If a woman insists on a caesarean section causing heavy bleeding, is the hospital responsible?

For medical professionals only

A real-life case is a wake-up call for obstetricians and gynecologists!

It is believed that many colleagues in obstetrics and gynecology have encountered patients who insist on caesarean section, and caesarean section is also very easy to bring a series of obstetric medical disputes. How to deal with this situation? What are the legal considerations? Today, I will analyze a medical dispute case caused by caesarean section.

The facts of the case

The plaintiff Chun Ni was admitted to the defendant hospital for 40 + 2 weeks of menstruation, and ultrasound B prompted that there was less amniotic fluid. Because Chun Ni was concerned about the vaginal trial delivery, she insisted on requesting a cesarean section. On the second day of admission, the hospital party performed a lower uterine caesarean section under lumbar hard combination anesthesia + general anesthesia to deliver a male live baby. After the placenta delivery, Chun Ni appeared to have contracture weakness, the doctor massaged the uterus, oxytocin, cara pregnancy plug, Alek to promote uterine contraction and hemostasis treatment, but the efficacy was not good, and then gave bilateral internal iliac artery ligation, but the bleeding volume was still not significantly reduced, the uterine contraction was poor, and she had to perform subtotal hysterectomy in desperation. During the operation, the patient had a large amount of bleeding, and the amount of bleeding was about 4000 ml.

Chun Ni believes that the defendant hospital violated medical practice by asking for a caesarean section as an indication for surgery due to fear of vaginal trial delivery; and the hospital's preoperative estimation was insufficient, and the uterine contraction weakness during the operation, heavy bleeding and then improper handling, resulting in the removal of the uterus, so the hospital sued the people's court.

Forensics

The expert opinion held that:

1. According to the patient's medical history, physical examination and related examinations, the doctor's diagnosis is clear, the preoperative examination is perfect, the information is sufficient, and there is no violation in the surgical process.

2. When the mother has uterine contraction weakness and bleeding after the intraoperative fetal delivery, the doctor will rescue the corresponding, and the superior physician will be present in time to take measures such as massaging the uterus, applying a variety of uterine shrinkants, ligating the uterine artery and the internal condyle artery, and handling it properly.

3. In the case that the mother is still bleeding and diffuse intravascular coagulation (DIC) occurs, the doctor transfuses blood in time, and in order to save the life of the mother, subtotal hysterectomy is performed with the consent of the patient's family, which is in line with the diagnosis and treatment routine. Maternal bleeding is a complication of childbirth, which can occur in vaginal delivery or caesarean section, and is clinically difficult to completely avoid.

4. In this case, there is no indication for absolute caesarean section surgery after prenatal examination, but the pregnant woman requests a caesarean section, and after the doctor informs the risk of the operation and the possibility of surgical complications, the pregnant woman still insists on caesarean section and signs the informed consent form for surgery. In this case, it is feasible to use "social factors" as a caesarean section. Because pregnant women have concerns about vaginal trial labor and require surgery to terminate the pregnancy, the doctor did not adopt the method of vaginal trial delivery with oxytocin for her preoperative contractions.

The appraisal opinion is: The hospital has no medical fault in the process of diagnosis and treatment of the appraisee.

In the end, the court held that there was no causal relationship between the defendant's diagnosis and treatment behavior and the patient's damage consequences, but according to the actual situation of the case, the defendant should share part of the plaintiff's losses, and the defendant would compensate the plaintiff for RMB3,000 at its discretion.

Brief analysis of case studies

Human reproduction has been going on for tens of thousands of years, but the way humans give birth is still debated, in fact, with the development of social and medical technology, more and more women will choose caesarean section. The "ideal proportion of caesarean sections" recommended by the World Health Organization (WHO) is 10% to 15%, while a study published in the famous medical journal The Lancet shows that The Caesarean section rate in China has jumped from 3.7% in 1988 to 34.9% in 2014. This means that in China, a third of babies are born by caesarean section, well above the world average of 20 percent.

Women initiate caesarean section because they are afraid of the pain of natural childbirth and subjectively believe that caesarean section is safer. However, the requirements for caesarean section put forward by the mother on the initiative generally do not have the indications for caesarean section surgery, as a doctor, you cannot blindly follow the wishes of the mother, but you cannot ignore the mother's self-choice and categorically refuse the mother's request. So, in the face of many pregnant women's caesarean section requests, should obstetricians and gynecologists stick to the indications for surgery, or should they respect the choices of pregnant women?

In this regard, the author analyzes as follows:

Indications for caesarean section are pathological or physiological conditions that cannot be delivered vaginally or are not suitable for vaginal delivery. Referring to the medical indications listed in the "Expert Consensus on Caesarean Section Surgery" proposed by the Obstetrics and Gynecology Branch of the Chinese Medical Association, the following situations are regarded as absolute indications for caesarean section, which is the scientific basis for clinicians to decide whether to have a caesarean section, including:

1. Abnormal bone birth canal (pelvic stenosis, head pelvis is not symmetrical);

2. Soft birth canal abnormalities (soft birth canal malformations, vaginal reconstruction surgery history, vulvar factors, etc.);

3. Contractions are weak;

4. Abnormal fetal position (transverse position, breech position);

5. Have a history of abnormal childbirth (multiple stillbirths, obstructed deliveries, infection and bleeding from the last childbirth);

6. Fetal factors (excessive fetus, twins, multiple births, fetal distress, etc.);

7. Pregnancy complications (eclampsia, gestational hypertension, placental abruption, etc.);

8. Internal medical complications (heart disease, liver disease, lung disease, kidney disease, cerebrovascular disease, etc.);

9. Surgical complications (pelvic fracture, cerebral hemorrhage, abdominal or perineal injury, etc.);

10. Others (failure to induce labor, failure to give birth to vaginal midwifery, etc.).

Relative indications generally refer to pathological fetal heart rate monitoring indicators; inability to proceed normally during labour; previous caesarean section experience, etc.

