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Inadequate anaesthesia during caesarean section (13HDC00515)
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(13HDC00515, 30 June
Anaesthetist ~ Obstetrician ~ District health board ~
Caesarean section ~ Anaesthesia ~ Information ~ Communication ~
Pain ~ Rights 4(1), 4(2), 6(1)(b)
A woman was admitted to hospital in labour, progress was slow
and the decision was made that it would be safest to deliver the
baby by an emergency lower segment Caesarean section (LSCS). The
woman was transferred to the operating theatre, where she met her
anaesthetist. The woman advised that the anaesthetist "joked
around", and she found it hard to tell when he was being serious.
She said he also focused in a very detailed manner on the risks of
a general anaesthetic, should one be required, including the risk
The anaesthetist conducted an "ice test" to check the woman's
sensation, and she said she could feel that the ice was quite cold.
However, the anaesthetist advised the obstetrician that she could
begin the surgery in two minutes' time. Initially, the woman could
not feel anything; however, when the obstetrician entered the
peritoneal cavity, the woman complained of pain. The anaesthetist
assured the obstetrician that she could continue with the
When the obstetrician attempted to deliver the baby the woman
complained of pain and began lifting both her knees. The
obstetrician asked the nurses to hold down the woman's legs. The
woman again voiced her pain, and the anaesthetist told her that she
was not feeling pain, and it was just pressure. He said that she
could not have any more pain relief unless they "put her under",
which would not be good for the baby.
After the delivery, the woman continued to complain of pain
while the obstetrician sutured the incision.. The anaesthetist
declined to administer extra pain relief. At the completion of the
procedure, when the woman was ready for transfer to recovery, he
commented that he was about to become involved in a "real"
It was held that the anaesthetist's failure to ensure that the
woman received adequate anaesthesia prior to commencement of the
Caesarean section was suboptimal, and breached Right 4(1). The
woman had the right to be informed about the options available to
her, including an assessment of the expected risks, side effects
and benefits of each option. The anaesthetist's provision of
information to the woman fell seriously short of accepted
standards, breaching Right 6(1)(b).
The anaesthetist's actions, and his failure to ensure that the
woman received adequate anaesthesia/analgesia during her Caesarean
section were suboptimal and a breach of accepted standards.
Accordingly, he breached Right 4(1). His communications with the
woman displayed a lack of sensitivity, and he treated her with a
striking lack of empathy, breaching Right 4(2).
It was also held that the obstetrician was aware that the woman
was expressing that she was in pain at a number of points and noted
on the operation record that the anaesthesia was suboptimal for
LSCS. The obstetrician should have spoken and acted with more
authority when she thought the woman was feeling pain. By
continuing to operate on her after delivery of the baby and after
realising that she was in pain, she breached Right 4(1).
The anaesthetist was referred to the Director of Proceedings for
the purpose of deciding whether any proceedings should be taken,
and a recommendation made that the Medical Council of New Zealand
consider carrying out a competence review of the anaesthetist.
Comment was made about staff training, orientation and policies at
DHBs. Recommendations were made that the DHB review the orientation
of locum staff, audit the implementation and effectiveness of its
policies and protocols for epidural anaesthesia and include in its
training and induction for all staff, information that the practice
of asking questions and reporting of concerns is expected and
accepted from all members of the multidisciplinary
The Director of Proceedings decided to institute a
proceeding, which is pending.