N	
  Lolatgis	
  FRANZCOG	
  
The	
  Lack	
  of	
  Dialogue	
  &	
  Agreement	
  
Among	
  Providers	
  of	
  Maternity	
 ...
Associated	
  Professions	
  
•  Obstetricians	
  
•  General	
  PracDDoners	
  
•  Midwives	
  
•  Child	
  Birth	
  Educ...
ReproducDon	
  
•  ConcepDon	
  is	
  a	
  normal	
  physiological	
  process	
  
•  Pregnancy	
  is	
  a	
  normal	
  phy...
Stages	
  of	
  Labour	
  
•  First	
  Stage	
  
	
   	
  Shortening	
  and	
  dilataDon	
  of	
  cervix	
  
•  Second	
  ...
PaDent	
  ExpectaDons	
  
•  Normal	
  vaginal	
  delivery	
  
•  No	
  complicaDons	
  
•  Healthy	
  baby	
  and	
  heal...
Antenatal	
  EducaDon	
  
•  Hospital	
  run	
  antenatal	
  courses	
  
•  EducaDonal	
  material	
  e.g.	
  RANZCOG	
  p...
Social	
  Media	
  
•  Facebook	
  
•  TwiRer	
  
•  Instagram	
  
•  Dr	
  Google	
  
•  Other	
  forums	
  
Understanding	
  the	
  InformaDon	
  
•  PaDents	
  raise	
  issues	
  during	
  their	
  care	
  that	
  are	
  
explain...
Understanding	
  the	
  InformaDon	
  
•  Any	
  communicaDon	
  that	
  focuses	
  on	
  the	
  
negaDves	
  e.g.	
  comp...
When	
  things	
  do	
  not	
  go	
  to	
  plan	
  
•  PaDents	
  expectaDons	
  not	
  met	
  
•  ComplicaDons	
  occur	
...
ComplicaDons	
  of	
  Vaginal	
  Delivery	
  
Acute	
  
•  Retained	
  placenta	
  
•  Haemorrhage	
  
•  Vaginal/rectal	
...
ComplicaDons	
  of	
  Vaginal	
  delivery	
  
Long	
  Term	
  
•  Urinary	
  inconDnence	
  
•  Faecal	
  inconDnence	
  
...
Risk	
  factors	
  for	
  LaceraDons	
  
•  Primigravida	
  
•  Short	
  perineal	
  body	
  
•  Instrumental	
  delivery	...
Decision	
  making	
  in	
  delivery	
  suite	
  
•  Prolonged	
  labour	
  	
  
•  Delay	
  in	
  second	
  stage	
  	
  ...
Decision	
  making	
  in	
  delivery	
  suite	
  	
  
•  Decision	
  made	
  to	
  deliver	
  
•  Discussed	
  with	
  paD...
Consent	
  in	
  delivery	
  suite	
  
•  How	
  do	
  you	
  consent	
  
•  	
  What	
  do	
  you	
  consent	
  to	
  
• ...
Consent	
  in	
  delivery	
  suite	
  
•  Dynamic	
  situaDon	
  
•  May	
  need	
  to	
  act	
  quickly	
  
•  No	
  Dme	...
Consent	
  to	
  intervene	
  
•  At	
  present	
  the	
  only	
  Dme	
  consent	
  is	
  obtained	
  is	
  
for	
  a	
  c...
Problem	
  
•  Minimal	
  interacDon	
  between	
  health	
  providers.	
  
•  No	
  standardizaDon	
  in	
  informaDon	
 ...
Problem	
  
•  ATtudes	
  in	
  delivery	
  suite	
  different	
  	
  
•  Private	
  versus	
  public	
  
•  Policies	
  	
...
The	
  Problem	
  
•  Obstetricians	
  are	
  the	
  paDents	
  insurance	
  policy	
  
•  Obstetricians	
  do	
  not	
  w...
Lack	
  of	
  dialogue	
  
•  Doctor	
  and	
  delivery	
  suite	
  staff	
  not	
  on	
  same	
  
page	
  
•  PaDent	
  se...
Teamwork	
  
•  Involve	
  yourself	
  in	
  best	
  pracDce	
  with	
  hospitals	
  
you	
  aRend	
  
•  ARend	
  Obstetr...
Teamwork	
  
•  Work	
  in	
  a	
  delivery	
  suite	
  where	
  you	
  are	
  
welcomed	
  
•  Know	
  your	
  group	
  o...
Summary	
  
•  Comfort	
  Zone	
  
•  Consistency	
  
•  Consent	
  
•  Co-­‐operaDon	
  
•  Code	
  of	
  Conduct	
  
•  ...
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Dr Nick Lolatgis - Monash Family Planning Service; Department of obstetrics & Gynaecology, Monash university - The Lack of Dialogue & Agreement Among Providers of Maternity Care of the Complications Associated with Vaginal Delivery

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Nick Lolatgis delivered the presentation at the 2014 Obstetric Malpractice Conference.

