigorously justified and documented, and do not compromise patient safety or the integrity of the credentialing process.

This scenario is professionally challenging because it requires a fetal surgeon to balance the immediate need for a complex procedure with the potential for unforeseen complications that could impact both the fetus and the mother. The decision-making process must prioritize patient safety, informed consent, and adherence to established credentialing standards, all within the framework of North American medical practice. Careful judgment is required to assess the surgeon’s preparedness for rare but severe adverse events. The best approach involves a comprehensive review of the surgeon’s documented experience with the specific fetal surgical procedure, including a detailed analysis of their management of any intraoperative or postoperative complications encountered in prior cases. This includes examining case logs, peer reviews, and any reported adverse events. This approach is correct because it directly addresses the core requirement of subspecialty procedural knowledge and complications management by seeking concrete evidence of the surgeon’s competence in handling the complexities of fetal surgery and its potential pitfalls. It aligns with the ethical principle of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm) by ensuring the surgeon has a proven track record of managing risks. Furthermore, credentialing bodies in North America mandate rigorous evaluation of a physician’s experience and ability to manage complications as a prerequisite for granting privileges for advanced procedures. An incorrect approach would be to rely solely on the surgeon’s self-reported confidence in their ability to manage complications, without independent verification of their past performance. This fails to meet the standard of due diligence expected of credentialing committees and overlooks the critical need for objective evidence of competence. It also presents a regulatory failure by not adhering to established credentialing protocols that require verifiable experience. Another incorrect approach would be to approve the credentialing based on the surgeon’s successful completion of a fellowship program, without further scrutiny of their independent practice experience and complication management. While fellowship training is essential, it does not guarantee proficiency in managing the full spectrum of complications that can arise in independent practice, especially in a highly specialized field like fetal surgery. This represents an ethical lapse by potentially placing patients at risk due to insufficient oversight of practical application of knowledge. A further incorrect approach would be to approve the credentialing based on the surgeon’s reputation within the broader surgical community, without specific focus on their fetal surgery complication management. While reputation is a factor, it is not a substitute for direct evidence of expertise in the specific subspecialty and the ability to handle its unique challenges. This approach risks overlooking critical skill gaps and is a failure to meet the specific requirements of credentialing for a highly specialized procedure. Professionals should employ a systematic risk assessment framework that begins with defining the specific procedural risks and potential complications. This should be followed by a thorough review of the applicant’s documented experience, focusing on their demonstrated ability to prevent, identify, and manage these specific complications. Peer review and consultation with experts in the field are crucial steps to validate the assessment. The decision should be based on objective evidence of competence and a clear understanding of the applicant’s capacity to ensure patient safety.

The performance metrics show a concerning trend in patient outcomes for a specific complex fetal surgery procedure. This scenario is professionally challenging because it requires a consultant to critically evaluate their own practice and potentially acknowledge areas for improvement, while balancing patient care continuity and the reputation of the surgical team. Careful judgment is required to distinguish between statistical anomalies and systemic issues that necessitate intervention. The best approach involves a comprehensive, data-driven review of the performance metrics, coupled with a proactive engagement with relevant professional bodies and hospital credentialing committees. This includes a thorough analysis of the specific cases contributing to the trend, identifying potential contributing factors such as patient selection, surgical technique variations, or post-operative care protocols. Subsequently, initiating a formal discussion with the credentialing committee to present findings and propose a remediation plan, which might include peer review, additional training, or protocol adjustments, demonstrates a commitment to patient safety and adherence to the highest standards of professional conduct. This aligns with the ethical imperative to provide competent care and the regulatory requirement for ongoing professional practice evaluation. An incorrect approach would be to dismiss the performance metrics as mere statistical fluctuations without a rigorous investigation. This fails to acknowledge the potential for patient harm and neglects the professional responsibility to self-assess and improve. Such inaction could be construed as a failure to uphold the duty of care and a disregard for the established credentialing processes designed to ensure consultant competency. Another incorrect approach is to focus solely on external factors, such as blaming referring physicians or resource limitations, without a critical self-examination of surgical technique or decision-making. While external factors can play a role, a professional consultant must first exhaust all possibilities within their own sphere of influence and practice. This approach avoids accountability and hinders the identification of actionable improvements. Finally, an approach that involves withholding information from the credentialing committee or misrepresenting the data would be a severe ethical and regulatory breach. Transparency and honesty are paramount in credentialing processes, and any attempt to obscure or manipulate information undermines the integrity of the system and jeopardizes patient safety. Professionals should approach such situations by adopting a framework of continuous quality improvement. This involves a commitment to data integrity, objective self-assessment, open communication with peers and oversight bodies, and a willingness to implement evidence-based changes to practice. The primary focus must always remain on optimizing patient outcomes and ensuring the highest standards of care.

