dr nick lolatgis - monash family planning service; department of obstetrics & gynaecology,...
DESCRIPTION
Nick Lolatgis delivered the presentation at the 2014 Obstetric Malpractice Conference. The Obstetric Malpractice Conference is only national conference for the prevention, management and defense of obstetric negligence claims. For more information about the event, please visit: http://www.informa.com.au/obstetricmalpractice14TRANSCRIPT
N Lolatgis FRANZCOG
The Lack of Dialogue & Agreement Among Providers of Maternity Care
of the ComplicaDons Associated with
Vaginal Delivery
Associated Professions
• Obstetricians • General PracDDoners • Midwives
• Child Birth Educators • Doulas
ReproducDon
• ConcepDon is a normal physiological process • Pregnancy is a normal physiological process
• Most babies are delivered vaginally
• Birth is a normal process
• The default posiDon when pregnant is a vaginal delivery
• This whole event is a normal process
Stages of Labour
• First Stage Shortening and dilataDon of cervix
• Second Stage Descent and birth of the infant
• Third Stage Birth of the placenta
Average length of labour 14 hrs
PaDent ExpectaDons
• Normal vaginal delivery • No complicaDons
• Healthy baby and healthy mother
• Breast feeding to be easy • Life to go on as normal
• Everyone is happy • In laws delighted
Antenatal EducaDon
• Hospital run antenatal courses • EducaDonal material e.g. RANZCOG pamphlets
• Internet and social media
• PublicaDons Books and Magazines
• Friends & Family
• ConsultaDons • Blogs
Social Media
• Facebook • TwiRer • Instagram
• Dr Google • Other forums
Understanding the InformaDon
• PaDents raise issues during their care that are explained but most doctors focus on the posiDves. PaDents believe they will come through the process unscathed.
• Obstetricians do not frighten paDents with tales of horror deliveries and what could happen.
• A posiDve aTtude is presented to the paDent.
Understanding the InformaDon
• Any communicaDon that focuses on the negaDves e.g. complicaDons and operaDve deliveries can be very confronDng and frightening for a couple in their first pregnancy.
• Most Obstetricians do not discuss complicaDons with their paDent during their antenatal care
When things do not go to plan
• PaDents expectaDons not met • ComplicaDons occur
• Damage to mother and/or baby
• QuesDons raised as to best management
• Blaming game
• Input of family & friends
• Obstetrician carries the blame
ComplicaDons of Vaginal Delivery Acute
• Retained placenta • Haemorrhage • Vaginal/rectal tears • Haematoma • Perineal pain • Injury to pelvic floor muscles • Urinary inconDnence/retenDon • Anal inconDnence
ComplicaDons of Vaginal delivery Long Term
• Urinary inconDnence • Faecal inconDnence • Pelvic organ prolapse • Fistula formaDon • EmoDonal trauma • Sexual dysfuncDon • Permanent disfigurement • Fear/Anxiety • Post natal depression • Post traumaDc stress disorder • Lack of bonding with the baby
Risk factors for LaceraDons
• Primigravida • Short perineal body • Instrumental delivery • Prolonged second stage • Large baby >4Kg • Persistent OP posiDon • Shoulder dystocia • Episiotomy • Asian Ethnicity • Previous anal sphincter tear • Maternal age >30
Decision making in delivery suite
• Prolonged labour • Delay in second stage • Shoulder dystocia • Foetal distress • Instrumental delivery • Pain relief • Adequate analgesia for intervenDon • Paediatrician in aRendance
Decision making in delivery suite
• Decision made to deliver • Discussed with paDent and partner • PreparaDons made • Baby delivered • ComplicaDons may or may not happen • ComplicaDons managed • Team effort required • Support from all staff important • Concerns should be expressed at the Dme not aaer the event
Consent in delivery suite
• How do you consent • What do you consent to
• Is the consent valid if the paDent has been given narcoDcs
• Can the husband consent • Should the paDent consent before labour commences
• Global consent
Consent in delivery suite
• Dynamic situaDon • May need to act quickly
• No Dme to explain all complicaDons
• MaRer of trust
• Healthy mother healthy baby
• Unavoidable complicaDons
• Proper management
Consent to intervene
• At present the only Dme consent is obtained is for a caesarean secDon
• No consent is signed for a normal vaginal delivery
• No consent is signed for an operaDve delivery • There is no waiver for complicaDons that may occur
Problem
• Minimal interacDon between health providers. • No standardizaDon in informaDon available • Conflict in delivery suite between doctors and midwives
• Best pracDce differs from doctor to doctor to midwife
• EmoDonally charged area for conflict • Bond between Obstetrician and private paDent oaen compromised in delivery suite
Problem
• ATtudes in delivery suite different • Private versus public • Policies and protocols may differ in different hospitals
• Conflict between certain doctors and delivery staff.
• Failure to follow orders
The Problem
• Obstetricians are the paDents insurance policy • Obstetricians do not wish to intervene. • Priority is a healthy baby and healthy mother
• Obstetricians do their best for the paDent • PaDents expectaDons are high • ComplicaDons happen
• Blame game is fearsome
Lack of dialogue
• Doctor and delivery suite staff not on same page
• PaDent senses disagreement • Partner senses disagreement • MisinformaDon given • PaDent confused • PaDent angry • ComplicaDons blamed on doctor
Teamwork
• Involve yourself in best pracDce with hospitals you aRend
• ARend Obstetric Mortality and Morbidity meeDngs
• Involvement in educaDonal evenings
• Know the staff • Deal with conflicts quickly and honestly
Teamwork
• Work in a delivery suite where you are welcomed
• Know your group of midwives and trust them
• Avoid hospitals that you dislike • Common sense and consistency in decision making are criDcal
• Apologize if complicaDons occur
Summary
• Comfort Zone • Consistency • Consent • Co-‐operaDon • Code of Conduct • Compassion