"Tirando o jaleco": notas etnográficas sobre as práticas obstétricas em um hospital de ensino / "Taking off the lab coat": ethnographic notes on obstetric practices in a university hospital

Resumo O estudo teve como objetivo descrever e analisar aspectos do cotidiano da assistência ao parto em um hospital universitário no Sul do Brasil. A expressão "tirando o jaleco" serve como uma metáfora para iluminar o processo de conversão da enfermeira obstetra em pesquisadora em um ambiente hospitalar. Trata-se de uma de pesquisa qualitativa que lançou mão da perspectiva socioantropológica como referencial teórico e metodológico. Os resultados mostraram uma recorrente ausência de informações sobre condutas e decisões médicas dadas as mulheres, desconsiderando-as como sujeitos de direitos, a despeito do que preconiza a política de humanização do parto, revelando nuances do parto e do nascimento pautadas no modelo tecnocrático de assistência. Esse modelo de assistência vigente nos hospitais de ensino requer importantes mudanças através da incorporação de práticas com fundamentos científicos, da inclusão de enfermeiras obstetras e do respeito à mulher como protagonista deste evento.

Abstract The study aimed to describe and analyze everyday aspects of childbirth care in a university hospital in southern Brazil. The expression "taking off the coat" serves as a metaphor to illuminate the process of converting the obstetrician nurse into a researcher in a hospital environment. This is a qualitative research work that made use of the perspective socio-anthropology as a theoretical and methodological framework. The results showed a recurrent lack of information about medical conduct and decisions given to women, disregarding them as subjects of rights, despite what the policy of humanization of childbirth, revealing nuances of childbirth and birth based on the model assistance technocracy. This current care model in teaching hospitals requires important changes through the incorporation of practices with scientific foundations, the inclusion of obstetric nurses and respect for women as the protagonists of this event.

Legalidade e ética entre obstetras do serviço de aborto legal em Alagoas no atendimento às vítimas de estupro / Legality and ethics among obstetricians of the legal abortion service in Alagoas during the care for rape victims

Objetivo: Determinar o perfil ético profissional dos obstetras do serviço de aborto legal no estado de Alagoas (Brasil) e delinear um protocolo e fluxograma para auxiliar no atendimento de mulheres estupradas. Métodos: Realizamos um estudo observacional-transversal, prospectivo e descritivo, incluindo todos os 26 obstetras do serviço de aborto legal. Na fase 1, investigaram-se o conhecimento legal e a posição ética, enquanto na fase 2 foram construídos um protocolo e um fluxograma para guiar o serviço nos casos de aborto legal. Resultados: Na fase 1, identificamos que a maioria dos obstetras não conhecia os aspectos legais sobre o aborto, não se sentiam confortáveis em estar no serviço e apontaram várias limitações no funcionamento dele. Na fase 2, foram desenvolvidos um protocolo e um fluxograma aplicados aos casos em que uma mulher estuprada deseja abortar por métodos legais. Conclusão: O perfil dos obstetras do serviço de aborto legal é insuficiente para lidar com a complexidade do aborto no estado. O protocolo e o fluxograma delineados tiveram o propósito de ajudar o serviço de aborto legal do estado a lidar com esse problema público/social.(AU)

Objective: To determine the professional ethical profile of obstetricians from the legal abortion service in Alagoas state (Brazil) and to design a protocol and flowchart to help the attendance of raped woman. Methods: We performed an observational- -sectional, prospective and descriptive study including all 26 obstetricians from the legal abortion service. Phase 1 investigated the legal knowledge and ethical position, while phase 2 was the construction of a protocol and flowchart to guide the service in cases of legal abortion. Results: In the phase 1 we identified that most obstetrician did not know the legal aspects about abortion; did not few comfortable to be in the service and they pointed out several limitations of how service works. Phase 2 of the study was the development of a protocol and flowchart applied to the cases which a raped woman wants to abort by legal methods. Conclusion: The profile of obstetrician from the legal abortion service is insufficient to deal with the complexity of abort in the state. The protocol designed have the purpose to help the state legal abortion service to deal with this public/social problem.(AU)

