Lawsuits against physicians insured by the Doctor’s Company for anesthesia related maternal arrests associated with labor and delivery were recently reviewed Ann Lofsky, M.D. The series included 22 cases that occurred between 1998 and 2006. Ten out of the 22 died, including 3 who were declared brain dead and removed from ventilators. Eleven suffered some degree of anoxic brain damage. Only one had no apparent post arrest neurologic residual deficit. Respiratory arrest after epidural or spinal block was the most common event (13 of the 22 of which 11 had a high neuraxial blockade and apnea and 2 had a caesarian section under spinal anesthesia with arrest after i.v. sedation). Of note was the fact that none of the patients were attached to a maternal monitor with audible alarms at the time of the arrest which may have delayed recognition of a developing problem. Epidural Catheters: Eight of these thirteen patients arrested in labor rooms following attempted insertion and dosing of epidural catheters to relieve labor pains. Of these, 7 had subsequent evidence of unintentional subarachnoid blocks. All eight arrests occurred within the first 30 min of initial catheter placement. In four cases the anesthesiologist was not in the room at the time of the arrest. Seven of the 8 cases involved transfer of a mother in respiratory or circulatory arrest from the labor room to the operating room for a STAT section due to fetal distress. In four of these cases there were documented delays in ventilation of the mother for reasons including failure to notice maternal arrest, desire for more optimal intubating conditions present in OR, difficulty locating an Ambu-bag, or anesthesia provider not present. In the one patient who did not have neurologic residual, the patient was placed supine in the delivery room by the anesthesiologist and was ventilated by bag and mask as soon as ventilation appeared inadequate. Blood pressure was supported by i.v. fluids and the caesarian section was done in the delivery room. Spinal Anesthesia: Five cases occurred in patients for elective caesarean section. In two cases intravenous benzodiazepine or opioid were given after delivery. In one case there was an arrest immediately after the spinal was placed. The arrest was thought to have been secondary to pre-eclampsia and volume depletion. In two other cases there was an apparent high spinal with delay in recognition or resuscitation. Maternal hemorrhage leading to arrest occurred in 7 cases. Three occurred after normal spontaneous vaginal delivery and 4 after caesarean section. Common problems included difficulty in recognizing the presence of hemorrhage, delays in obtaining blood, waiting for typed and crossed blood, inadequate venous access, and not getting help. In this total series of arrests 17 pts had regional blocks and five had general anesthetics. One of the general anesthetics involved a difficult intubation and loss of airway. There was no evidence of aspiration of gastric contents in the series. Conclusions: 1) Since all of the respiratory arrest after labor epidurals in this series occurred within 30 minutes after catheter insertion increased monitoring and/or the continuous presence of the anesthesiologist might have prevented or allowed earlier recognition of a developing problem. 2) Having audible alarms for pulse oximetry might have called attention to a problem earlier. 3) Airway equipment including oxygen needs to be present and immediately available in the room when regional anesthetics are placed. 4) Ventilation and oxygenation of the mother should be established before transporting the mother to another location. 5) Massive hemorrhage on labor and delivery is rare, but the incidence may be increasing given the increased rate of repeat Cesarean sections and an associated rise in placenta previa and acreta. One New York hospital established an obstetric rapid response team and demonstrated a reduction in maternal death despite an increase in their cases of major obstetrical hemorrhage. This is a link to the article as it appeared in the Anesthesia Patient Safety Foundation Newsletter of 2007
The Doctors Company is a very large and respected physician owned company specializing in physician malpractice insurance.
Dr Arkoosh comments on the above: 1) Isn't it remarkable how far we have come with decreasing the risks from management of the maternal airway. This is due to heightened awareness of the problem and implemented strategies to prepare for and respond to challenging maternal airways. We need to apply this same level of diligence to potential complications from neuraxial blocks. 2) It has been shown over and over that we underestimate the amount of maternal blood loss. Data from the UK consistently finds that we under resuscitate this patient population. I would point out that it is not always possible to observe all of the maternal blood loss and that we should generally error on the side of giving what we think might be "too much".
Valerie Arkoosh M.D., MPH is Professor of Clinical Anesthesiology and Critical Care and Professor of Clinical Obstetrics and Gynecology at the University of Pennyslvania.
David S. Smith, M.D., Ph.D.