Obstetric Anesthesia Closed Claims What have we learned over the last three decades

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Obstetric Anesthesia Closed Claims What have we
learned over the last three decades?

• Jo Davies MB BS, FRCA
• Assistant Professor
• Dept. of Anesthesiology
• UWMCSeattle WA

September 9th, 2006
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The Beginning of Anesthesia as a
Specialty October 16, 1846 Massachusetts
General Hospital Boston
By 1831 all three basic anesthetic agents,
nitrous oxide, ether, and chloroform had been
discovered, but no medical applications of their
pain relieving properties had been made. That
was about to change.
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The First Obstetric Anesthetic
1st delivery - ether - Jan. 19, 1847 delivery
deformed pelvis 20 rickets internal podalic
version because of unengaged head and
prolapsed cord (3 months after Mortons
demonstration)
2nd delivery - ether - Feb. 3, 1847 for
forceps delivery satisfactory outcome for
mother child
3rd delivery - ether - Feb. 12, 1847 for
forceps delivery satisfactory outcome for
mother child
James Young Simpson
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April 7th, 1847
Henry Wadsworth Longfellow Fanny Appleton
Longfellow
Nathan Cooley Keep
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The Dilemma

• Was it right to abolish or prevent pain?
• Could the agents be used safely?
• Was it morally right to use these recreational
  drugs?
• Would the progress of labor be slowed?
• Would the agents have any effect on the newborn?

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In November 1847 Simpson began experimenting in
an attempt to find a better anesthetic agent than
ether. On November 4th, chloroform was tried and
considered far stronger and better than ether.
Presented at the Edinburgh Medico-Chirurgical
Society.
James Young Simpson It will be necessary to
ascertain anesthesias precise effect, both on
the action of the uterus and on the assistant
abdominal muscles its influence, if any, upon
the child whether it has a tendency to
hemorrhage or other complications.
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John Snow
1853
Queen Victoria
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Simpson prophesied the role of public opinion in
the acceptance of Obstetric anesthesia, a fact
not lost on his adversaries. Early in the
controversy he wrote Medical men may oppose
for a time the superinduction of anesthesia in
parturition but they will oppose it in vain for
certainly our patients themselves will force use
of it upon the profession. The whole question
is, even now, one merely of time.
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First Death DURING Anesthesia (Chloroform) 28
January, 1848 Patient - Hannah Greener, Newcastle
England Surgeon - Mr. Thomas Nathaniel Maggison
An inquest was heldon view of the body of
Hannah Greener (of Winlaton, about 5 miles from
Newcastle-upon-Tyne), a girl of 15 years of age,
who died on Friday, the 28th of January under the
influence of chloroform, administered in order to
allay sensibility while undergoing a painful
surgical operation (during the operation of
removing one of her toe nails).
15 months after first demonstraton of ether
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An Earlier Death

• Ann Parkinson, March 11th, 1847
• Died 2 days after removal of a thigh tumor
• First death certificate to mention anesthesia as
  a cause.
• Died from the effects of Ether administered for
  the purpose of alleviating pain during a surgical
  operation
• First time medico-legal concerns were raised
  against her attending physicians by the Coroner.

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The First Major Anesthesia Morbidity Study - 1870
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Obstetric Mortality Databases

• England Wales
• The Confidential Enquiry into Maternal Deaths
• Publishes triennial reports (1st report 1952-54)
  on deaths occurring during or within 1 year of
  pregnancy
• Now The Confidential Enquiry into Maternal and
  Child Health
• Most comprehensive obstetric mortality database
  in the world
• USA
• The Pregnancy Mortality Surveillance System
• Established in 1987 to collect data on all deaths
  causally related to pregnancy during or within 1
  year of the end of pregnancy
• Includes data from 1979 onwards

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ASA Closed Claims Project
35 Insurance Companies
60 of all MD Practitioners
6894 files in the ASA Closed Claims
Project Database
12 (n 840) of claims ASA Closed
Claims involved Obstetric Care

• 67 involve cesarean section patients

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Limitations of the ASA Closed Claims Database

• The incidence of complications cannot be
  determined
• There is no denominator
• Not all complications result in a claim
• The total number of anesthetics is unknown
• Sources of bias
• Often more severe injuries result in a claim
• Retrospective transcription of data
• Changes in practice patterns

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• Anesthesiology
• 199174242-49
• A Comparison of Obstetric and
• Non-Obstetric Malpractice Claims
• H.S. Chadwick, Karen Posner, Robert A.Caplan,
  Richard J. Ward, Frederick W. Cheney