In addition, there are many sequelae of caesarean section surgery, such as:

● Increases the chance of major bleeding and infection;

• 10-30 times more likely to occur in the postpartum period than natural childbirth;

● Postoperative pathological pain has a long time and slow recovery;

● The mortality rate is 3 times higher than that of spontaneous childbirth, and the likelihood of amniotic fluid embolism is 10 times higher than that of spontaneous childbirth.

Saying that natural childbirth is good, what is good in the end? In fact, as the most natural delivery, the recovery of pregnant women after normal delivery is fast, through the delivery channel, the baby's lung function can be exercised, and the nerve and sensory organs will be stimulated, which is conducive to the development of the baby. However, the patient often does not have medical expertise, so the doctor should inform the pregnant woman in detail about the pros and cons of caesarean section delivery and vaginal delivery.

Medicine is a developing science, there are still many medical problems that have not been overcome, and a large number of medical puzzles are difficult to solve, which means that medical technology in any period has certain limitations. At the same time, medical behavior is also characterized by a high degree of professionalism and high risk, and medical personnel are often accompanied by many unpredictable risks when treating patients with diseases and relieving pain. It is precisely for this reason that China's law adopts a "standard of conduct" rather than a "standard of outcome" when judging whether medical institutions and their medical personnel are at fault.

Article 57 of the Tort Liability Law stipulates that "if medical personnel fail to fulfill the diagnosis and treatment obligations corresponding to the medical level at that time in the diagnosis and treatment activities, causing damage to the patient, the medical institution shall bear the liability for compensation." That is to say, whether the medical staff has fulfilled the duty of care appropriate to the current level of medical treatment and whether the medical acts carried out are in line with the medical conventions at that time, rather than whether the diagnosis and treatment effect is good or whether the patient is satisfied, as the criterion for judging whether the medical staff is at fault. In this case, Chun Ni went to the hospital to give birth, and strongly requested the hospital to perform caesarean section surgery under the condition that there was no indication for caesarean section, and the contractions were weak, causing heavy bleeding, although the hospital actively rescued and treated, and finally the hysterectomy was removed, which was unfortunate for a woman, and the real value of sympathy. However, as far as the doctor is concerned, the doctor has indicated the risks and possible complications of the operation, and signed the informed consent for the operation, etc., according to Article 55 of the Tort Liability Law, "the medical staff shall explain the condition and medical measures to the patient in the diagnosis and treatment activities." Where surgery, special examinations, or special treatments need to be carried out, medical personnel shall promptly explain to patients the medical risks, alternative medical plans, and other circumstances, and obtain their written consent. "The medical party fully fulfilled the relevant notification obligations, so there is no causal relationship between the defendant hospital's diagnosis and treatment behavior and the plaintiff Chun Ni's damage consequences in this case."

At present, there are more and more medical disputes caused by caesarean section, on the one hand, the number of people who choose caesarean section surgery is large, on the other hand, it is due to the fault of the hospital in the diagnosis and treatment process, and the relevant notification obligations have not been fulfilled. According to the overall data statistical analysis of medical damage liability cases in 2017, the medical party's fault in the diagnosis and treatment process is the main reason for the doctor's failure to solve the lawsuit, of which the proportion of failure to fulfill the obligation to inform is 23%.

This case also gives some warnings to the medical staff of medical institutions, in the face of pregnant women who do not have absolute indications for caesarean section surgery, the author believes that the practice of "Expert Consensus on Caesarean Section Surgery" proposed by the Obstetrics and Gynecology Branch of the Chinese Medical Association should be referred to, and the overall advantages and disadvantages and risks of caesarean section delivery compared with vaginal delivery should be informed in detail, and recorded; at the same time, psychological counseling and counseling for pregnant women can be provided to help alleviate their fears, and the delivery sedation method can also be applied during the labor process to reduce the pain of delivery of pregnant women and shorten the course of labor. Painless childbirth is widely used, rather than blind rejection or compromise.

Caesarean section surgery is very easy to cause a variety of complications, when the mother has complications and personally experienced the harm of caesarean section, often regret the original decision, anger at the doctor, resulting in doctor-patient conflict, leading to medical disputes, do a detailed written notice or informed consent, but also to prevent the dilemma of the doctor when there is a dispute.

As patients, we must understand that treating patients and saving people is the eternal pursuit of doctors, and doctors must also sympathize with the anxiety and fear of patients when they seek medical treatment. Fear arises, then contradiction arises; trust is in, and the doctor and patient are reconciled.

This article was first published: Medical Law Exchange

Editor-in-Charge: Ichikawa