Ética em ginecologia e obstetrícia - 2021 / Ethics in gynecology and obstetrics - 2021

Durante a pandemia de covid-19, o Conselho Regional de Medicina do Estado de Goiás (Cremego) encontrou na tecnologia um aliado para manter a atualização de conhecimentos dos médicos que atuam na região. Ao longo do período, a autarquia organizou uma série de lives para discutir diferentes temas de interesse para os profissionais que, independentemente da emergência sanitária, se desdobravam nos cuidados com a população. É dessa iniciativa que nasceu o livro Ética em Ginecologia e Obstetrícia. Trata-se da continuidade dessa grande aposta do Cremego na valorização da educação médica continuada e do estímulo ao debate e à troca de experiências. Assim, ao transformar as discussões promovidas em artigos, o Conselho permite que médicos de outros estados possam acessar o conteúdo gerado, ampliando seu alcance. O leque de assuntos é dos mais relevantes. As discussões abordam temáticas que encerram polêmicas e suscitam dúvidas, como ética na reprodução assistida e em medicina fetal; atendimento à adolescente; assistência ao parto; direitos da gestante; e impactos da covid-19 na gravidez. Quem saborear essa publicação se deparará com um trabalho que vai além da discussão teórica sobre cada um dos temas. Na verdade, isso se deve aos autores que tiverem a felicidade de trazer para seus textos suas experiências e visões privilegiadas de quem conhece a linha de cuidados que deve ser oferecida à mulher.

Empatía y Componentes de la Empatía en Estudiantes de Obstetricia / Empathy and Components of Empathy in Obstetrics Students

Introduction: Empathy with the patient is an important attribute that contributes to the success of treatment. This attribute must be object of teaching in the training stage of the student of the health sciences. Objective: To evaluate the levels of empathy and its components in students of the Obstetrics course at the University of Norbert Wiener, Peru. Material and Methods: Design: cross-sectional study. Participants: The sample was composed of 219 first-year to fifth-year students. Measurements: The Jefferson Empathy Scale, S version for students was applied. The internal reliability of the data was estimated using the general Cronbach's alpha, interclass correlation coefficient, Hotelling's T2, and Tukey non-additive test; the mean and standard deviation were estimated. A bi-factorial analysis of variance (ANOVA), model III was applied in the academic years, the genders and the interaction of these two factors. Results: The empathic level of obstetrics students has an average of 105,95 points, out of a maximum of 140, and it is higher (in absolute values) than other values observed in analogous measurements in Latin America. In general, there are no significant differences in empathy between academic years and genders, and in the components of empathy. Conclusions: The average level of empathy among obstetrics students at Wiener University shows relative little growth per year of study(AU)

Introducción: La empatía con el paciente es un importante atributo que contribuye al éxito del tratamiento. Este atributo debe ser objeto de enseñanza en la etapa de formación del estudiante de ciencias de la salud. Objetivo: Evaluar los niveles de empatía y de sus componentes en estudiantes del curso de Obstetricia de la Universidad Norbert Wiener, Perú. Material y métodos: Diseño: estudio transversal; Participantes: la muestra fue de 219 estudiantes que estaban en el primer a quinto año de su carrera; Medidas: se aplicó la escala de empatía de Jefferson, versión S para estudiantes. La confiabilidad interna de los datos se estimó utilizando el alfa general de Cronbach, el coeficiente de correlación interclase, el T2 de Hotelling y la prueba no aditiva de Tukey, estimando las medias y la desviación estándar. Se aplicó un análisis bifactorial de varianza (ANOVA), modelo III entre los años académicos, entre los géneros y en la interacción de estos dos factores. Resultado: El nivel empático de los estudiantes de obstetricia examinados tiene un promedio de 105,95 puntos de un máximo de 140 y es mayor (en valores absolutos) a otros valores observados en mediciones análogas en América Latina. En general, no hay diferencias significativas entre los años académicos y entre los géneros en la empatía y en los componentes de la empatía. Conclusiones: El nivel promedio de empatía entre los estudiantes de obstetricia en la Universidad de Wiener muestra un crecimiento relativamente pequeño por año de estudio(AU)

Ethical challenges in invasive maternal-fetal intervention.

