Obstetric accidents: the patient's perspective

Article Abstract:

Information concerning medical accidents is limited, and systematic investigations of the frequency, causes, and outcomes of such events have rarely been carried out; however, obstetricians may have contributed a greater number of such reports than colleagues in other branches of medicine. A brief review of the literature concerning this topic is presented. A report from the British Medical Protection Society about obstetrical accidents showed that many were due to inappropriate use of forceps, inadequate examination of the fetal heart monitor tracings (cardiotocographic or CTG records), or lack of involvement by senior medial staff. To determine whether similar factors were involved in cases from the files of Action for Victims of Medical Accidents (AVMA), an organization that offers legal advice to people who believe themselves to be victims of medical negligence, the records from 41 cases were reviewed. The cases selected involved stillbirths, deaths in the perinatal (during the weeks just before or just after delivery) and neonatal periods (during the first month after birth), and long-term mental and physical handicaps. Data concerning five aspects of obstetrical care (such as cause of death, risk factors and warning signs, expert criticisms of obstetrical management) were obtained. The reviewer's main concerns were inadequate or inaccurate monitoring of the fetal heart (CTG tracings were absent in 7 cases); inadequate or altered records (in 22 percent of the cases records were missing); and the absence of senior obstetrical staff (in 17 cases, inexperienced staff members performed the deliveries, and in 6, a senior physician was called but did not arrive). Several women felt that staff did not take their worries seriously, and still more perceived a lack of sympathy or concern from staff members. Parents described their difficulty in obtaining clear information concerning the nature and cause of their child's condition. Although most babies are delivered safely, it is likely that problems such as these are more widespread than is commonly thought. Junior physicians, who are not skilled at reading CTG traces or recognizing fetal distress, ought not be left unsupervised in potentially dangerous clinical situations. (Consumer Summary produced by Reliance Medical Information, Inc.)

Psychological aspects, Care and treatment, United Kingdom, Causes of, Accidents, Malpractice, Parents, Obstetrics, Labor, Complicated, Labor complications, Great Britain

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Two-tier approach to biophysical assessment of the fetus

Article Abstract:

Tests that measure fetal well-being can be used to predict which infants are likely to experience chronic asphyxia, a decreased oxygen supply to the fetus leading to a poor pregnancy outcome. Pregnancies complicated by fetal asphyxia involve fewer fetal movements and fetuses that are smaller than others at the same gestational age. The fetuses are often born to women with pregnancies complicated by high blood pressure and hemorrhage. Biophysical tests include measuring the movement of the fetus, nonstress test (NST) cardiography, contraction stress testing (CST) and the biophysical profile (BPP). BPP scores are obtained by serial ultrasonographic images of the fetus, which determines patterns of growth. The circumferences of the head and abdomen are compared against standardized charts. CST can cause premature labor and is thus not widely used. The NST measures fetal heart rate patterns in response to increased fetal activity or contractions. Since the BPP scores are obtained by serial assessments, patients must make weekly hospital visits. These visits can be inconvenient and time consuming. Additionally, BPP assessments require a great deal of technical expertise and place demands on hospital personnel. To help justify this approach, a two-tiered system to assess fetal well-being was studied using NST backed up by BPP. A total of 2,038 biophysical profile scores were obtained for 500 high-risk deliveries. There was a good correlation between the normal BPPs and normal NSTs. NST alone had an predictive accuracy of 77.5 percent, while the BPP had an accuracy rate of 98.7 percent. The BPP is therefore superior to NST in detecting chronic fetal asphyxia. A protocol was developed in which fetal growth is assessed weekly, or if growth is abnormal, biweekly. If a NST is abnormal or if there is a suspicion of an decrease in amniotic fluid surrounding the fetus, a BPP is performed. This method, along with home fetal heart monitoring, can help reduce the demands of serial BPP testing. (Consumer Summary produced by Reliance Medical Information, Inc.)

Diagnosis, Testing, Fetus, Fetal anoxia

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Total perinatal wastage. A clarification of priorities

Article Abstract:

The perinatal period has been defined as 28 weeks of gestation (full-term delivery is at 40 weeks) through the first week following delivery, and therefore perinatal infant mortality includes deaths occurring in this time period. This definition is rather limited, however, and all deaths occurring after 16 weeks' gestation and after the first week of life should be assessed as well. The pregnancy outcome for that time span (16 weeks' gestation through one year of age) was studied in a hospital population for a three-year period. The total perinatal wastage rate was 21.6 per 1,000 fetuses who were alive at 16 weeks. This compares with a perinatal mortality calculated in the standard way (thus including primarily stillbirths and early newborn deaths) of 7.8 per 1,000 births. Thus, in addition to the 60 stillbirths and 74 first-week deaths among 17,352 fetuses alive at 16 weeks, there were 185 deaths before 28 weeks, 10 neonatal deaths after one week, and 46 deaths after the neonatal period, many due to sudden infant death syndrome. Among the deaths occurring before 28 weeks, there were seven miscarriages, eight stillbirths, and 32 abortions related to congenital abnormalities or other factors. The study shows that half of all fetal and neonatal deaths occur before 28 weeks of gestation. Among all deaths, only 9 percent were due to immaturity, reflecting the success of neonatal intensive care units. Eighty-eight percent of these deaths occurred in births before 28 weeks. The study suggests that analysis of fetal and infant deaths according to total perinatal wastage is more informative than is the standard perinatal mortality. (Consumer Summary produced by Reliance Medical Information, Inc.)

Statistics, Perinatal death, Fetal death

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