The efficiency study reveals a critical need to streamline the credentialing process for Elite North American Fetal Surgery Consultants. This scenario is professionally challenging because it requires balancing the imperative of rapid access to highly specialized surgical expertise with the absolute necessity of ensuring patient safety and maintaining the integrity of the credentialing standards. Misjudgments in eligibility criteria or process oversight could lead to unqualified individuals gaining access to vulnerable patient populations, or conversely, unnecessarily delaying access to vital care. The best approach involves a comprehensive review of an applicant’s documented surgical outcomes, peer-reviewed publications specifically in fetal surgery, and evidence of advanced fellowship training in fetal medicine and surgery, alongside a rigorous assessment of their participation in multidisciplinary fetal care teams. This aligns with the core purpose of Elite North American Fetal Surgery Consultant Credentialing, which is to identify and recognize individuals who have demonstrated exceptional skill, knowledge, and experience in this highly specialized field, thereby ensuring the highest standards of patient care and safety. Regulatory frameworks and ethical guidelines for medical credentialing universally prioritize patient well-being and require objective, evidence-based assessments of competence. An approach that prioritizes only the number of years in general pediatric surgery practice, without specific validation of fetal surgery experience or outcomes, fails to meet the specialized nature of this credentialing. This overlooks the unique skill set and knowledge required for fetal interventions, potentially leading to the credentialing of individuals who lack the requisite expertise, posing a direct risk to patients. Another unacceptable approach would be to grant provisional credentialing based solely on a letter of recommendation from a senior surgeon, irrespective of the applicant’s individual documented qualifications or performance. While recommendations are valuable, they are subjective and do not replace objective evidence of competence. This bypasses the essential due diligence required to verify the applicant’s actual capabilities and adherence to established standards, creating a significant ethical and safety vulnerability. Furthermore, an approach that relies primarily on the applicant’s self-reported experience without independent verification or peer review is fundamentally flawed. Self-reporting is prone to bias and lacks the objective validation necessary for high-stakes credentialing. This method fails to uphold the principle of accountability and rigorous assessment that underpins professional medical credentialing. Professionals should employ a decision-making framework that begins with a clear understanding of the credentialing body’s mandate and the specific requirements for the credential being sought. This involves meticulously evaluating all submitted documentation against established, objective criteria. When faced with ambiguity or incomplete information, the professional reasoning process dictates seeking clarification, requesting additional evidence, and consulting with relevant experts or committees to ensure a fair and thorough assessment that prioritizes patient safety and upholds professional standards.

The scenario of a candidate preparing for Elite North American Fetal Surgery Consultant Credentialing presents a significant professional challenge due to the high stakes involved. The credentialing process ensures that only highly competent and ethically sound individuals are entrusted with the care of critically ill fetuses and their families. Missteps in preparation can lead to delays in credentialing, potential gaps in patient care, or even reputational damage. Careful judgment is required to navigate the complex requirements and ensure a thorough, compliant, and efficient preparation. The best approach involves a structured, proactive engagement with the credentialing body’s guidelines and a realistic timeline. This includes meticulously reviewing all stated requirements for documentation, education, experience, and any specific competency assessments. Candidates should allocate ample time for gathering supporting materials, such as letters of recommendation, surgical logs, and proof of continuing medical education, anticipating potential delays in obtaining these from third parties. Furthermore, dedicating sufficient time for self-assessment against the credentialing criteria and seeking mentorship from already credentialed consultants can identify potential gaps early. This proactive and thorough method aligns with the ethical imperative to ensure patient safety and the professional responsibility to meet established standards of practice. It also reflects a commitment to transparency and due diligence, which are foundational to professional credentialing. An incorrect approach would be to rely solely on informal advice from colleagues without cross-referencing official documentation. While collegial advice can be helpful, it may not always be up-to-date or fully encompass the nuances of the specific credentialing body’s requirements. This can lead to the submission of incomplete or incorrect information, causing delays and requiring resubmission, which is inefficient and potentially impacts patient access to care. Another incorrect approach is to underestimate the time required for gathering and verifying documentation. This often results in a rushed submission, increasing the likelihood of errors or omissions. Such haste can be perceived as a lack of seriousness or diligence, undermining the candidate’s professionalism and potentially leading to rejection or a request for extensive revisions. This approach fails to uphold the ethical standard of meticulousness expected in medical practice. Finally, a flawed strategy is to assume that prior experience in similar credentialing processes elsewhere will suffice without a thorough review of the specific North American requirements. Each credentialing body has unique protocols and standards. Failing to adapt preparation to these specific requirements demonstrates a lack of attention to detail and a disregard for the established process, which is ethically problematic as it could compromise the integrity of the credentialing system. Professionals should adopt a decision-making framework that prioritizes understanding the specific requirements of the credentialing body, creating a detailed project plan with realistic timelines, actively seeking clarification from the credentialing body when needed, and engaging in self-reflection and peer review of their application materials before submission. This systematic and compliant approach ensures both efficiency and adherence to the highest professional and ethical standards.