The Obstetric Malpractice Conference is only national conference for the prevention, management and defense of obstetric negligence claims.

For more information about the event, please visit: http://www.informa.com.au/obstetricmalpractice14

Published in: Health & Medicine, Education
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Dr Nick Lolatgis - Monash Family Planning Service; Department of obstetrics & Gynaecology, Monash university - The Lack of Dialogue & Agreement Among Providers of Maternity Care of the Complications Associated with Vaginal Delivery

  1. 1. N  Lolatgis  FRANZCOG   The  Lack  of  Dialogue  &  Agreement   Among  Providers  of  Maternity  Care   of  the   ComplicaDons  Associated  with   Vaginal  Delivery  
  2. 2. Associated  Professions   •  Obstetricians   •  General  PracDDoners   •  Midwives   •  Child  Birth  Educators   •  Doulas  
  3. 3. ReproducDon   •  ConcepDon  is  a  normal  physiological  process   •  Pregnancy  is  a  normal  physiological  process   •  Most  babies  are  delivered  vaginally   •  Birth  is  a  normal  process   •  The  default  posiDon  when  pregnant  is  a   vaginal  delivery   •  This  whole  event  is  a  normal  process  
  4. 4. Stages  of  Labour   •  First  Stage      Shortening  and  dilataDon  of  cervix   •  Second  Stage     Descent  and  birth  of  the  infant   •  Third  Stage     Birth  of  the  placenta   Average  length  of  labour  14  hrs  
  5. 5. PaDent  ExpectaDons   •  Normal  vaginal  delivery   •  No  complicaDons   •  Healthy  baby  and  healthy  mother   •  Breast  feeding  to  be  easy   •  Life  to  go  on  as  normal   •  Everyone  is  happy   •  In  laws  delighted  
  6. 6. Antenatal  EducaDon   •  Hospital  run  antenatal  courses   •  EducaDonal  material  e.g.  RANZCOG  pamphlets   •  Internet  and  social  media   •  PublicaDons  Books  and  Magazines   •  Friends  &  Family   •  ConsultaDons   •  Blogs  
  7. 7. Social  Media   •  Facebook   •  TwiRer   •  Instagram   •  Dr  Google   •  Other  forums  
  8. 8. Understanding  the  InformaDon   •  PaDents  raise  issues  during  their  care  that  are   explained  but  most  doctors  focus  on  the   posiDves.  PaDents  believe  they  will  come   through  the  process  unscathed.   •  Obstetricians  do  not  frighten  paDents  with   tales  of  horror  deliveries  and  what  could   happen.   •  A  posiDve  aTtude  is  presented  to  the  paDent.  
  9. 9. Understanding  the  InformaDon   •  Any  communicaDon  that  focuses  on  the   negaDves  e.g.  complicaDons  and  operaDve   deliveries  can  be  very  confronDng  and   frightening  for  a  couple  in  their  first   pregnancy.   •  Most  Obstetricians  do  not  discuss   complicaDons  with  their  paDent  during  their   antenatal  care    
  10. 10. When  things  do  not  go  to  plan   •  PaDents  expectaDons  not  met   •  ComplicaDons  occur   •  Damage  to  mother  and/or  baby   •  QuesDons  raised  as  to  best  management   •  Blaming  game   •  Input  of  family  &  friends   •  Obstetrician  carries  the  blame  
  11. 11. ComplicaDons  of  Vaginal  Delivery   Acute   •  Retained  placenta   •  Haemorrhage   •  Vaginal/rectal  tears   •  Haematoma   •  Perineal  pain   •  Injury  to  pelvic  floor  muscles   •  Urinary  inconDnence/retenDon   •  Anal  inconDnence  
  12. 12. ComplicaDons  of  Vaginal  delivery   Long  Term   •  Urinary  inconDnence   •  Faecal  inconDnence   •  Pelvic  organ  prolapse   •  Fistula  formaDon   •  EmoDonal  trauma   •   Sexual  dysfuncDon   •  Permanent  disfigurement   •  Fear/Anxiety   •  Post  natal  depression   •  Post  traumaDc  stress  disorder   •  Lack  of  bonding  with  the  baby  
