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Over the last three decades, the practice of obstetric
anesthesiology has changed considerably. Anesthesia
workforce surveys conducted in 1981 and 1992 revealed
a significant increase in the proportion of cesarean
sections performed under regional anesthesia and
a corresponding decrease in those performed under
general anesthesia.1
The latest data looking at U.S. obstetric anesthesia
practice shows a continuation of this pattern.2
We utilized ASA’s Closed Claims Project database
to determine if these changes in obstetric practice
patterns were reflected in patterns of injury and
liability in malpractice claims. Although the ASA
Closed Claims Project database lacks the ability
to determine the incidence of complications and
relative risk of anesthetic techniques because of
an unknown denominator (the total number of anesthetics
performed) and an incomplete numerator (not all
complications result in a claim), it provides valuable
insight into the types and patterns of injury associated
with malpractice claims.
Obstetric Anesthesia Claims
To date, approximately 12 percent (792) of the 6,449
claims in the ASA Closed Claims Project database
involve obstetric anesthesia care. Thirty-three
percent of these claims involved patients undergoing
vaginal delivery, and 67 percent involved cesarean
section. From the 1970s through the 1990s, the proportion
of cesarean section claims associated with general
anesthesia has progressively declined, while the
proportion associated with regional anesthesia has
steadily increased (p < 0.05) [Figure 1]. These
changes in liability are consistent with changing
trends in anesthesiology practice documented in
workforce surveys.1,2
Figure 1: Anesthetic
Technique in Cesarean Section Claims
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Regional Techniques
Vaginal delivery and cesarean section claims were
grouped according to regional technique: caudal, lumbar
epidural or spinal [Table 1]. With the decreased use
of caudal anesthesia for labor,2
it is not surprising that claims associated with this
regional technique have gone from 15 percent of all
vaginal delivery claims in the 1970s to zero in the
1990s. The proportion of lumbar epidural claims has
increased over the decades for both vaginal delivery
and cesarean section. Part of this rise in claim numbers
is due to the relative increase in the use of epidurals
for obstetric anesthesia.2
The number of claims for spinal anesthesia used in
labor are small, and claims associated with its use
have decreased from the 1970s to the 1980s and 1990s
[Table 1]. Despite the increasing use of spinal and
combined spinal-epidural anesthesia for cesarean section
in obstetric anesthesia practice, the proportion of
claims related to spinal anesthesia has remained static
(approximately 25 percent) over the last three decades
[Table 1].
Outcomes and Damaging Events
In the 1970s, maternal death accounted for the highest
proportion of obstetric anesthesia claims (30 percent),
but this number decreased by more than half by the
1980s and 1990s [Table 2]. The number of claims for
aspiration pneumonitis, albeit small, also decreased
significantly at this time [Table 2]. Obstetric claims
associated with newborn brain damage decreased from
22 percent in the 1970s and 1980s to 14 percent in
the 1990s (p < 0.05) [Table 2]. Maternal nerve
injury increased significantly since the 1970s (11
percent) and became the most common damaging event
in the 1990s (20 percent) [Table 2]. Obstetric claims
associated with back pain also increased significantly
between the 1970s and 1990s. Claims for headache have
remained stable over this same time period.
Discussion
A decrease in high-severity injury claims and increase
in lower-severity claims (e.g., nerve injury and back
pain) correlates temporally with decreased use of
general anesthesia and increased use of regional anesthesia
in obstetrics. The anesthesiologist who has administered
an epidural/spinal may be implicated in a nerve injury
claim even when the injury is obstetric in origin.
Perhaps the most surprising finding from the ASA Closed
Claims Project database is the large proportion of
relatively minor injuries in the obstetric claims
[Table 2], which may reflect a greater incidence of
such problems among obstetric patients. Alternately
it may reflect unrealistic expectations and dissatisfaction
with care. The proportion of claims for pain during
surgery, which are almost always associated with cesarean
section performed under regional anesthesia, have
remained stable despite the overwhelming increase
in the use of regional anesthesia. Spinal anesthesia
produces a denser, more reliable block for cesarean
section than epidural anesthesia, making claims for
“pain during surgery” less likely with
spinals and combined spinal/epidurals, which have
increased in popularity. Inadequate analgesia may
partially result from the reluctance of anesthesiologists
to convert to general anesthesia because of the risk
of aspiration or difficult intubation. It is clear,
however, that many of these patients were unhappy
with their care and believed that they had been ignored,
mistreated or assaulted.3
Malpractice litigation may serve the purpose not only
of reparation of injury and deterrence of substandard
care but also of emotional vindication.4,5
Summary
Changes in outcomes, with a decrease in severe-injury
claims and an increase in nerve injury and back pain
claims, may reflect the decreased use of general anesthesia
and increased use of regional anesthesia in obstetrics.1,2
Changing medicolegal strategies and improved medical
care also may have contributed to the reduction in
severe outcomes in obstetric claims over the decades,
however.
It is crucial to provide patients with realistic expectations
and an understanding of potential major and minor
risks associated with obstetric and anesthetic procedures.
General anesthesia still carries a high risk in this
patient population compared to regional anesthesia.
Obstetricians, obstetric nurses and anesthesia care
providers should work together to coordinate patient
care and develop a good rapport with patients and
their families so that patients will not be motivated
to bring suit for an unexpected outcome. Anesthesia
involvement in prenatal education and a thorough preanesthetic
evaluation are crucial.
References:
1. Hawkins JL, Gibbs CP, Orleans M, et al. Obstetric
anesthesia workforce survey, 1981 versus 1992. Anesthesiology.
1997; 87:135-143.
2. Hawkins JL, Beaty BR, Gibbs CP. Update on U.S.
OB anesthesia practice. Anesthesiology. 1999;
91(suppl):A1060.
3. Chadwick HS, Posner K, Caplan RA, et al. A comparison
of obstetric and nonobstetric anesthesia malpractice
claims. Anesthesiology. 1991; 74:242-249.
4. Meyers AR. ‘Lumping it’: The hidden
denominator of the medical malpractice crisis.
Am J Public Health. 1987; 77:1544-1548.
5. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors
that prompted families to file medical malpractice
claims following perinatal injuries. JAMA. 1992;
267:1359-1363.
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Joanna M. Davies, M.B., is Assistant Professor
of Anesthesiology, University of Washington,
Seattle, Washington. |
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