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Trends in Outcomes in OB Claims by Decade
plt0.05 compared to 1970s ASA Closed
Claims plt0.05 compared to 1980s
N6894
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• SPECIAL ARTICLE
• Anesthesiology
• 2005103645-53
• Obstetric Anesthesia Workforce Survey
• Twenty-year update
• Brenda A. Bucklin, Joy L. Hawkins, James R.
  Anderson, Fred A. Ullrich

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Anesthesia Technique in Cesarean Section Claims
ASA Closed
Claims plt0.05 compared to 1970s (Z test)

N6894
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Regional Anesthesia Technique
100
80
60
of regional blocks in delivery group in decade
40
20
0
Lumbar
SAB
Caudal
Lumbar
SAB
Epidural
Epidural
Vaginal Delivery (n246)
Cesarean Section (n362)
plt0.05 compared to 1970s
ASA Closed Claims plt0.05 compared to
1980s N6894
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Trends in Outcomes in OB Claims by Decade
plt0.05 compared to 1970s ASA Closed
Claims plt0.05 compared to 1980s
N6894
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Maternal Mortality by Decade
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OBSTETRICS GYNECOLOGY Volume 101 February
2003 Number 2 Pregnancy-Related Mortality in the
United States, 1991-1997 Cynthia J. Berg, Jeani
Chang, William M. Callaghan, Sara J. Whitehead
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Berg, Obstet Gynecol 2003101289-296
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CLINICAL INVESTIGATIONS Anesthesiology 1997862
77-284 Anesthesia-Related Deaths During
Obstetric Delivery in the United States,
1979-1990 Joy L. Hawkins, Lisa M. Koonin, Susan
K. Palmer, Charles P.Gibbs
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Demographics of Women Dying of
Anesthesia-Related Causes During Obstetric
Deliveries () Age Education
lt20 12 lt12 yr 11 20-24 32 12
yr 36 25-29 28 gt12 yr 23 30-34 19 Unknow
n 30 35-39 5 40- 4 Race Trimester
Prenatal White 45 Care Began Black 52 No
Care 2 Other 3 First 57 Second 11 D
elivery Procedure Third 6 Cesarean 82 Unk
nown 28 Vaginal 5 Unknown 13 Hawkins,
Anesthesiology 19978627-284
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Causes of Anesthesia-Related Death during
Obstetric Deliveries 1979-90
Hawkins et al Anesthesiology 199786277-84
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Anesthetic Causes of Maternal Mortality in the
1990s
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• Clinical Obstetrics and Gynecology
• 200346(3)679-687
• Anesthesia-Related Maternal Mortality
• Joy L. Hawkins

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• Why the decline in Deaths Associated with
  Regional Anesthesia?
• Increased awareness of local anesthetic toxicity
• Withdrawal of 0.75 bupivacaine in 1984
• Increased use of test doses

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High Risk General Anesthesia

• Far fewer general anesthetics performed in
  obstetrics now
• Nearly 8 x higher difficult intubation rate
• Sicker patients receiving GA with increased risk
  factors for difficult intubation
• Majority are for emergency cesarean sections
• Deskilled anesthesia providers
• Inadequate exposure of residents
• Subspeciality anesthesia providers who rarely
  intubate

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Solutions

• All Obstetric personnel should be familiar with
  the ASA Difficult Airway Algorithm
• Difficult airway cart in OR
• Anticipation of patients with difficult airway
  and early regional intervention
• Availability of extra, experienced hands at
  induction of GA

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Trends in Outcomes in OB Claims by Decade
plt0.05 compared to 1970s ASA Closed
Claims plt0.05 compared to 1980s
N6894
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Nerve Injury in the 1990s
N 74
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Nerve Injury in the 1990s
n 74
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Nerve Injury by Block
n 74
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• EDITORIAL
• International Journal of Obstetric Anesthesia
• 199871-4
• Auditing complications of regional analgesia in
  obstetrics
• Few of the public, or even the medical
  profession, appreciate that for epidural blockade
  to cause paraplegia or cauda equina syndrome
  requires some abnormal causative factor or
  error.
• Felicity Reynolds

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• Anaesthesia
• 2000551106-26
• Ability of anaesthetists to identify a marked
  lumber interspace.
• C.R. Broadbent, W.B. Maxwell,R. Ferrie, D.J.
  Wilson, M. Gawne-Cain, R. Russell
• Anaesthesia
• 200156238-247
• Damage to the conus medullaris following spinal
  anaesthesia.
• F. Reynolds

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Obstetric Nerve Injuries
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Minimizing Nerve Injuries

• A through preanesthesia evaluation and
  documentation of any current or previous deficits
• Rigorous attention to asepsis when performing a
  neuraxial block.
• Anesthesia Nursing attention to patient
  position and unusual sensory or motor symptoms
  out of proportion to the low-dose epidural in
  situ.
• Post-delivery evaluation to check full return of
  neurological function

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What to do with a possible nerve injury?

