Risk Management in Obstetrics

Fahad Syed

991541355

Risk Management in Obstetrics

Introduction

Obstetrics is defined as the branch of medicine which deals with the care of women during pregnancy, childbirth, and the period during which they recover from childbirth (Agency for healthcare research and quality, 2000).

The major factor that makes obstetrics a high risk area is expectation. The majority of women who are about to give birth tend to be young and healthy (Clements, 2001). Naturally, they expect to give birth to a healthy child, who is free from defects and/or illness. A key reason for such high expectations may also stem from the belief that society has become so technologically advanced that complications during birth are now a thing of the past. Hence, if the baby is born with a birth/neurological defect, the parents feel that someone in a position of authority is to be blamed (Herczeg, 1997).

Litigation in obstetrics has been noticeably increasing, with tremendous impact on obstetric medical practice. For instance, in the state of Washington, approximately 45% of family physicians who practice obstetrics have considered stopping obstetric practice, over concerns of increasing malpractice insurance rates (Norris, 2003). In England, 27% of litigation claims were related to Obstetrics and Gynaecology, totalling approximately Ј6,876,033 (Wilson, 1999). In Canada, 1 in 7 obstetricians/gynaecologists can expect to be sued in a given year (Sibbald, 1999). Other effects of increased litigation also mean a large part of funding allocated towards healthcare may end up being diverted towards litigation cases (Herczeg, 1997).

Problems with risk identification

All pregnant patients can be at risk for complications. In fact, Clements (2001) notes that a pregnancy can only be called "healthy" in retrospect. Hence, pregnant women can only be classified as being at low or high risk; the former being those who do not have any major health problems while in pregnancy, whereas the latter refers to women who have pre-existing health conditions that can potentially endanger the foetus, i.e. diabetes, hypertension, cardiac disease, and lifestyle factors, such as alcohol consumption, smoking, and nutritional status (Clements, 2001). In addition, a number of complications in pregnancy cannot be identified beforehand, which include eclampsia, haemorrhages and infection. Paradoxically, women designated as "low risk" for complications in pregnancy have actually had a greater incidence of complications, than those designated as "high-risk" (Herczeg, 1996). Clearly, problems in identifying and classifying risk will make it more difficult to accurately predict and manage the risk of possible complications in pregnant women.

Common risks of complications in Obstetrics

Risk identification in obstetrics is problematic. Different sources are all stating different risks for the specialty. For instance, Herczeg (1996) notes a number of obstetrical complications that lead to maternal mortality, such as post-partum haemorrhage, infections during labour and delivery, puerperal sepsis, complications arising from the second stage of labour, pregnancy induced hypertension, obstructed labour, and abortion related problems. However, Clements (2001) identifies prenatal asphyxiation, shoulder dystocia, anal sphincter injury, abuse of Oxytocin administration, and consent as common clinical risks in obstetrics. Furthermore, Lee (1990) cites failure to properly monitor an infant during labour, the failure to diagnose and treat problems of pregnancy, and the delay or failure to perform a Caesarean section or delivery, as common causes for litigation in Obstetrics.

For the sake of brevity, this paper will specifically look at the risks and management of asphyxia, issues of consent, shoulder dystocia, and improper oxytocin administration in obstetrics.

Brain damage due to Asphyxia

Asphyxia, or lack of oxygen, may result in brain damage to the foetus, leading to neurological disorders such as cerebral palsy or encephalopathy. Although the foetus is better able to withstand a hypoxic (oxygen deprived) environment, a number of factors are associated with the occurrence of asphyxia. Hypertension in the mother, for instance, has been shown to increase the susceptibility of the fetus to brain damage (Steer, Little, Kold-Jensen, Chapple, and Elliot, 2004). A low birth weight, particularly in the delivery of twins, has been associated with a higher likeliness of asphyxia-induced brain damage. There also appears to be some evidence to suggest a link between hyperglycaemia and asphyxia-related brain damage (Vannuci, and Perlman, 1997). However, demonstrating a causal connection between asphyxia and brain damage can be a formidable task. For instance, Cerebral Palsy can occur without the presence of asphyxia. Furthermore, determining brain function of the fetus before birth is not possible; this makes it difficult to establish whether the brain was damaged prior to birth, and therefore caused by other mechanisms. Lastly, foetuses vary in their vulnerability to asphyxiation, and asphyxiation does not necessarily lead to brain damage in all instances. Given such conditions, it is nearly impossible to prove asphyxiation as a direct cause of brain damage. Needless to say, legal decisions relating to asphyxia during birth are mostly based on probability rather than causality (Clements, 2001).

Risk management measures for asphyxia often involve foetal heart, and acidity (PH) monitoring, as well as therapeutic interventions, usually involving drug therapy (Vannuci and Perlman, 1997). Foetal heart rate monitoring, by assessing heart rate variability in the foetus, can detect when asphyxia is occurring, and allows for early intervention, and therefore is only a tool for detection, not treatment (Sinha and Arulkumaran, 1999). Acidity (PH) monitoring, however, is not free of problems. Often, differentiation between a high PH value in a foetus that results in potentially damaging asphyxia and one that is not is not always possible. Oxytocin, a hormone naturally produced in the body, is often administered by doctors to increase uterine contractions; however, injection of exogenous oxytocin has also been shown to increase the risk of asphyxia in the foetus (Banack, 2004). Therefore, alternatives to oxytocin use should be considered during childbirth to prevent asphyxiation. Counselling the patient in terms of lifestyle habits, e.g. cessation of smoking and alcohol consumption, is also essential in preventing impaired development of the foetus. In fact, supplementation of folic acid before beginning