Dra. Ana Margarida Mourato

Gynecology
and Obstetrics Service

Obstetric violence:
Between myth and clinical practice. A medical view on Law nº 33/2025

HPA Magazine 24 // 2025

Law No. 33/2025, which aims to prevent and combat obstetric violence, has generated debates among the general population and health professionals. Although it aims to promote rights during pregnancy and the peripartum period, it is crucial to distinguish between clinically based practices and acts that constitute mistreatment. This article aims to clarify these differences and promote a constructive, informed and balanced dialogue between health professionals and society, in an area as sensitive as childbirth

Understanding Law No. 33/2025
The Law defines “obstetric violence” as any physical or verbal act carried out by health professionals that results in inhumane or clinically unjustified treatment during pregnancy, childbirth or the postpartum period, violating the rights provided for in the User Law (No. 15/2014), such as the right to information, informed consent, choice, dignity, privacy and refusal of treatment.
The main measures provided for include:
• Creation of a Multidisciplinary Committee to promote rights during pregnancy and childbirth;
• Training of health professionals in human rights and reproductive health;
• Integration of the theme of “obstetric violence” into school sex education;
• Mandatory recording of all clinical acts during childbirth, with respective justification;
• Prohibition of routine practices, not clinically justified, such as episiotomy or the Kristeller maneuver.
Although the Law represents an advance in the humanization of care, it also raises challenges in its interpretation and practical application, requiring a balance between the safety of evidence-based clinical practice and respect for women's rights.

Obstetric Practices: Between Clinical Need and Perception of Violence
Episiotomy: When is it really necessary?
Episiotomy is an incision in the perineum, which serves to widen the vaginal opening during the expulsive period of labour.
The WHO recommends avoiding episiotomy routinely and promotes alternative and/or additional techniques, such as warm compresses and perineal massage.
Thus, although episiotomy is not recommended routinely, there are clinical situations in which it is necessary, such as instrumental deliveries, non-reassuring foetal state (signs of foetal distress).
Which requires shortening the expulsive period, and in the face of imminent risk of high-grade perineal lacerations (3rd or 4th degree), which present a risk of injury to the anal sphincters, with a consequent risk of fecal incontinence.
Therefore, when properly justified, episiotomy is recommended, particularly to ensure foetal well-being and protect perineal integrity by preventing high-grade lacerations.

Kristeller manoeuvre versus support at the highest point of the foetus in the uterus
The Kristeller manoeuvre consists of applying pressure to the uterine fundus to facilitate the exit of the foetus.
The WHO advises against its execution when performed without clear criteria or consent, and the current law prohibits its routine practice.
However, it is important to distinguish this manoeuvre from other forms of manual assistance or postural guidance of the foetus during labour, which aim to optimize the progression of foetal descent safely.
One way to assist the expulsive period is to support the highest point of the foetus in the uterus to prevent the foetal presentation from rising between expulsive efforts, a measure of support and not of applying pressure or force, as in the Kristeller manoeuvre.
Therefore, the Kristeller Manoeuvre should not be performed, but it may be recommended to support the highest point of the foetus in the uterus during labour to optimize safe foetal descent.

Vaginal Examinations and Clinical Examinations
Vaginal examinations are the only way to assess the characteristics of the cervix (dilation, effacement, consistency, and position) and the descent and orientation of the foetal presentation. Thus, they are clinically indicated to verify whether or not the pregnant woman is in labour, to assess whether labour is progressing adequately, or if there are signs of stationary labour.
They are also necessary in cases of suspected rupture of the membranes, reassessment after changes in uterine dynamics or foetal heart rate, and before performing procedures such as epidural analgesia or instrumental delivery.
The WHO recommends that they be spaced out (ideally every 4 hours) and performed only with informed consent.
Law No. 33/2025 requires that they be recorded and clinically justified, in accordance with DGS standards.
Therefore, vaginal examinations must be performed in the event of clinical changes and to assess the progression of labour. Before performing them, the reason for their performance must be explained, and the pregnant woman's verbal consent requested. Afterwards, the vaginal examinations must be recorded.

Administration of Medication
During labour, medication administration must be performed judiciously. Only drugs should be prescribed in clinical situations with a clear indication, namely oxytocin (for induction or acceleration of labour, for example, in the case of ruptured waters or prolonged labour), antibiotics (in the case of prolonged rupture of membranes or the presence of Streptococcus agalactiae, group B, in the vaginal and rectal exudate), or analgesics or anaesthetics such as epidural, in the case of pain complaints.
The WHO advises against the routine use of medications to speed up labour without a clear indication.
Thus, medications should only be prescribed and administered when indicated based on scientific evidence and preceded by informed consent.

The Importance of Communication and Free and Informed Consent
Law No. 33/2025 reinforces the obligation to respect women's autonomy, justify any intervention, and formally record procedures.
During pregnancy and the peripartum period, the couple must be respected, as well as their ideals and desires, as long as they do not compromise foetal well-being or the proper progression of labour.
Effective communication between the health team and the woman in labour is essential. Informing, listening, respecting, and sharing decisions are the pillars of humanized obstetric care.
Informed consent should be seen as an ongoing process, and not as a bureaucratic act.
During labour or pregnancy monitoring, clinical situations may arise that require medical intervention to ensure maternal and foetal well-being, which are not included in the pregnant woman's birth plan, such as the need for an instrumental delivery or an episiotomy. In situations that require medical intervention, which are clinically justified, these should be performed as part of good medical practices. However, before performing them, the clinical reasons that justify their execution should be explained and these should only be performed after the informed consent of the pregnant woman, even if only verbal.
Sometimes, pregnant women, faced with clinical situations to which they had not been previously exposed, may change their wishes and plans, and should explain the changes to health professionals and respect the necessary timetables for the necessary adjustments.

Conclusion
Law No. 33/2025 represents an advance in the protection of women's rights, but it should be interpreted in light of clinical reality and good medical practices.
Active listening, empathy and ongoing training are the keys to ensuring more humane, safe and respectful obstetric care, respecting the rights of all women.
The challenge lies in promoting safe, empathetic and evidence-based obstetric care, without compromising women's autonomy and the good clinical practices of health professionals.