The family members of a pregnant woman staged a protest demonstration at Murshidabad Medical College and Hospital in West Bengal alleging that their baby died in her womb due to medical negligence of the doctors as reported by Millennium Post last week. The family members of the woman alleged that during the examination, the nursing staff members told the patient that the baby was moving inside the womb. But later, the family members of the patient were told that the baby had died inside the mother's womb.
WHO/ICD defines stillbirths as the death of a fetus with a birth weight of 500 g, gestational age of 22 weeks or crown-to-heel length of 25 cm. Within this category, ICD classifies late fetal deaths (greater than 1000 g or after 28 weeks) and early fetal deaths (500–1000 g or 22–28 weeks). The WHO recommends using the higher limit (1000 g/28 weeks/35 cm) of third-trimester stillbirths for international comparisons and reporting. The European Medicines Agency (EMA) uses the term stillbirth as the synonym of late fetal death, which is the death after 22 completed weeks of gestation (Vaccine. 2016;34(49): 6057–6068). Fetal deaths later in pregnancy (at 20 weeks of gestation or more, or 28 weeks or more) are referred to as stillbirths as per CDC.
The stillbirth rate is approximately 6.2/1000 live births and fetal deaths.
Several factors may account for stillbirths including maternal, fetal, and placental factors. Risk factors for stillbirth include older maternal age, obesity, multiple gestation, concurrent medical disorders, smoking and pregnancy complications. But, about 25-60% of stillbirths, especially late in gestation are unexplained.
No intervention has been proven to significantly reduce the stillbirth rate in the general obstetrical population. While in high-risk women, achieving good glycemic control, induction of labor, Doppler velocimetry and early induction of labor may help. A full autopsy without restrictions and including placental pathologic examination is optimal for determining the cause of death
Fetal death is diagnosed on ultrasound examination that documents absence of fetal cardiac activity. Once fetal death has been confirmed by ultrasound, the mother or parents should be informed in person without delay, in an empathetic and straightforward manner, in surroundings where she/they can react privately.
Women or couples who lose a baby may also experience the five stages of grief experienced by individuals when told that they have a terminal illness: Denial, anger, bargaining, depression and acceptance). The six-step SPIKES protocol can be followed to deliver bad news
lS: SETTING up the interview with the patient and others she chooses to include
lP: Assessing the Patient's PERCEPTION of the situation
lI: Obtaining the Patient's INVITATION i.e. understanding the amount of information that the patient wants to receive
lK: Providing KNOWLEDGE and information to the patient
lE: Addressing the EMOTIONS of the patient with empathic responses
lS: STRATEGY and SUMMARY
Adverse events are an undeniable part of clinical practice. Death of a patient does not always mean negligence as no doctor practices medicine with an intention to harm the patient. Despite all care, however, sometimes errors may happen inadvertently.
The point to be re-emphasized here is documented informed consent. In addition to other relevant information, anticipate and inform the patient of every possible complication that may occur during treatment, however rare they might be.
The Hon’ble Supreme Court of India has defined ‘adequate information’ in the landmark case of Samira Kohli vs Dr Prabha Manchanda. This includes “(a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment.”
Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA