Closed Claims Project Focuses on 3 Decades of Obstetric Complications

Joanna M. Davies, MB BS, FRCA

Obstetric Claims Summarized Over Time

Providing anesthesia to the obstetrical patient is a clinical challenge, due to both maternal physiologic changes as well as neonatal concerns. As the U.S. population has become increasingly obese over the past 30 years, obesity is becoming a common problem in the obstetric population and is associated with a higher complication rate.1 More than 18% of American women have a BMI ≥30 kg/m2.1 The cesarean section rate is nearly three-fold in obese versus non-obese parturients, with a higher incidence of failed epidurals and difficult intubations.1 We recently provided epidural anesthesia for a 640-pound woman undergoing an elective cesarean section. Despite considerable anxiety for the anesthesia team and a patchy block requiring ketamine sedation toward the end of the case, the mother and baby did well.

The ASA Closed Claims database has provided a wealth of information about malpractice claims involving anesthesia complications since the 1970s. We therefore used the Closed Claims database to examine complications in claims related to obstetric anesthesia and compared it with claims for non-obstetric patients.

Obstetric versus Non-Obstetric Outcomes

The proportion of obese patients in obstetric claims (25%) was greater than in non-obstetric claims (19%, p<0.05). The proportion of obese patients increased in both groups since the 1970s (p<0.05). Obstetric claims more often involved regional anesthesia (70%) than non-obstetric claims (20%, p<0.05). The proportion of claims associated with general anesthesia was lower in both groups in the 1990s (15% in obstetric and 65% in non-obstetric) compared to the 1970s (p<0.05). Eight percent of obstetric patients were ASA 3-5 compared to 24% of non-obstetric patients (p<0.05).

In the 1970s, maternal death accounted for 30% of obstetrics claims (Figure and Table). By the 1980s, the proportion of maternal death claims was reduced by 50% (not shown) and decreased even further by the 1990s (12%, p<0.05 vs. 1970s, Figure and Table). The proportion of claims for maternal brain damage was also lower in the obstetric group compared to the non-obstetric group in the 1990s (Table). Nerve injury became the most common complication in obstetric claims in the 1990s (20%), and had nearly doubled since the 1970s (11%, p<0.05, Figure and Table). Among obstetric claims, the number two complaint after nerve injury in the 1990s was headache (Figure and Table). Claims for back pain increased between the 1970s and 1990s (p<0.05, Table). On the other hand, the proportion of claims for aspiration pneumonitis in obstetric claims decreased significantly between the 1970s (9%) and the 1990s (1%, p<0.05, Figure and Table).

Trends in Complications in OB Claims 1970s vs. 1990s

In the non-obstetric group, claims for patient death also decreased steadily but significantly over the decades (43% in the 1970s, 35% in the 1980s, and 23% in the 1990s, p<0.05), but still accounted for double that of maternal death in obstetric claims in the 1990s (p<0.05, Table). Nerve injury claims for the non-obstetric group increased in similar proportions to those in the obstetric group, while claims for headache, back pain, and aspiration pneumonitis remained low and stable over time (Table). In contrast, the proportion of claims for headache and back pain increased in the obstetric group, especially in the 1990s (p<0.05, Table).

Discussion

Proper interpretation of closed claims data requires the following caveat. The ASA Closed Claims database does not reflect the incidence of complications because the denominator (total number of anesthetics given) is unknown and the numerator (not all complications result in a claim) is incomplete. However, closed claims data do provide insight into the types and pattern of injuries that result in malpractice claims.

With the increasing use of regional anesthesia and the decreasing use of general anesthesia in obstetrics, it is not surprising that the proportion of claims for maternal death has dropped so dramatically since the 1970s. However, the proportion of claims for death in the non-obstetric group remained double that of the obstetric group in the 1990s. This may reflect the fact that the non-obstetric claims involved patients with more severe systemic disease and greater use of general anesthesia than in obstetric patients.

The introduction of sodium citrate, in the mid to late 1980s, to neutralize the acidity of stomach contents, and the decreased use of general anesthesia in obstetric anesthesia may be responsible for the small but significant drop in aspiration pneumonitis.

The increased use of regional techniques or nerve blocks throughout anesthesia practice may account for the similar increases in proportions of nerve injury claims over the decades in both the obstetric and non-obstetric groups. The anesthesiologist who administers any nerve block (neuroaxial or peripheral) may be implicated in a claim that is obstetric or surgical in origin.

Interestingly, obstetric claims involve a larger proportion of claims for more minor injuries, such as headache, back pain, and emotional distress, than in the non-obstetric population (Table). This may be related to the greater use of regional techniques for obstetric patients, but it may also reflect differing expectations between the 2 patient groups. Obstetric patients generally expect childbirth to be a joyous, natural, rather than medical experience, especially with modern methods of analgesia. One study reported, “It is clear that many of these patients were unhappy with the care provided and believed they had been ignored, mistreated, or assaulted.”2 Other studies have included the concepts that malpractice litigation may serve the purpose not only of reparation of injury and deterrence of substandard care, but also of emotional vindication.”3,4 Alternatively, most non-obstetric patients having surgery expect some discomfort and appear to be more aware of the risks of their procedure. Improved obstetric patient education before labor and delivery and increased physician-patient communication, and interpersonal support after the delivery may reduce claims for minor injuries.

Summary

Over the last 3 decades, the proportion of claims for death has decreased and the proportion for nerve injury has increased in both obstetric and non-obstetric claims. The proportions of claims for death, brain damage, and aspiration pneumonitis were lower in obstetric claims, and the proportion of claims for minor complications (headache, backache and emotional distress) was increased in obstetric claims. Changes in anesthesia techniques, differences in patient fitness, or improvements in patient safety may account for these findings. However, due to the lack of denominator data, a decrease in the proportion of claims for death and serious injuries may also reflect an increase in the proportion of claims for less serious injuries. In addition, changing medico-legal strategies may contribute to these findings.

In all areas of anesthesia it is imperative that patients have realistic expectations and a full understanding of the potential major and minor complications associated with their procedure. A visit to the preanesthesia clinic for evaluation and education, together with further discussion between the anesthesiologist and patient on the day of surgery, aids this process. Postoperative visits often pick up the more minor complications, allowing the patient to be counseled and allowing follow-up to be arranged as necessary. Extending this approach to the obstetric patient may reduce anesthesia liability associated with providing anesthesia for labor and delivery. A team approach between obstetricians, anesthesiologists, and nurses, with good interpersonal communication, improves the patient’s confidence and may make a claim less likely for an unexpected outcome.

Ms. Davies is an Assistant Professor of Anesthesiology at the University of Washington in Seattle.


References

  1. Sheiner E, Levy A, Menes T, et al. Maternal obesity as an independent risk factor for caesarean delivery. Paediatr Perinat Epidemiol 2004;18:196-201.
  2. Chadwick HS, Posner K, Caplan RA, et al. A comparison of obstetric and nonobstetric anesthesia malpractice claims. Anesthesiology 1991;74:242-9.
  3. Meyers AR. ‘Lumping it’: The hidden denominator of the medical malpractice crisis. Am J Public Health 1987;77:1544-8.
  4. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA 1992;267:1359-63