This scenario is professionally challenging due to the inherent risks associated with fetal surgery, demanding a meticulous and comprehensive approach to patient safety and informed consent. The complexity of applied surgical anatomy, physiology, and perioperative sciences in this specialized field requires a consultant to not only possess deep technical knowledge but also to effectively communicate potential risks and benefits to expectant parents. Careful judgment is required to balance the potential for life-saving intervention with the significant uncertainties and potential complications. The best professional practice involves a thorough, multi-disciplinary risk assessment that integrates the latest evidence-based guidelines, the specific fetal anomaly, the gestational age, and the unique physiological status of both the fetus and the mother. This approach prioritizes a comprehensive understanding of potential surgical outcomes, including both short-term and long-term implications for fetal development and maternal health. It necessitates open and transparent communication with the parents, ensuring they fully comprehend the risks, benefits, alternatives, and the uncertainties involved, thereby enabling truly informed consent. This aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, and is implicitly supported by professional credentialing bodies that emphasize patient-centered care and evidence-based practice. An approach that focuses solely on the technical feasibility of the surgery without adequately addressing the broader physiological implications for both mother and fetus is professionally unacceptable. This failure to consider the holistic perioperative picture can lead to unforeseen complications and suboptimal outcomes, violating the principle of non-maleficence. Similarly, an approach that relies on anecdotal evidence or personal experience without rigorous adherence to current, peer-reviewed scientific literature and established clinical guidelines is ethically unsound and poses a significant risk to patient safety. This disregards the professional obligation to provide care that is informed by the best available evidence. Furthermore, an approach that minimizes or omits discussion of potential long-term developmental impacts on the fetus, or the maternal recovery process, constitutes a failure in providing complete and accurate information, thereby undermining the foundation of informed consent and violating the principle of patient autonomy. Professionals should employ a decision-making framework that begins with a comprehensive review of the patient’s specific clinical presentation and the fetal anomaly. This should be followed by a thorough risk-benefit analysis, drawing upon the most current and relevant scientific literature and expert consensus. Crucially, this analysis must be translated into clear, understandable language for the expectant parents, facilitating a shared decision-making process. Regular consultation with a multi-disciplinary team, including neonatologists, pediatric surgeons, anesthesiologists, and genetic counselors, is essential to ensure all aspects of the fetal and maternal well-being are considered.

