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Substandard Care in Obstetric Practice
V.Rajasekharan Nair, M.D, D.G.O;
President, KFOG.
Senior Consultant in OBGYN,
Sree Uthradom Thirunal Hospital,
Trivandrum 695 004.
From medieval times to modern era, medical practice revolve around a single pivotal concept , viz to keep the interest and welfare of the patient in front of yours. The interpretation is simple but the implications are profound. With advancing knowledge and technology, one has to redefine the standards of "interests of the patient" . In fact this is has to be continuous process as the standard of medical care and the expectations of patients change continuously.
Even in a court of law when judgments are made, the judiciary only expects a practitioner to exercise average or reasonable skill commensurate with the prevailing medical practice. As a matter of fact this concept comes to the rescue of the doctor as any average obstetrician (or any doctor ) is able to offer reasonable care in most circumstances. But by professional and ethical standards one may ask whether it is enough to stick to these norms. Why not go beyond this concept of reasonable standard and offer superior services? If that is the case then morbidity and mortality will dramatically fall.
It is difficult to quantify substandard care with certainty. It may defined as a situation in which "a different type of management would have resulted in a better outcome" . It can be categorized into three types.
Major: Contributed significantly to the death of the mother, ie a different type of management would have saved the mother.
Minor: It was a relevant contributory factor.
Incidental: Although lessons can be learnt, it would not have affected the outcome.
Examples :
" A woman with compensated heart disease had a vaginal delivery. Methergin was withhold . As the bleeding became excessive 10 units of oxytocin was given as a bolus dose. Patient went in for cardiac arrest. She was revived but later died due to a pulmonary oedema and a second cardiac arrest".
Methergin was rightly withheld in this case due to heart disease. Even though oxytocin is not contraindicated, it should be given as a dilute solution, and never as a bolus dose. The help of a cardiologist and physician should be sought when a heart disease patient is being delivered.
" A 35 year old third para had an uneventful delivery. On the third day while she was being discharged, she complained of a vague pain in her right leg. Analgesics were prescribed and she was discharged. Two days later she was admitted severe respiratory distress and cyanosis. A diagnosis of pulmonary embolism was made, but she died on that day itself.
High index of suspicion for DVT should be there when a postpartum woman complains of leg pain. Clinical examination and necessary investigations should have been done to rule out DVT in this patient. A timely heparin treatment would have prevented the pulmonary embolism.
Extend of the Problem.
Confidential enquiry into maternal deaths in U.K and other countries have helped us to realize that substandard care can be associated with a significant number of maternal deaths. In the absence of any such data from our country, we will have to go by the Confidential review reports from U K. It is seen that nearly 60 % of the direct obstetric deaths had some form of substandard care out of which 50% were major. The percentage of cases who had substandard care is shown below.
Table1.Cause of death number substandard care
On the other hand only in 9% of cardiac cases and 39% of psychiatric cases among the indirect deaths, substandard care was noticed.
The identification of substandard care in case management has resulted in continuous debate on the issue resulting in evolution of guidelines to prevent such occurrence in future. Thus recognizing substandard care in obstetric practice (in fact any other branch of medicine) results in constant inputs into the management protocols, which results in improvements in services offered to the patients.
Health of the individual is primarily must be the concern of the individual and not of the state. Health care providers are only assisting the individual to maintain the desired level of health and well being. But at the same time it is the individual's right to get good quality medical care, whether it is from a public or private institution. So it is mandatory that health sector should be warmed up to give the best possible service to the society. From an obstetrician's point of view, this is a step beyond reasonable quality care.
References:
(1)Hinshaw
K.ALSO (UK) – ARE WE MAKING A DIFFERENCE? Webpage URL: http://www.also.org.uk/chairman2.asp
(accessed Sept 2, 2004)
(2)TanK
H , WyldesM P , SettatreeR , Mitchell T.Confidential
Regional Enquiry into Mature Stillbirths and Neonatal Deaths-A
Multi-Disciplinary Peer Panel Perspective of the Perinatal Care of
238 Deaths.Singapore
Med J 1999; Vol 40(04) http://www.sma.org.sg/smj/4004/articles/4004a5.html
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