Potential Areas of Litigation in Obstetrics PDF

Potential Areas of Litigation in Obstetrics Dr EnasMohamed Lofty Associated Professor In Nursing Administration College Of Nursing, PNU Lecture 3 at 55851 1425 1  691 Learning objectiv...

Potential Areas of Litigation in Obstetrics Dr EnasMohamed Lofty Associated Professor In Nursing Administration College Of Nursing, PNU Lecture 3 at 55851 1425 1  691 Learning objectives On completion of this lecture the student will be able to: State the term Litigation in Obstetrics Explain the potential areas of litigation in antepartum, intrapartum and postpartum care.  Litigation in Obstetrics Obstetrics malpractice can cause morbidity and mortality that may engender litigation. Litigation may occur if a patient suffers or believe to have suffered adverse effects of negligent care. Litigation means ‫اﻟﺘﻘﺎ‬the process of taking an argument between people or groups to a court of Foust law.  Potential areas of Litigation in Obstetrics - Antepartum care w BS i - Intrapartum care 01h0 - Postpartum care POTENTIAL AREAS OF LITIGATION IN OBSTETRICS ANTEPARTUM CARE: Pregnancy is perceived to be a natural phenomenon, any unexpected outcome is due to medical negligence in. History Diagnosis Investigations Subsequent visits to POTENTIAL AREAS OF LITIGATION IN OBSTETRICS Antenatal care-contd.. 1. Antenatal screening for congenital abnormalities 2. Intrauterine growth retardation 3. Multiple pregnancy 4. Intrauterine fetal death 5. Sex selection and PNDT act 6. HIV women and pregnancy History This can lead to litigation. Failure to take comprehensive history can lead to inappropriate antenatal care which can result in unfavorable outcomes. Only a proper history can be a clue for further diagnosis and management of many cases. sf Patients may sue the practitioner for failing to identify the risk factors, the management of which could have altered the outcome.  0dg Hw Examples …. d 1 Abiy Failure of taking drug history – drug induced Coil Do teratogenesis Teratogens are substances that may produce physical or functional defects in the human embryo or fetus after the pregnant woman is exposed to the substance. Teratogens include some medications, recreational drugs, tobacco products, chemicals, alcohol, certain infections etc., Venous thromboembolism A deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, usually in the lower leg, thigh, or pelvis. Failure to provide prophylaxis for same based on the previous history T.EE Can lead to litigations IS I Had  o Diagnosis and Investigations Clinical diagnosis of early pregnancy must be confirmed by : - Biochemistry - Ultrasound if required. Investigations Routine check-up like Hb, ABO, Rh, grouping, blood sugar, HbsAg, VDRL and HIV to be done. HIV testing must be done only after informed consent; coffee High risk pregnancies are picked up from: -through history - routine examinations - investigations. Identifying High risk patients and failure lead to litigations of e_ timely referral Can  Subsequent Visits Antenatal Screening for Congenital abnormalities In patients with history of congenital abnormalities, at least I basic screenings are necessary to avoid litigation. The basic screening is mostly done by USG. ( ultra sonogram) Other examinations like CVS, amniocentesis or some biochemical investigations may be necessary depending on the individual case.  - Chronic villus sampling (CVS) is a prenatal test in which a sample of chorionic villi is removed from the placenta for testing chromosomal abnormalities and certain other genetic problems - Amniocentesis is a procedure in which amniotic fluid is removed from the uterus for testing or treatment. Fam Patient’s counseling is very necessary regarding false positive or negative tests thereby avoiding legal problems.  Issues involved are competence and referral, disclosure, confidentiality and routine screening. Competency of the sonologist Informed consent Strict confidentiality to be maintained. Investigations Fetal anomalies and missing a anomaly during a routine ultrasound. Un recognized images that are visible in the ultrasound 0 Malpractice claims are missing heart malformation, absent limbs and multiple pregnancy. 11 Intrauterine Growth Retardation Intrauterine growth restriction, or IUGR:-is when a baby in the womb (a fetus) does not grow as expected. o - weighing less than 90% of other fetuses at the same gestational age. They are at greater-than-normal risk for a variety of E health problems before, during and after their birth. These problems include: - low oxygen levels while in the womb too - a high level of distress during labor and delivery - an increased risk of infectious disease after birth.  Litigation issues…. Modern gadgets like ultrasonography, and ultrasonic Doppler study are important to detect the end diastolic volume are important. Cardiotocography (CTG) is a technique used to monitor the fetal heartbeat and the uterine contractions during pregnancy and labour. g If there are signs and symptoms of a baby that is not getting the ess oxygen and nutrients in needs. Intervention is required to save that child Failure of timely detection may lead to Intrauterine fetal death ( IUGD) The cause of IUFD must be explored. MII Multiple Pregnancy It is a high risk pregnancy involving more than one fetal lives. Multiple pregnancy is increasingly considered a complication of in vitro fertilization (IVF). Involves enormous risk and in modern concept is to be delivered by cesarean section. fetal complications which may lead to legal problems. premature birth low birth weight birth defects -  W Sex Selection and PNDT Act The Prenatal Diagnostic Technique Act 0 ie in The PC-PNDT Act was enacted on 20 September 1994 with the intent to 31W prohibit prenatal diagnostic techniques for determination of the sex of the fetus leading to female feticide. provides for the prohibition of sex selection, before or after conception. It regulates the use of pre-natal diagnostic techniques, like ultrasound and amniocentesis by allowing them their use only to detect : genetic abnormalities. metabolic disorders. The amended act: - prohibits unnecessary sex determination without any disease problem Here are four multiple-choice questions based on the content in the image: 1. What is the main purpose of the PC-PNDT Act of 1994? a) To allow sex determination before conception b) To promote it prenatal genetic testing for all purposes c) To prohibit prenatal diagnostic techniques for sex 2 determination e e d) To regulate fetal growth disorders Correct Answer: c) www.T 2. 