Author: Medical Law Collection.
*Please specify**: Medical Law Collection.
Brief facts of the case
The patient, Ms. Du (29 years old), was hospitalized in the city hospital for delivery because she had stopped menstruation for 39 weeks and found that the amniotic fluid was too low for half a day. Preliminary diagnosis: oligohydramnios, oligohydramnios, 1 parity, 0 intrauterine gestation, 39 weeks of LOA single live fetus. 3 days later, he was sent to the delivery room for natural delivery, and at 20:40 that night, the fetal heart rate suddenly slowed down to 55 minutes, and did not recover, and immediately performed a negative examination, and after the patient and his family signed to agree to cesarean section, the lower uterine segment cesarean section was performed under local anesthesia immediately, and the operation went smoothly, and a baby was born, and was diagnosed as severe neonatal asphyxia.
On the same day, the newborn was taken to the Provincial Hospital for hospitalization**. On the second day of admission, the neonatal spontaneous breathing was very weak, the blood oxygen saturation dropped to the lowest 60%, and the endotracheal intubation was immediately given, and the blood oxygen saturation of the child was normal after ventilator-assisted ventilation, and the child was in critical condition, and the family requested to be discharged, and the discharge diagnosis was: severe neonatal asphyxia, neonatal hypoxic-ischemic encephalopathy (severe), neonatal metabolic acidosis, neonatal shock, neonatal hyperglycemia, pneumothorax. Discharge: The child was in a deep coma, did not respond to painful stimuli, was pale, had no spontaneous breathing, had normal blood oxygen saturation under ventilator-assisted breathing, the bregma was not flat and soft, the pupils were equal to the same circle, the diameter was about 5mm, and the light reflex disappeared. Muscle tone is low, and primitive reflexes are absent. On the day of discharge, the newborn died.
The patient believed that the doctor violated the diagnosis and treatment norms, and in the event of acute distress, the midwife doctor instructed Ms. Du to do a squatting midwifery action to aggravate the fetal distress, and should bear full responsibility for the death of the newborn, and sued the city hospital for compensation of more than 1.01 million yuan.
Heard by the courts
The appraisal opinion believes that the diagnosis of neonatal asphyxia (severe) is clear, and the cause of death is consistent with the pathophysiological process of death due to multiple organ dysfunction (respiratory, nervous, cardiac, metabolic) caused by severe neonatal asphyxia. The mother began to have abnormal fetal heart rate at 20:40, the fetal heart rate was as low as 80bpm, which was class III, and the doctor took corrective measures (oxygen inhalation, change of position), and the umbilical cord prolapse was not found in the vaginal examination, and the fetal ear could not be palpated (not suitable for ** midwifery), and the fetal head was pushed up to see the amniotic fluid third-degree turbidity, after careful examination and symptomatic treatment, the fetal heart rate could not be recovered at 20:45, and there was an indication for immediate termination of pregnancy. According to the examination results and delivery records, the cause of fetal distress was that the umbilical cord was short, the umbilical cord was wrapped around the neck (tight) and the umbilical cord was stretched too tightly, which caused fetal distress caused by obstruction of fetal blood circulation. Since the umbilical cord is not short during pregnancy by ultrasound technology, the doctor's failure to clarify in advance in the prenatal examination that the umbilical cord is due to medical limitations is not a violation of diagnosis and treatment standards. The newborn was transferred to a higher-level hospital after 1 hour and 23 minutes of resuscitation, and there was no causal relationship between the doctor's diagnosis and treatment behavior and the consequences of neonatal death, and it was recommended that the fault participation should be 0%.
Ms. Du was pregnant for the first time, and the blood group test at the first prenatal examination showed that AB Rh was negative, and the doctor was at fault for not giving or recommending her to monitor the anti-D titer test during the whole pregnancy and at the time of admission. According to the results of routine blood and coagulation tests, Ms. Du did not have a lack of coagulation factors and fibrinogen, and there was no indication for blood transfusion and plasma during and after cesarean section, so it was a violation of diagnosis and treatment routine for the doctor to give 2 units of red blood cells and 400ml of plasma to prevent postpartum hemorrhage. As a result of the doctor's negligence, Ms. Du lost the anti-D immunoglobulin desensitization measures as soon as possible before delivery (or before sensitization) and within 72 hours after delivery, increasing the chance of hemolytic disease in her second child. There is a causal relationship between the fault of the doctor and the increased probability of fetal hemolytic disease in Ms. Du's repregnancy, and the causal force is the main factor, and it is recommended that the fault participation rate should be about 75%.
