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
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