  13. 13. Risk  factors  for  LaceraDons   •  Primigravida   •  Short  perineal  body   •  Instrumental  delivery   •  Prolonged  second  stage   •  Large  baby  >4Kg   •  Persistent  OP  posiDon   •  Shoulder  dystocia   •  Episiotomy   •  Asian  Ethnicity   •  Previous  anal  sphincter  tear   •  Maternal  age  >30  
  14. 14. Decision  making  in  delivery  suite   •  Prolonged  labour     •  Delay  in  second  stage     •  Shoulder  dystocia   •  Foetal  distress   •  Instrumental  delivery   •  Pain  relief   •  Adequate  analgesia  for  intervenDon   •  Paediatrician  in  aRendance    
  15. 15. Decision  making  in  delivery  suite     •  Decision  made  to  deliver   •  Discussed  with  paDent  and  partner   •  PreparaDons  made     •  Baby  delivered   •  ComplicaDons  may  or  may  not  happen   •  ComplicaDons  managed   •  Team  effort  required   •  Support  from  all  staff  important   •  Concerns  should  be  expressed  at  the  Dme  not  aaer  the   event  
  16. 16. Consent  in  delivery  suite   •  How  do  you  consent   •   What  do  you  consent  to   •  Is  the  consent  valid  if  the  paDent  has  been   given  narcoDcs   •  Can  the  husband  consent   •  Should  the  paDent  consent  before  labour   commences   •  Global  consent  
  17. 17. Consent  in  delivery  suite   •  Dynamic  situaDon   •  May  need  to  act  quickly   •  No  Dme  to  explain  all  complicaDons   •  MaRer  of  trust   •  Healthy  mother  healthy  baby   •  Unavoidable  complicaDons   •  Proper  management  
  18. 18. Consent  to  intervene   •  At  present  the  only  Dme  consent  is  obtained  is   for  a  caesarean  secDon   •  No  consent  is  signed  for  a  normal  vaginal   delivery   •  No  consent  is  signed  for  an  operaDve  delivery   •  There  is  no  waiver  for  complicaDons  that  may   occur  
  19. 19. Problem   •  Minimal  interacDon  between  health  providers.   •  No  standardizaDon  in  informaDon  available   •  Conflict  in  delivery  suite  between  doctors  and   midwives   •  Best  pracDce  differs  from  doctor  to  doctor  to   midwife   •  EmoDonally  charged  area  for  conflict   •  Bond  between  Obstetrician  and  private  paDent   oaen  compromised  in  delivery  suite  
  20. 20. Problem   •  ATtudes  in  delivery  suite  different     •  Private  versus  public   •  Policies    and  protocols  may  differ  in  different   hospitals   •  Conflict  between  certain  doctors  and  delivery   staff.   •  Failure  to  follow  orders    
  21. 21. The  Problem   •  Obstetricians  are  the  paDents  insurance  policy   •  Obstetricians  do  not  wish  to  intervene.     •  Priority  is  a  healthy  baby  and  healthy  mother   •  Obstetricians  do  their  best  for  the  paDent   •  PaDents  expectaDons  are  high   •  ComplicaDons  happen   •  Blame  game  is  fearsome  
  22. 22. Lack  of  dialogue   •  Doctor  and  delivery  suite  staff  not  on  same   page   •  PaDent  senses  disagreement   •  Partner  senses  disagreement   •  MisinformaDon  given     •  PaDent  confused   •  PaDent  angry   •  ComplicaDons  blamed  on  doctor  
  23. 23. Teamwork   •  Involve  yourself  in  best  pracDce  with  hospitals   you  aRend   •  ARend  Obstetric  Mortality  and  Morbidity   meeDngs   •  Involvement  in  educaDonal  evenings   •  Know  the  staff   •  Deal  with  conflicts  quickly  and  honestly  
  24. 24. Teamwork   •  Work  in  a  delivery  suite  where  you  are   welcomed   •  Know  your  group  of  midwives  and  trust  them   •  Avoid  hospitals  that  you  dislike   •  Common  sense  and  consistency  in  decision   making  are  criDcal   •  Apologize  if  complicaDons  occur  
  25. 25. Summary   •  Comfort  Zone   •  Consistency   •  Consent   •  Co-­‐operaDon   •  Code  of  Conduct   •  Compassion  

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