The court of first instance held that there was no causal relationship between the doctor's diagnosis and treatment and the consequences of the neonatal death, so it did not support the patient's claim for death compensation and funeral expenses for the neonatal death. As for the solatium for mental damages, because the doctor was at fault for Ms. Du's diagnosis and treatment, there was a causal relationship between her fault and the consequences of Ms. Du's increased probability of hemolytic disease in her repregnancy, and 20,000 yuan was supported as appropriate. The court ruled that the city hospital should compensate the patient with a solatium of 20,000 yuan for mental damages, and rejected other litigation claims.
Dissatisfied, the affected party appealed. The patient believes that in the event of acute distress, the doctor's requirement for the woman to squat for 5 minutes obviously does not comply with the diagnosis and treatment standards, which objectively aggravates the degree of distress, and there is a direct causal relationship between the fetal suffocation and death, and the doctor should be presumed to be at fault.
The court of second instance held that the reappraisal lacked sufficient basis and was not supported. The fetal heart rate monitoring value dropped to 80 times during childbirth is a warning signal, the doctor instructed the mother to squat and cause the fetal heart rate monitoring to be interrupted, the doctor has not considered the lack of effective monitoring, the patient's appeal opinion is reasonable, combined with the court of first instance to determine the fault of the doctor, the city hospital was sentenced to compensate the patient for mental and economic losses totaling 100,000 yuan.
A brief analysis of the law
Maternal and infant health is a major public health issue, and maternal mortality and infant mortality are internationally recognized basic health indicators, as well as important comprehensive indicators to measure economic and social development and human development. The "Healthy China 2030" Planning Outline takes maternal mortality and infant mortality as the main health indicators, and puts forward clear task goals, and by 2030, China's infant mortality rate and maternal mortality rate will be reduced to 50 and 120 100,000. It also calls for improving the health level of women and children, implementing projects to ensure maternal and child health and family planning services, and improving the ability to treat pregnant women and newborns in critical and critical cases.
The Department of Obstetrics and Gynecology has always been a department with a high incidence of medical damage liability disputes, and according to the data of the National Big Data Report on Medical Injury Liability Disputes in the past six years, the number of cases in the Department of Obstetrics and Gynecology has always been in the top two. In particular, after the adjustment of China's fertility policy, the number of elderly and high-risk pregnant women has increased, and the risk of complications and complications during pregnancy and childbirth has increased.
China's Civil Code stipulates that if a patient suffers damage in the course of diagnosis and treatment, and the medical institution or its medical staff is at fault, the medical institution shall bear the liability for compensation. The determination of whether a medical institution should bear tort liability to a patient should be based on whether the medical institution's medical act was at fault and whether there was a causal relationship with the patient's harmful consequences. Medicine is an exploratory empirical discipline with boundary limitations, clinical diagnosis is especially affected by objective factors such as the patient's condition and individual physique, clinical diagnosis is like moving forward in the fog, and the negligence in the fog is a highly professional technical problem, which should be judged by experts, so the appraisal opinion is an objective standard that both doctors and patients should follow and an important basis for the people's court to hear medical damage liability dispute cases.
In accordance with the provisions of the "Several Provisions of the Supreme People's Court on Evidence in Civil Proceedings", the people's court shall permit any of the following circumstances where a party has objections to an appraisal opinion and applies for a new appraisal: (1) the evaluator does not have the corresponding qualifications;(2) The appraisal procedures are seriously illegal;(3) The basis for the evaluation opinion is clearly insufficient;(4) Other situations where the evaluation opinion cannot be used as evidence. In this case, the patient only applied for a re-appraisal in the second instance, and it did not meet the above requirements, so his application for re-appraisal was approved by the court of second instance.
On the issue of whether the doctor's instruction to the mother to do squatting midwifery in this case is in line with the standard of diagnosis and treatment, and whether it aggravates the degree of fetal distress. According to books on obstetrics and gynecology, "......If the fetus does not decline well in the second stage of labor, the pregnant woman can try to increase the position of the birth canal gravity, such as sitting or squatting, but the duration should not be too long. "In Western countries, women are encouraged to choose any position of delivery according to their own volition, based on environmental factors, the midwife's proficiency in each positional delivery method, and the condition of the mother and fetus, including supine, (supported) sitting, sideways, (supporting) squatting, kneeling, upright and hands and knees. It can be seen that the position in the delivery is a free choice, and in this case, the doctor instructed the mother to squat in an attempt to increase the gravity of the birth canal, so the appraisal agency believes that the squatting position is a way to change the position during childbirth, and there is no causal relationship between the squatting midwifery and the consequences of the death of the newborn.
Medical institutions should strictly manage the safety of diagnosis and treatment, pay close attention to the various situations of pregnant women, strengthen the safe care of pregnant women and newborns, eliminate all kinds of risks in the medical process and hospital environment in a timely manner, and minimize unnecessary harm to patients during the hospital to ensure patient safety.
This article is the original work of Medical Law Collection, adapted from real cases, and pseudonyms are used to protect the privacy of the parties).