5 f What does the amended act specifically prohibit? a) The use of ultrasounds for genetic testing b) Unnecessary sex determination without a medical issue c) All prenatal diagnostic techniques d) Female feticide and any prenatal testing Correct Answer: b) rid a PC PND Is Act? 3. set Which of the following is allowed under the PC-PNDT Wall a) Determination of the sex of the fetus b) Use of ultrasound to detect genetic abnormalities c) Sex selection after conception I d) Routine prenatal diagnostic testing without regulation Correct Answer: b) j o 4. What is explicitly prohibited under the PC-PNDT Act? a) Metabolic disorder detection during pregnancy b) Prohibition of genetic testing before birth I c) Sex selection before or after conception d) Ultrasound use for fetal growth monitoring t.ws Correct Answer: c) HIV positive women and pregnancy The risk of vertical transmission can be potentially reduced to less than 2% : - by the judicious use of combination anti retro viral therapy, T.FI - delivery by caesarean section - avoidance of breast feeding. Neither the woman nor her child should suffer any discrimination on their HIV status. POTENTIAL AREAS OF LITIGATION IN OBSTETRICS Intrapartum care Common areas of litigations are: 1. Failure to intrapartum fetal monitoring 2. Caesarean section 3. Difficult vaginal delivery - Shoulder dystocia E - Breech - Multiple pregnancy - Instrumental delivery: forceps/vacuum  Intrapartum care Failure to intrapartum fetal monitoring A majority of the malpractice claims during labour relate to failure to intrapartum fetal monitoring. This can lead to serious outcomes. factors commonly associated with litigation includes: - misinterpretation of CTG (Cardiotocography ) - inappropriate or delayed action - technical and equipment problems - inappropriate use of syntocin E - record keeping - communication issues - poor supervision Intrapartum care - Caesarean section Increased incidence of caesarean section Delay in deciding or performing LSCS ( lower (uterine) segment Caesarean section ), this can lead to: - Brain damage in the fetus - Newborn illness due to low birth weight babies - Increase in maternal morbidity and mortality - Obstructed labour –lead to fetal and maternal morbidity and mortality  e VBAC – Vaginal birth after caesarean VBAC : the term applied to women who undergo vaginal delivery following cesarean delivery in a prior pregnancy it reduces caesarean deliveries, but malpractice arise due to : failure to warn women about the risk of scar rapture and its sequalea. It includes fetal distress and rarely disability or death Operative litigations Risk of anesthesia Injury to bladder and bowel and great vessels Tear of uterus involving to broad ligament Unintended injuries to other organs may prolong hospital stay Retention of placental tissues after caesarian delivery Retention of swabs or instruments in the peritoneal cavity Injury to fetus with scalpel “Careless” practices canΣlead to poor defense.  Operative procedure due to negligence may lead to litigation because of failure to : Warn the patients about the recognized complications Take precautionary actions such as failure to catheterize the bladder before procedure Seek help from seniors during emergency Document the incident Difficult vaginal delivery – Shoulder dystocia Shoulder dystocia: It is a condition that happens when one or both of the baby's shoulders get stuck during vaginal delivery. There are no signs and no way to prevent the condition. Causes may include: - having a large baby- Risk factors like diabetes leads to big baby - having a small pelvis - being in the wrong position o Delay in Identification and management of Shoulder dystocia may lead to litigation. Experienced Obstetrician to handle such cases. Difficult vaginal delivery - Breech delivery Mothers who have been injured from breech delivery due to negligence may file a medical malpractice claim. This can result in: - baby getting stuck in the birth canal -injury or death to fetus - umbilical cord may also be damaged or blocked. This can reduce the baby's oxygen supply. Elective caesarean section (ELCS) for a breech at term has been shown to reduce perinatal and neonatal mortality rates. Difficult vaginal delivery - Multiple pregnancy Involves enormous risk and in modern concept it is to be delivered by CS Difficult vaginal delivery- instrument deliveries Ventouse and forceps deliveries eats may cause injury that can lead to litigation. Ventouse must be avoided in premature baby and fetal distress. High forceps should be avoided. Litigations are due to: - injury to the organs and tissues - facial palsy - injury to mother and baby Other potential causes for medico-legal problems Wound breakdown – ceaserain or episiotomy e Perineal tear - it is a laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus. Anal incontinence - is the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum. Fistulae - an abnormal connection between two body parts Dyspareunia it is a persistent or recurrent genital pain that occurs just before, during or after sex.  