Obstetric emergencies should not be equated to medical negligence, say doctors

The recent series of incidents in Kerala, wherein unexpected maternal deaths resulted in mob violence and the doctors were accused of medical negligence has been quite demoralising for obstetric professionals

Illustration of a woman standing in her hospital room and holding her newborn baby | Photo Credit: GETTY IMAGES

Unexpected complications that arise during delivery, at the end of what might have been a normal gestation, is the nightmare of any Gynaecologist and Obstetrician.

Safe motherhood is taken so much for granted by people today that sudden and serious complications during delivery that ends in maternal death is immediately attributed to medical negligence, followed often by violent mob attacks against the hospital and doctors. The recent series of incidents in Kerala, wherein unexpected maternal deaths resulted in mob violence and the doctors were accused of medical negligence has been quite demoralising for obstetric professionals.

According to WHO, while most pregnancies and births are uneventful, all pregnancies are at risk and around 15% of all pregnant women will develop a potentially life-threatening complication that calls for skilled care, and some will require a major obstetrical intervention to survive.

A 2015 study which assessed 10,458,616 pregnancies in the U.S ( 38% of which were identified as low risk) reported that 29% of pregnancies considered to be low risk had unexpected complications necessitating non-routine obstetric or neonatal care.

“Normal” is not always normal

“There is nothing “normal” about a “normal” pregnancy. A young patient of mine had no known risk factors but regardless of an uneventful gestation, she developed heart failure while she was undergoing a C-section. It was touch and go but luckily, the cardiologist was there to take over and we could save the mother. None could have predicted this complication but people presume that when a “normal” pregnancy goes into complications during delivery, it is solely because the doctor was negligent,” says Smithy Sanel George, a Kochi-based senior ObGyn consultant and a member of Cochin Obstetrics and Gynaecology Society.

There is so much uncertainty and disheartenment surrounding the practice of obstetrics today that many young doctors are now seeking safe havens like infertility medicine, laparoscopy, foetal medicine or gynaec-oncology rather than obstetrics.

Kerala Federation of Obstetrics and Gynaecology, which represents the 1,700-odd obstetric professionals in the State and which has been working continuously with the Government to train doctors and nurses in mid-level hospitals on reducing and managing obstetric complications, has been viewing the situation with much concern.

Public awareness video

Led by Dr. Smithy George, a group of obstetricians and KFOG have now come out with a short video in Malayalam, “The Dark Side of Pregnancy”, to create public awareness on how unpredictable an event pregnancy can be and how even a very “normal” gestation can throw up unexpected and life-threatening complications during delivery, shaking the composure of even the most experienced obstetrician.

The 9-minute video in Malayalam, where doctors narrate their real experiences with difficult births and how they managed the near-miss cases, has been hosted on the Youtube channel of KFOG.

Dr. George recollects one obstetric emergency she had helped manage while working in a secondary care hospital.

“The 19-year-old had no prior risk factors but she was profusely bleeding on the operating table. Despite ligating all arteries and an unplanned hysterectomy, the bleeding did not stop and she was going into a dangerous state called DIC (disseminated intravascular coagulation). The hospital had only a blood storage facility and it was important that she was managed in a tertiary care centre. Thanks to the hospital management who stood like a rock behind us, we shifted the patient in an advanced life support ambulance to a major hospital, where an emergency obstetric team was waiting. She had to be transfused with 30 units of blood (the human body has only 10 units of blood), before she came out of the ICU alive on the third day,” she says.

Rapid situation assessment and decision making and the time taken for performing the required intervention becomes crucial during unexpected obstetric emergencies like amniotic fluid embolism or HELLP or cardiac emergencies.

“As treating doctors we need the trust and support of everyone, including the patient’s family and the establishment at that time. But when people turn violent and threaten us, it clouds our judgement and destroys our confidence in rapid decision making,” a senior obstetrician says.

The solution to saving mothers is not to have every delivery performed in a tertiary care hospital because not everyone can afford it.

Hospital networking and teamwork is crucial

There is no need for all deliveries to be conducted in major centres. Mid-level centres should continue to manage obstetric cases but these have to be closely networked with major centres. There should be good rapport building and teamwork between mid-level and large hospitals so that in the event of unexpected obstetric emergencies, patients from smaller hospitals should be taken over by the bigger hospital without judgement or any blame game.

“Rapport and networking between hospitals is the key so that the doctor at the mid-level centre has the courage and confidence to take the crucial decision to refer the patient to a bigger hospital. This is something the Government as well as the KFOG should address,” Dr. George says.

“I tell all my patients and their families just before entering the labour room that I am on their team and to keep me also in their prayers. People need to believe that like them, we too want a happy ending,” she adds.