Consent for Common Obstetric and Gynaecological Procedures

Presented by Dr Stella Mwenechanya

Calderdale and Huddersfield NHS Trust

Aims and objectives

Compliance of current practice to GMC/RCOG advice– Looking at process, documentation

More specifically:– Who is taking consent – Serious and frequent risks documented.

Background and Standards

Legal document

may help reduce complaints/litigation

GMC: informed consent– By investigator/operator– Delegation to suitably qualified and trained person– Sufficient knowledge of procedure and risks

Standards

RCOG consent advice given on several gynae procedures and C/S– Based on DOH/welsh assembly consent form 1– Advice on risks to be discussed for each

procedure also given.

Method

Retrospective review of cases July and August 2007– August: new SHO intake– July: SHOs in post atleast 4 months

 Theatre Registers Procedures looked at were

– Abdominal hysterectomy for heavy periods– Caesarean section– Diagnostic hysteroscopy– Diagnostic laparoscopy– Laparoscopic tubal occlusion – Pelvic floor repair and vaginal hysterectomy for prolapse

Information looked at

Patient identification Name and benefits of

procedure Serious and frequently

occurring risks Extra procedures to/not to

be carried out Leaflet Anaesthetic

Health professional completing the form compared to performing the procedure and their competency

Patient signature Confirmation of consent

Results

57 cases analysed. (10 C/S) 100% compliance in:

– Patients’ surname, first name, DOB and NHS/hosp number

– Name of procedure – appropriate benefits

28%(16) named consultant

Risks

Serious and frequent risks discussed in 98%

Documentation variable for:– Procedure specific risks

– Additional procedures 18% of consent forms contained none

Abdominal Hysterectomy

Abdominal Hysterectomy

0 10 20 30 40 50 60 70 80 90 100

SERIOUS RISKS Damage to bladder/ureters

Longterm disturbance to bladder function

Bowel damage

Haemorrhage

Return to theatre

Pelvic abcess/inf

VTE/PE

Death

FREQUENT RISKS Wound infection

Frequency of micturition

Delayed wound healing

Keloid formation

Early menopause - evidence inconclusive

OTHER RISKS NOT STATED BY RCOG Vessel damage

EXTRA PROCEDURES Blood transfusion

Repair Bladder

Repair bowel

Repair vessel

Oophorectomy

Caesarean Section

Caesarean Section

0 10 20 30 40 50 60 70 80 90 100

SERIOUS RISKS Hysterectomy

Bladder injury

Ureteric injury

Fetal Lacerations

Uterine rupture in future preg

PP/Accreta in future preg

Antenatal stillbirth

Need for further surgery

ICU - very dependent on reason for CS

Death - Rare/dependent on indication

FREQUENT RISKS Discomfort

Subsequent

Infection

DVT/PE

OTHER RISKS NOT STATED BY RCOG Bowel injury

Bleeding

Vessel damage

EXTRA PROCEDURES Blood transfusion

Repair bladder/bowels

Repair vessels

Response to unsuspected pathology

Hysterectomy

Diagnostic Hysteroscopy

Diagnostic Hysteroscopy

0 10 20 30 40 50 60 70 80 90 100

SERIOUS RISKS Uterine

Perforation

Infection

Failure to visualise uterine cavity

FREQUENT RISKS Vaginal

bleed/discharge

Pain - pelvic/shoulder

OTHER RISKS NOT STATED BY RCOG Injury to

pelvic organs

EXTRA PROCEDURES Laparoscopy in rare event of

perforation

Transfusion - very rare

Diagnostic Laparoscopy

0 10 20 30 40 50 60 70 80 90 100

SER IOUS R ISK S Bow el damage

B ladder damage

B lood vessel damage

Failure to enter abdominal cavity

Uterine perforat ion

Death

FREQUENT R ISK S Failure to identify …

Bruis ing

Shoulder t ip pain

OTHER R ISK S NOT STA TED BY RCOG …

B leeding

B lood trans fus ion

EXTRA PROCEDURES …

Repair bow el

Repair bladder

Repair vessels

Diagnostic Laparoscopy

Laparoscopic Tubal Occlusion

Laparoscopic Tubal Occlusion

0 10 20 30 40 50 60 70 80 90 100

SERIOUS RISKS Failure 1in200Future preg in fallopian tube

Failure to enter abdominal cavityUterine Perforation

Bowel damageBladder damageVessel damage

Death

FREQUENT RISKS BruisingShoulder tip pain

OTHER RISKS NOT STATED BY RCOG InfectionBlood transfusion

BleedingIrreversible

DVT/PE

EXTRA PROCEDURES LaparotomyRepair bowel

Repair bladderRepair vessels

Herniation

Pelvic Floor Repair & Vaginal Hysterectomy

Pelvic Floor Repair and Vaginal Hysterectomy

0 10 20 30 40 50 60 70 80 90 100

SERIOUS RISKS Bladder damageBowel damage

HaemorrhageReturn to theatre

Long term disturbance to bladderPelvic Abscess

VTE/PEDyspareunia

Recurence/failure

FREQUENT RISKS Urinary retentionVaginal bleeding

Frequency of micturitionInfection

Pain

OTHER NOT STATED BY RCOG Vessel damageIntermittent self catheterisation

EXTRA PROCEDURES Blood transfusionRepair Bladder

Repair BowelLaparotomy

Leaflet/Anaesthetic

32%(18) Leaflet

79%(45) type of anaesthetic ticked

Doctor Signature/Date/Name/Position

96%(55) Signed and Dated

93% Printed name (legible)– 19% were complete by consultants– 21% by associate specialists– 46% by registrars – 7% by SHOs

43%(25) completed by the health professional performing the procedure

Competency

94%(54) competent to perform the procedure

3 VTS SHOs – 2 c-section – 1 diagnostic laparoscopy

Patient Signature/Date/Name

96%(54) Signed 84% Dated

68% Name printed

Conclusion

Good compliance with guidelines on documentation of– patient/procedure details– Procedure benefits– Person obtaining consent

Serious and frequent risks– Reasonable compliance with local guidelines– Poor compliance with RCOG

Compliance also to be improved in:– Leaflets provision/documentation– Anaesthetic discussion– Named consultant

Recommendations

Use of procedure specific consent forms to ensure all risks discussed with patient.

– May even reduce repeat C/S rate

Registrar Inductions to include guidelines in obtaining valid consent.

Audit of local risks for each procedure. Re-audit in 3years

Royal College ofObstetricians andGynaecologists

Setting standards to improve women’s health

Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting

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