• Discuss with the obstetric team.
• Full history physical incl. detailed
  neurological examination.
• Try to establish which nerve has been affected.
• Get an early neurology opinion
• Timely investigations
• EMG
• MRI
• X-rays
• Follow-up with the patients progress.

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Trends in Outcomes in OB Claims by Decade
plt0.05 compared to 1970s ASA Closed
Claims plt0.05 compared to 1980s
N6894
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Newborn Brain Injury in the 1990s

• Decreased from 22 in 1980s to 13 in the 1990s
• 40 of claim cases in 1990s were diagnosed with
  cerebral palsy
• Cesarean section mode of delivery in 80
• 79 of these were urgent or emergent
• In 60 of claims the anesthesiologist was either
  dismissed or dropped from the case or no payment
  was made.

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Possible Contributing Factors in Newborn Brain
Injury in the 1990s
62.5

33.3
25
16.7
8.3
n 48
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• British Medical Journal
• 2004328665-9
• National cross sectional survey to determine
  whether the decision to delivery interval is
  critical in emergency caesarean section.
• Jane Thomas, Shantini Paranjothy, David James
• Obstetrics Gynecology
• 20061086-11
• Decision-to-Incision Times and Maternal and
  Infant Outcomes.
• Steven L. Bloom, Kenneth J. Leveno, Catherine Y.
  Spong, et al

1.
2.
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Etiology of Cerebral Palsy

• Incidence 2-3 per 1000 live births
• 75 of cases due to antenatal factors
• Only 6-8 are related to birth asphyxia
• Most of these are not preventable
• 10-18 post-natal acquired CP

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• Known Causes of Cerebral Palsy
• ANTEPARTUM
• congenital brain malformations
• fetal vascular events
• maternal infections in 1st/2nd trimesters of
  pregnancy
• metabolic disorders
• maternal ingestion of toxins
• rare genetic syndromes
• Essential criteria that define an acute
  INTRAPARTUM event sufficient to cause CP
• Metabolic fetal acidosis in fetal umbilical
  arterial blood at delivery pHlt7, BE? 12 mmol/l
• Early onset severe or moderate neonatal
  encephalopathy in infants born at 34 or more
  weeks of gestation
• Spastic quadraplegic or dyskinetic cerebral palsy

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• Risk Factors for Cerebral Palsy
• DURING PREGNANCY
• Pre eclampsia term infants
• APH preterm birth
• Multiple pregnancy
• Abnormal antenatal CTG
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• DURING LABOR
• major events likely to cause intrapartum
  asphyxia
• Prolapsed cord
• Massive intrapartum hemorrhage
• Prolonged or traumatic delivery
• Maternal shock
• - other assoc. with CP

• AT BIRTH
• Decreasing birth weight assoc. with increasing CP
• Decreasing age at delivery assoc. with increasing
  CP
• Poor intrauterine growth
• Low placental weight (lt 300g)
• Low Apgar scores (scores of 0-3 at 5 mins had 81x
  increased risk of CP)
•  
• IN NEWBORN PERIOD
• Neonatal seizures
• sepsis
• Respiratory disease

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• SOUNDING BOARD
• NEJM
• 20033491765-69
• Can We Prevent Cerebral Palsy?
• .. Apart from our ability to avoid exposure to
  a few associated risk factors in a small majority
  if cases, there is little evidence at present
  that we can.
• Karin B. Nelson

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• HIGH-RISK OBSTETRICS SERIES AN EXPERTS VIEW
• Obstet Gynecol
• 2003102628-635
• Defining the Pathogenesis and Pathophysiology of
  Neonatal Encephalopathy and Cerebral Palsy
• Gary D. V. Hankins and Michael Speer

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Payment Data
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To Conclude

• ? claims for maternal mortality
• Need to improve difficult airway management
• ? claims for nerve injury
• Care with placement of blocks
• ? claims for newborn brain injury
• New criteria to establish cause
• High proportion of claims for minor injuries
• Provision of psychosocial support

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H.W. Haggard - 1929 The position of woman in
any civilization is an index of the advancement
of that civilization the position of woman is
gauged best by the care given her at the birth of
her child.
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Nerve Injuries Associated with Spinal Anesthesia

• Direct nerve root or spinal cord damage
• Infection
• Meningitis
• Neurotoxicity
• 5 hyperbaric lidocaine
• Intrathecal 2-chloroprocaine
• Chemical contaminants