Obstetric anaesthesia is a particularly stressful subspecialty of anaesthesia. It is important that all staff are aware that there are times when colleagues may need someone to talk to, and they may need support in communicating with the patient and other colleagues. It is also clear that proper debriefing after catastrophes is an important part of risk management.
A crisis may be precipitated by a variety of factors, some obvious and others less obvious (Table 174.1).
Problems and special considerations
Obstetric anaesthesia is a particularly stressful subspecialty, for several reasons:
• The anaesthetist is looking after two people - the mother and the baby - during an important life event. There is therefore much at stake should things go wrong.
Table 174.1 Causes of major stress when support and counselling of colleagues may be required
|
Serious adverse outcome |
Maternal death or severe impairment Fetal death or severe impairment |
|
Unexpected crisis |
Anaphylaxis Failed or difficult tracheal intubation Shoulder dystocia Sudden severe maternal haemorrhage Maternal cardiac arrest |
|
Complication of technique |
Accidental dural puncture Neurological deficit following regional analgesia and anaesthesia |
|
Failure of technique |
Awareness during general anaesthesia for caesarean section Pain during regional anaesthesia for caesarean section Failed regional anaesthesia for labour |
|
Human error |
Giving the wrong drug or blood Not checking a blood result Wrong route of injection of drugs |
|
Other |
Letter of complaint from patient or solicitor Formal complaint from other hospital staff Violence from patient or relative/partner Coincidental professional or personal crisis |
• Both mother and fetus may be physiologically stressed and thus have less reserve than healthy patients. When adverse events occur, they often do so rapidly and without warning, with little time to treat them before irreparable damage occurs. Obstetrics thus represents a truly ‘high-risk’ area of medical practice.
• Pregnancy is perceived as a normal physiological function in which the outcome should be safe and happy. The public expectations are very high, and it is inevitable that these high expectations may sometimes not be met.
• It is obvious that a maternal death will be a very traumatic event, but less obvious that a junior anaesthetist may be very upset by causing an accidental dural puncture.
As maternity units are often very busy places and turnover of staff is high, there may not be a suitable opportunity to discuss potential problems with colleagues.
Maternity units are areas where different professional groups (anaesthetists, obstetricians and midwives) work closely together, with sometimes different priorities. Therefore, it is important to ensure good communication within this multidisciplinary group.
Management options
Failure of communication is one of the main reasons for complaint, and it is important that the anaesthetist continually informs the patient and her relatives when there are problems.
Communication between staff is also crucial. Trainees must always feel able to discuss a problem with their senior colleagues, without embarrassment, and must see themselves as part of the team whose aim is a high standard of care to all the women. Recent emphasis on team working (e.g. the World Health Organization’s surgical safety checklist) has highlighted the need for proper communication between team members.
It is important that there is regular multidisciplinary discussion, and that staff do not automatically blame each other when outcomes are bad. Senior staff of all disciplines should ensure that each major catastrophe is fully discussed in an open fashion, and that all staff involved with the case have a chance to discuss it. Severe adverse events may lead to the development of strong negative emotional responses in some clinicians, triggering feelings of guilt, loss of confidence and even suicidal thoughts. Counselling and a formal support system should be made available to them.
When any member of staff is worried that there has been a problem, it is often helpful to seek advice from their medical protection organisation. It is also useful to go back to the medical record and, where appropriate, expand the account of the events and keep a full copy for personal use.
Post-crisis management also includes identification of any legal and/or financial threats to the hospital and taking steps to avoid or reduce them.
Key points
• All staff are vulnerable to experiencing a catastrophe in the maternity unit.
• Communication with all levels of staff and a non-judgemental approach are essential.
• All members of staff involved in a catastrophe should be offered support and, if necessary, counselling.
Further reading
Association of Anaesthetists of Great Britain and Ireland. Catastrophes in Anaesthetic Practice: Dealing with the Aftermath. London: AAGBI, 2005. www.aagbi.org/sites/default/files/catastrophes05.pdf (accessed December 2018).
McCready S, Russell R. A national survey of support and counselling after maternal death. Anaesthesia 2009; 64: 1211-17.
Pratt SD, Jachna BR. Care of the clinician after an adverse event. Int J Obstet Anesth 2015; 24: 54-63.