PubMed · 5184430
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M R Fell. 1968-03-22. Prolonged labour.. https://pubmed.ncbi.nlm.nih.gov/5184430/
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Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.
What have we learned so far from the Closed Claims database? For the most part, analysis of the claims made supports the generally held beliefs about the medico-legal risk of obstetrical anesthesia. However, the obstetric files do reveal a risk profile that differs significantly from the nonobstetric files. One of the most surprising observations was the large proportion of relatively "minor" injuries in the obstetric files in contrast to the nonobstetric files. These claims may simply be the result of an increased incidence of such problems in obstetric patients. However, careful review of statements made in the files revealed that a substantial number of patients were unhappy with the care provided and felt themselves ignored and mistreated. Meyers has suggested that malpractice litigation serves the purpose not only of reparation of injury for substandard care but also one of emotional vindication [19]. Not unexpectedly, anesthesiologists are frequently named in claims involving bad fetal outcomes. Most of these claims, for whatever reason, do not result in payments to the litigant. Problems involving airway management, focusing on difficult intubation and pulmonary aspiration, are unfortunately well represented in the obstetrical files. There is no clear indication that this is changing. One of the principle causes of major adverse outcomes with regional anesthesia is local anesthetic toxicity. There is evidence that the frequency of these claims is on the decline. Nerve injury as a result of direct neural trauma continues to appear at regular intervals in the claims files. It is clear from review of the ASA Closed Claim database that there are many unrecognized factors, separate from major injuries, that must be important motivating factors in patients who bring claims against anesthesiologists. A lawsuit does not necessarily signify injury. It has been suggested that the number of patients harmed by negligent care who actually file a claim may be less than 2% [12]. In contrast, lawsuits are usually not filed unless people perceive that they or a family member have been wronged by the system. Anesthesia care providers should give attention to conducting themselves in such a manner that patients will not be motivated to bring suit for an unexpected outcome [20]. Therefore, merely focusing one's attention on reducing the potential for major injuries may have little effect on solving the medico-legal dilemma in obstetrical anesthesia. The uniqueness of the ASA Closed Claims database is that it reflects the consumer's perspective. This point can not be emphasized enough because one of the best measures of quality of care comes from the patient's perspective. What can help? Careful personal conduct Establish good rapport Involvement in prenatal education Early pre-anesthetic evaluation Provide realistic expectation Regularly review potential major and minor risks.
The recommended dose of Syntocinon used for uterine contraction at Caesarean section is5 units intravenously, given slowly. We conducted a survey of the use of Syntocinon at Caesarean section among 240 lead obstetric anaesthetists in the UK in 2001 and found that 155 (87%) of the 179 (75%) respondents gave 10 units, 77 of them (50%) by rapid bolus. The risks of Syntocinon, especially given by rapid injection, were highlighted in the report of the Confidential Enquiries into Maternal Deaths in the UK (1997-99), which was published at the end of 2001, and so the survey was repeated in 2002. Of the 256 forms sent, 198 completed replies were returned (77%); these indicated a dramatic change of practice: only 30 (15%) now gave 10 units and only 7 of these (23%) by a rapid injection. One hundred and sixty-seven respondents to the second survey (84%) stated they had changed their practice and 159 of these (95%) gave the Confidential Enquiries report as the main reason for change. These results highlight the importance of the Confidential Enquiries as a means of improving practice.