The field of maternal-fetal intervention is rapidly progressing and with it comes new and often complex ethical considerations that must be addressed. The purpose of this article is to review the ethical issues that arise in maternal-fetal intervention. We will provide two clinical scenarios and discuss the ethical issues related to each scenario and how they were addressed. We will also provide a list of recommended resources that any institutional offering maternal-fetal intervention should have in place to meet the ethical obligations of such work.

Surgeon Volume in Benign Gynecologic Surgery: Review of Outcomes, Impact on Training, and Ethical Contexts.

It is becoming increasingly clear that surgeon volume affects surgical outcomes. High-volume surgeons demonstrate reduced perioperative complications, shorter operative times, and reduced blood loss during multiple modalities of benign gynecologic surgery. Furthermore, high-volume surgeons consistently demonstrate higher rates of minimally invasive approaches, low rates of conversion to laparotomy, and lower per-procedure case costs. It is suggested that surgeons who have completed postresidency training have improved surgical outcomes, although these data are limited. Surgical exposure in obstetrics and gynecology residency is varied and does not consistently meet demonstrated surgical learning curves. Deficiencies in residency surgical training may be related to the volume-outcome relationship. We suggest reforming residency surgical training and tracking postresidency practice to provide optimal surgical care. Additionally, surgeons may have an ethical obligation to inform patients of their surgical volume and outcomes, with options for referrals if needed.

Obstetricians' views on the ethics of cardiac surgery for newborns with common aneuploidies.

OBJECTIVE: To examine whether obstetricians think that cardiac surgery is ethical in babies with common aneuploidies and whether insurance companies should be required to pay for these surgeries. STUDY DESIGN: A survey was e-mailed to 2897 OB-GYNs, and 898 (31%) actively practicing obstetricians responded to the survey. Respondents were asked whether it is ethical to offer cardiac surgery for babies with heart defects diagnosed with trisomies 21, 18, and 13 and Turner syndrome and whether insurance companies should be required to pay for such surgeries in cases of trisomy 18 or 13. Chi-square tests were utilized to compare responses by using an alpha level of .05. RESULTS: Most obstetricians thought that offering cardiac surgery was ethical if the baby had trisomy 21 or Turner syndrome (94%), but not trisomy 18 or 13 (75%). Most obstetricians (69%) thought that insurance companies should not be legally required to pay for cardiac surgery for the latter group. CONCLUSION: Obstetricians were more likely to think cardiac surgery was ethical if the prognosis or the outcome was good. Most respondents did not think that insurance companies should be required to subsidize the cost of cardiac surgeries for all babies with trisomy 18 or 13.

¿Némesis obstétrica o disminución del riesgo? A debate bioético el abordaje intervencionista en los partos de bajo riesgo / Obstetric nemesis or decrease risk? A discussion bioethical the approach interventionist in low-risk deliveries / Nemesis obstétrica ou diminuição do risco? A debate bioético a abordagem intervencionista em partos de baixo risco

Resumen: Desde hace décadas el parto de bajo riesgo ha sido abordado, fundamentalmente en el ámbito clínico-hospitalario, desde una perspectiva intervencionista, caracterizada por la medicalización, tecnificación y mecanización asistencial. En este contexto se sitúa el presente estudio, cuyo objetivo ha sido explorar las limitaciones bioéticas de este paradigma asistencial intervencionista, mediante el análisis de su pragmatismo clínico frente a otros abordajes más humanistas. Para ello se ha llevado a cabo un profundo análisis documental en diferentes bases de datos del ámbito de las ciencias médicas y sociales, seleccionando tanto artículos de difusión científica como libros, declaraciones, estrategias y guías de práctica clínica. Los resultados muestran un patrón asistencial medicalizado, que parece incrementar las intervenciones no justificadas y con ello los efectos iatrogénicos en los partos de bajo riesgo. Se concluye que estamos ante una cultura del nacimiento que, en cierta medida, vulnera los principios bioéticos fundamentales, al subyugar la dignidad de la corporalidad femenina a intereses económicos contingentes e ideologías transhumanistas, biopolíticas y tayloristas cosificadoras.