Scenario Analysis: This scenario is professionally challenging because it involves a high-stakes fetal surgery where the potential for catastrophic outcomes is significant. The credentialing of a consultant requires a rigorous assessment of their preparedness for complex operative planning, especially concerning structured approaches to risk mitigation. The pressure to proceed with potentially life-saving interventions must be balanced against the imperative to ensure patient safety through meticulous preparation and foresight. The consultant’s ability to anticipate and address potential complications is paramount, reflecting a commitment to both clinical excellence and ethical patient care. Correct Approach Analysis: The best professional practice involves a comprehensive pre-operative assessment that includes a detailed review of the fetal anomaly, the proposed surgical technique, potential intraoperative complications, and post-operative management strategies. This approach necessitates a multidisciplinary team discussion to identify all foreseeable risks and develop specific, actionable mitigation plans for each. This aligns with the ethical principles of beneficence and non-maleficence, ensuring that all reasonable steps are taken to maximize the benefit to the fetus and minimize harm. It also reflects a commitment to due diligence, a cornerstone of professional responsibility in specialized medical fields, and implicitly supports the regulatory expectation for evidence-based practice and patient safety protocols. Incorrect Approaches Analysis: One incorrect approach involves relying solely on the surgeon’s extensive experience without a formal, documented risk assessment. While experience is valuable, it does not substitute for a structured, systematic evaluation of the specific case’s unique challenges and potential pitfalls. This can lead to overlooking novel or less common complications, violating the principle of thoroughness and potentially exposing the patient to preventable harm. It fails to meet the standard of care that mandates a proactive, documented approach to risk management. Another unacceptable approach is to delegate the primary responsibility for risk assessment to junior team members without adequate senior oversight and validation. While team input is crucial, the ultimate accountability for the operative plan and its risk mitigation strategies rests with the credentialed consultant. This abdication of responsibility can result in incomplete or flawed risk assessments, compromising patient safety and violating professional accountability standards. A further flawed approach is to prioritize speed of operative planning over thoroughness, assuming that the complexity of the anomaly will dictate the necessary precautions. This reactive stance, rather than a proactive, structured planning process, can lead to critical oversights. It fails to acknowledge that even seemingly straightforward procedures can harbor hidden risks, and that a deliberate, comprehensive risk assessment is always required to ensure optimal patient outcomes. This approach is ethically unsound as it prioritizes expediency over the patient’s well-being. Professional Reasoning: Professionals should adopt a systematic decision-making process that begins with a thorough understanding of the patient’s condition and the proposed intervention. This involves actively seeking information, engaging in critical analysis of potential risks and benefits, and consulting with relevant experts. The process should be iterative, allowing for refinement of the plan as new information emerges or potential challenges are identified. Documentation of this process is essential for accountability and continuous improvement. In high-risk specialties like fetal surgery, a culture of safety that emphasizes open communication, meticulous planning, and a commitment to mitigating all foreseeable risks is paramount.

Scenario Analysis: This scenario is professionally challenging due to the inherent unpredictability of fetal surgical emergencies and the critical need for rapid, coordinated intervention. The consultant must balance the immediate life-saving needs of both the fetus and the mother with the complex ethical considerations surrounding fetal interventions, particularly when the mother’s condition is also precarious. The lack of established, universally agreed-upon resuscitation protocols for fetal surgical emergencies adds another layer of complexity, demanding a high degree of clinical judgment and adherence to best available evidence and ethical principles. Correct Approach Analysis: The best professional practice involves a multidisciplinary team approach, immediately initiating a structured resuscitation protocol that prioritizes maternal stabilization while simultaneously preparing for fetal intervention. This approach recognizes that the fetus’s survival is inextricably linked to the mother’s physiological status. The protocol should be evidence-based, drawing from established critical care and trauma guidelines, and adapted for the unique context of fetal surgery. This includes rapid assessment of maternal hemodynamics, airway, breathing, and circulation (ABC), along with prompt consultation with anesthesia, neonatology, and the fetal surgery team. The ethical justification lies in the principle of beneficence, acting in the best interests of both patients, and non-maleficence, minimizing harm by ensuring a coordinated and comprehensive response. This aligns with professional standards that emphasize patient safety through collaborative care and adherence to established emergency management principles. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on fetal intervention without adequately stabilizing the mother. This fails to acknowledge the physiological interdependence of mother and fetus. Ethically, it risks causing significant harm to the mother by diverting critical resources and attention away from her immediate needs, potentially violating the principle of non-maleficence. Regulatory frameworks for critical care emphasize the primacy of maternal stability in such scenarios. Another incorrect approach would be to delay fetal intervention until the mother is completely stable, even if the fetal condition is deteriorating rapidly. This could lead to irreversible fetal compromise or loss, failing the principle of beneficence towards the fetus. While maternal stability is crucial, a dynamic assessment of fetal well-being and the potential for timely intervention, even in a less-than-ideal maternal state, is often necessary. This approach neglects the urgency dictated by the fetal condition. A third incorrect approach would be to proceed with intervention without clear communication and consensus among the multidisciplinary team. This can lead to fragmented care, missed critical steps, and increased risk of adverse outcomes for both mother and fetus. Professional ethical guidelines and regulatory requirements for patient care mandate clear communication and collaborative decision-making in complex medical situations. Professional Reasoning: Professionals should employ a structured, evidence-based decision-making framework that prioritizes rapid assessment, clear communication, and collaborative action. This involves: 1) immediate activation of the multidisciplinary team; 2) simultaneous assessment and management of maternal and fetal status; 3) adherence to established resuscitation principles adapted for the fetal surgery context; 4) continuous reassessment and dynamic adjustment of the plan based on evolving clinical conditions; and 5) clear documentation of all decisions and interventions. Ethical considerations, particularly beneficence and non-maleficence for both mother and fetus, must guide every step.