POTENTIAL AREAS OF LITIGATION IN OBSTETRICS Postpartum Care Negligence in cases involving the postpartum care of the mother, including failure to recognize and treat : Postnatal complete perineal tear, obstetric anal sphincter injuries (OASIS) Perinatal morbidity - brain damage Damage to bones and viscera Analgesia and anesthesia Drugs in pregnancy and lactation Bleeding disorder and hypovolemia Pulmonary embolism (leading to stroke)  Postnatal complete perineal tear, obstetric anal sphincter injuries (OASIS) - Forceps deliveries may lead to such injures. - Patients must be counselled about this to avoid oofed litigations. Perinatal morbidity - brain damage: any neurological or psychological deficiencies after delivery is the major litigation issue where compensation is claimed.  Damage to bones and viscera this may occur in breech delivery. Health professionals must be conscious during face, legs and arm delivery in breech. Analgesia and anesthesia Experts anesthetist are required to avoid litigation  Drugs in pregnancy and lactation - a small group of drugs are harmful to the fetus, but it is a wise precaution to avoid vast majority of drugs if it is not indicated. - must not use off license drugs ( medicine has a license for treating some conditions, but that the manufacturer has not applied for a license) or  Bleeding disorder and hypovolemia: - Excessive blood loss associated with postpartum hemorrhage can lead to hypovolemic shock. Pulmonary embolism (leading to stroke) - If a blood clot forms inside a vein after childbirth, the body may not be able to dissolve it. - Sometimes, this clot can break free inside the vein and travel to the lung, known as a pulmonary embolism. Reasons of litigation Litigation most often relates to specific types of failures on the part of nurses. Reasons: failure to …… follow standards of care  adequately communicate (to patient, physician, and other nurses),  adequately document (if it isn’t documented, it wasn’t done)  carry out appropriate assessment and monitoring of patients  delegate appropriately. Ways to reduce litigation Case records: It provide basis for defense of cases in medico-legal claims. Each sheet must have patient’s name, age and hospital number 5 01 Avoid non standard abbreviations Information contained should be complete, accurate, and factual All entries signed and dated legibly Case records-contd… No alterations should be made unless they Are signed and dated Investigation reports / results should be signed and dated at the time of receipt and when they are placed in the records to demonstrate that the Report has been noted and appropriate action taken. Save the patient documents as per the policy of the hospital.  Consent II the competent adult patient has right to give or withhold consent to exam, investigation or treatment. Any treatment or deliberate touching without consent may amount to Tas battery. w Consent must be full and informed, or it becomes invalid. Except in emergency situations. Must be signed before premedication, by the patient and, ideally, by the doctor Should be honored; Not altered, doctor should not exceed authority  Delegation - Never ask a more junior member of the team to perform a procedure - Never counsel a patient unless this falls within the normal remit for their grade, Or you know that they are competent in the procedure.  Skills awareness and proper consultation Do not perform a procedure that you have infrequently performed, or believe yourself to be inexperienced to perform. If your results for a particular procedure give you, staff or patients cause for concern, seek advice from an appropriate colleague You may be extremely competent at a particular procedure, but if either the condition or the procedure is associated with significant mortality or morbidity seek supervision from colleague / consult. ‫الوفيات أو األمراض‬ Conclusion Reducing the risk of liability exposure and avoiding preventable injuries to mothers and infants during antenatal, labor and birth and postpartum period can be relatively easy when all members of the health care team (nurses, nurse- midwives, and physicians) agree to follow the standards of clinical practice in midwifery. Here are four multiple-choice questions in English based on the text, along with the correct answers: 1. What is the main focus of the text? A) Training doctors in surgical techniques. B) Reducing legal risks and preventing injuries to mothers and infants. C) Increasing the number of nurses in hospitals. D) Improving hospital infrastructure. Answer: B) Reducing legal risks and preventing injuries to mothers and infants. 2. According to the text, when is maternity care relatively easy? A) When nurses attend advanced courses. B) When all team members agree to follow the standards of clinical practice in midwifery. C) When physicians focus solely on labor and delivery. D) When technology is used for postpartum care. Answer: B) When all team members agree to follow the standards of clinical practice in midwifery. 3. Which healthcare team members are mentioned in the text? A) Pharmacists. B) Surgeons and technicians. C) Nurses, nurse-midwives, and physicians. D) Radiologists. Answer: C) Nurses, nurse-midwives, and physicians. 4. What should healthcare team members agree to follow? A) Guidelines for postnatal care. B) Modern technologies in obstetrics. C) The standards of clinical practice in midwifery. D) Patient entertainment programs. Answer: C) The standards of clinical practice in midwifery. Let me know if you need further clari cation!