Abstract: For decades in low-risk deliveries has been addressed, mainly in the clinical-hospital setting, from an interventionist perspective characterized by medicalization, mechanization and machining care. In this context the present study lies, whose aim was to explore the bioethical limitations of this interventionist paradigm of care through an analysis of its clinical pragmatism compared to other approaches more humanistic. For this it has conducted a thorough analysis of documents in different databases in the field of medical and social sciences, selecting both items of scientific diffusion as books, statements, strategies and clinical practice guidelines. The results show a medicalized care pattern appears to increase the iatrogenic effects in low-risk deliveries. We conclude that this is a culture of birth which, to some, it violates basic bioethical principles to subjugate the dignity of female corporeality to contingent economic interests and transhumanists, biopolitics and taylorist ideologies reifying.

Resumo: Por décadas o parto de baixo risco tem sido abordado, fundamentalmente no campo clinico-hospitalar, a partir de uma perspectiva intervencionista caracterizada pela medicalização, tecnificação e mecanização assitencial. Nesse contexto se situa o presente estudo, cujo objetivo tem sido explorar a limitações bioéticas desse paradigma assistencial intervencionista através da análise de seu pragmatismo clínico frente à outras abordagens mais humanistas. Para isto, fora realizada uma profunda análise documental em diferentes bases de dados no campo das ciências médicas e sociais, selecionando tanto artigos de divulgação científica como livros, declarações, estratégias e guias de prática clínica. Os resultados mostram um padrão assistencial medicalizado que parece intensificar as intervenções não justificadas e, por conseguinte, os efeitos iatrogénicos em partos de baixo risco. Conclui-se estamos diante de uma cultura de nascimento que, em certa medida, viola os princípios bioéticos fundamentais ao subjugar a dignidade da corporalidade feminina por interesses econômicos contingentes e ideologias transumanistas, biopolíticas e tayloristas reificantes.

Dime quién lo define y te diré si es violento. Reflexiones sobre la violencia obstétrica / Diga-me por quem é definido e vou dizer se é violento: uma reflexão sobre a violência obstétrica / Tell me by whom is defined and I'll tell if it is violent: a reflection on obstetric violence

Resumen: La propuesta de trabajo es problematizar la definición de la violencia obstétrica (VO), que nace en ciertas prácticas y relaciones en la atención médica de partos. Para ello se proponen dos ejes de trabajo interrelacionados: primero, la aplicación de un modelo de análisis socioantropológico de la violencia a lo específico de la VO; segundo, el cruce entre definiciones objetivas (legales, políticas y académicas) y subjetivas (a raíz de un documento producido por asociaciones de la sociedad civil) para abordar tal problematización. Partimos del supuesto de que subyace en la definición de VO un campo de disputa por las legitimidades (de su definición), en una interrelación constante entre las nominaciones objetivas y las significaciones subjetivas sobre ciertas prácticas obstétricas, definidas como violentas. Sostenemos que el cambio en las sensibilidades sociales sobre diversas formas de violencia (que generó cambios en las legitimidades) explica la actual discusión sobre la definición de la VO.

Resumo: Neste artigo discutimos a definição de violência obstétrica (VO) em relação a certas relações e práticas na assistência médica à gravidez e ao parto. Abordamos a violência no caso específico do VO por meio de um modelo de análise sócio-antropológica e pela comparação entre definições objetivas (jurídicas, políticas, acadêmicas) e subjetivas produzidas por associações da sociedade civil. Assumimos que o que subjaz aos discursos sobre o VO é uma disputa sobre a legitimidade de sua definição e que, neste processo, a nomeação objetiva e os significados subjetivos atribuídos a certas práticas obstétricas como violentas se entrelaçam. Argumentamos que a mudança nas sensibilidades sociais em relação a muitas formas de violência (que resultou em mudanças de discursos legítimos) explica a discussão atual sobre a definição do que é VO.

Abstract: In this article we discuss the definition of obstetric violence (VO) regarding certain relationships and practices in medical care of pregnancy and childbirth. We approached violence in the specific case of VO through a socio-anthropological model of analysis, and through the comparison between objective definitions (juridical, political, academic) and subjective ones as produced by civil society associations. We assume that what underlies the discourses on VO is a dispute over the legitimacy of its definition, and that, in this process, objective naming and subjective meanings attributed to certain obstetric practices as violent are intertwined. We argue that the change in social sensitivities regarding many forms of violence (which resulted in changes of legitimate discourses) explains the current discussion on the definition of what is VO.

O desafio do direito à autonomia: uma experiência de Plano de Parto no SUS / The challenge of the right to autonomy an experience of birth plan in the health public sector

Na assistência ao parto no Brasil, predominam intervenções desnecessárias em detrimento de valores como o cuidado. Algumas políticas públicas têm sido desenvolvidas com o intuito de alterar tal cenário, porém, com lentos resultados. Há também algumas estratégias e ferramentas desenvolvidas e difundidas entre as próprias mulheres. Uma destas é a construção do plano de parto, que objetiva informar e promover uma maior participação durante o parto. Apesar de mais difundida entre camadas médias, tal ferramenta tem sido utilizada em alguns serviços de atenção primária do país como a UBS Thérsio Ventura-São Paulo, campo de estágio para o curso de Obstetrícia EACH-USP. Este estudo objetivou descrever e analisar o uso de plano de parto entre usuárias do SUS e médicos-gestores. De metodologia qualitativa, os dados empíricos foram produzidos a partir de entrevistas com mulheres que vivenciaram a experiência de plano de parto no SUS; entrevistas com médicos-gestores; observação de uma consulta de orientação para o plano e parto; observação de dois grupos de apoio à gestação e ao parto realizados na UBS, e análise documental de material educativo, e de documentos referentes às políticas de saúde materna municipal e nacional. O material foi submetido à análise de conteúdo, da qual emergiram as seguintes categorias: (a) Não é uma incapacidade sua, e sim do sistema; (b) De coitada a poderosa; (c) Intervenção que era ajuda; (d) Resistência e negociação do encontro; (e) Plano de parto como mobilizador do cuidado como valor; (f) A segurança do bebê como chantagem; (g) Sobre comandantes, aviões e a necessidade de novas analogias; (h) Plano de parto como provocação: negligência e retaliação; (i) Limites para a decisão informada no SUS.

Birth care in Brazil is marked by strong predominance of unnecessary interventions at the expense of values such as care. Some policies have been developed in order to change such a scenario but with slow results. There are also some strategies and tools developed and disseminated among women themselves. One of those is the construction of the birth plan, which aims to inform and expand participation and decision making during childbirth. Widespread among middle class women, this tool has been used in some primary care services in the country such as UBS Thérsio Ventura-São Paulo, a training field for the course of Midwifery EACH-USP. This study aimed to understand and analyse the use of birth plan between women who use the public health system and doctors-managers. Using qualitative methodology, empirical data was produced from interviews with women who experienced birth plan in the public system; interviews with doctors-managers; observation of a guidance for the birth plan construction; observation of two support groups at the studied health center, and document analysis of educational materials and documents relating to municipal and national maternal health policies. The material was subjected to content analysis of which the following categories emerged: (a) It is not your disability, but the systems; (b) From poor thing to powerful; (c) Intervention that once was 'help'; (d) Resistance and negotiation of the encounter; (e) Birth Plan as a mobilizer of care as a value; (e) The safety of the baby as blackmail; (f) About commanders, airplanes and the need for new analogies; (g) Birth plan as defiance: negligence and retaliation; (h) Limits for 'informed decision' in the public health system.

Intervenciones de enfermería para la atención del parto de bajo riesgo de la mujer en el primer nivel de atención / Nursing interventions for low-risk delivery of women at the first level of care

Intervenciones de enfermería para la atención del parto de bajo riesgo de la mujer en el primer nivel de atención.Introducción. Diariamente mueren 1500 mujeres por complicaciones en el embarazo y el parto. Por tanto, la mejora de la salud materna es considerada como uno de los ocho objetivos del Milenio adoptados en la Cumbre del Mileno de las Naciones Unidas en el año 2000.Métodos. Con “Delivery, Obstetric” como descriptor y el planteamiento de preguntas clínicas, se realizó la búsqueda sistemática en: PUBMED, BvS, Trip Database y Scielo para la revisión de meta análisis, revisiones sistemáticas, guías clínicas y ensayos clínicos aleatorizados, cuyas evidencias y recomendaciones con mayor gradación y fuerza respectivamente, dieran respuesta en la detección de factores de riesgo, atención del parto y prevención de complicaciones. Se incluyeron documentos en inglés, portugués y español publicados entre 2011-2015.Resultados. Se analizaron 213 documentos, de los cuales 15 fueron utilizados en esta guía. La evidencia científica enfatiza la valoración oportuna de riesgos como: hipertensión arterial, infecciones de vías urinarias recurrentes, sangrado durante el embarazo, multiparidad, edad mayor a 35 años y nivel socioeconómico bajo, considerados como causas obstétricas de mortalidad materna y la prevención de posibles complicaciones derivadas de la atención del parto. Además, vigilar la evolución del parto, uso y reacción adversa de uterotónicos, constantes vitales de la mujer y la actividad cardíaca fetal así como cuidados que faciliten la atención humanizada. Conclusiones. Las intervenciones de enfermería basadas en evidencia científica influyen en la calidad de la atención del parto con el menor riesgo de morbilidad y mortalidad materna. Palabras clave. Parto obstétrico, factores de riesgo, enfermería, complicaciones.

Introduction. Every day 1500 women die from complications in pregnancy and childbirth. Therefore, improving maternal health it is regarded as one of the eight Millennium Development Goals adopted at the Millennium Summit of the United Nations in 2000.Methods. With ""Delivery, Obstetric"" as descriptor and approach to clinical questions, the systematic search was conducted: PUBMED, BvS, Trip Database and Scielo for review of meta-analyzes, systematic reviews, clinical guidelines and randomized clinical trials, whose evidence and recommendations more gradation and strength respectively, would respond in detecting risk factors, delivery care and prevention of complications. documents in English, Portuguese and Spanish published between 2011-2015 were included.Results. 213 documents were analyzed, of which 15 were used in this guide. Scientific evidence emphasizes the timely assessment of risks such as low blood pressure, infections recurrent urinary tract infections, bleeding during pregnancy, multiparity, older than 35 years, and socioeconomic status considered obstetric causes of maternal mortality and the prevention of possible complications of care delivery. In addition, monitoring the progress of labor, use and adverse reaction of uterotonics, vitals of women and fetal heart activity and facilitate care humanized care.Conclusions. Nursing interventions based on scientific evidence influence the quality of care delivery with lower risk of maternal morbidity and mortality.Keywords. obstetrical delivery, risk factors, nursing, complications.

As intervenções de enfermagem para prestação de cuidados de mulheres de baixo risco no primeiro nível de atenção.Introdução. Todos os dias 1500 mulheres morrem de complicações na gravidez e no parto. Portanto, melhorar a saúde materna é considerado como um dos oito Objectivos de Desenvolvimento do Milénio adoptados na Cimeira do Milénio das Nações Unidas em 2000.Métodos. Com ""Parto Obstétrico"" como descritor e abordagem de questões clínicas, a busca sistemática foi conduzida: PubMed, BvS, Banco de Dados de viagem e Scielo para revisão de meta-análises, revisões sistemáticas, diretrizes clínicas e estudos clínicos randomizados, cujas provas e recomendações mais gradação e força, respectivamente, iria responder na detecção de fatores de risco, assistência ao parto e prevenção de complicações. documentos em Inglês, Português e Espanhol, publicados entre 2011-2015 foram incluídos.Resultados. 213 documentos foram analisadas, dos quais 15 foram usadas neste guia. A evidência científica enfatiza a avaliação atempada dos riscos, tais como pressão arterial baixa, infecções do trato urinário infecções recorrentes, sangramento durante a gravidez, multiparidade, mais de 35 anos e nível socioeconômico considerado causas obstétricas de mortalidade materna ea prevenção de possíveis complicações da prestação de cuidados. Além disso, o monitoramento do progresso do trabalho de parto, uso e de reacções adversas de uterotônicos, sinais vitais de mulheres e atividade cardíaca fetal e facilitar o atendimento cuidado humanizado.Conclusões. As intervenções de enfermagem baseadas em evidências científicas influenciar a qualidade da prestação de cuidados a um menor risco de morbidade e mortalidade materna. entrega obstétrica, fatores de risco, enfermagem, complicações.

A comparison of medical litigation filed against obstetrics and gynecology, internal medicine, and surgery departments.

BACKGROUND: The aim of this study was to review the typical factors related to physician's liability in obstetrics and gynecology departments, as compared to those in internal medicine and surgery, regarding a breach of the duty to explain. METHODS: This study involved analyzing 366 medical litigation case reports from 1990 through 2008 where the duty to explain was disputed. We examined relationships between patients, physicians, variables related to physician's explanations, and physician's breach of the duty to explain by comparing mean values and percentages in obstetrics and gynecology, internal medicine, and surgical departments with the t-test and χ(2) test. RESULTS: When we compared the reasons for decisions in cases where the patient won, we found that the percentage of cases in which the patient's claim was recognized was the highest for both physician negligence, including errors of judgment and procedural mistakes, and breach of the duty to explain, in obstetrics and gynecology departments; breach of the duty to explain alone in internal medicine departments; and mistakes in medical procedures alone in surgical departments (p = 0.008). When comparing patients, the rate of death was significantly higher than that of other outcomes in precedents where a breach of the duty to explain was acknowledged (p = 0.046). The proportion of cases involving obstetrics and gynecology departments, in which care was claimed to be substandard at the time of treatment, and that were not argued as breach of a duty to explain, was significantly higher than those of other evaluated departments (p <0.001). However, internal medicine and surgical departments were very similar in this context. In obstetrics and gynecology departments, the proportion of cases in which it had been conceded that the duty to explain had been breached when seeking patient approval (or not) was significantly higher than in other departments (p = 0.002). CONCLUSION: It is important for physicians working in obstetrics and gynecology departments to carefully explain the risk of death associated with any planned procedure, and to obtain genuinely informed patient consent.

Delivering the truth: challenges and opportunities for error disclosure in obstetrics.

Disclosing harmful medical errors to patients is a prominent component of the patient safety movement. Patients expect it and safety agencies and experts advocate its implementation. Obstetrics presents unique challenges to carrying out disclosure recommendations: childbirth is a life-changing, emotionally charged, and dynamic family event characterized by high expectations and unpredictability, and perinatal care is provided by complex ad hoc teams in a litigious area of medicine. Despite these challenges, transparent communication with parents about unexpected adverse birth outcomes remains critical. We call on clinicians and professional societies to pursue a deeper understanding of the unique challenges of disclosure in obstetrics and prepare themselves to conduct these difficult conversations well.

Revisiting "The maximin strategy in modern obstetrics".

Published in 1981, "The Maximin Strategy in Modern Obstetrics" offered two claims: first, that obstetrical interventions ought to be assessed not singly, but rather as packages of interconnected measures that could cumulatively increase risks of harm; and second, that many of these interventions, considered either singly or as a package, lacked a sound evidence base. The first claim has been well supported by later literature, although the term "cascade effect" has proven a more felicitous descriptor for the phenomenon of interventions that trigger the use of other interventions to monitor, prevent, or treat possible side-effects. The second claim was initially supported in a very inadequate way, since the "Maximin" article appeared before an understanding of the methods of systematic reviews of medical evidence had been widely promulgated. Despite these defects, subsequent, rigorously conducted systematic reviews have tended to confirm the impression first offered in 1981, that practices that support physiologic childbearing and the innate, hormonally driven capacities of childbearing women and their fetuses/newborns are much more in keeping with the available evidence than practices involving common or routine high-technology interference with physiologic processes. Harm may occur either directly, through high-technology interventions, or when such procedures distract attention and resources from safe, effective biological processes and lower-technology measures. Surveys indicate a lack of knowledge of this evidence among childbearing women, signaling a serious ethical deficiency in shared decision-making processes and perhaps the skills and knowledge of maternity care clinicians.