International journal of obstetric anesthesia
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Int J Obstet Anesth · Oct 1996
Untoward incident reporting in obstetric anaesthesia: a 6-month prospective study in Northern Ireland.
The marked reduction in the number of cases related to the provision of anaesthesia, included in the triennial Reports on Confidential Enquiries into Maternal Deaths in the UK, may limit the educational value of such reports for anaesthetists in the future. The collection, analysis and reporting of untoward events related to obstetric anaesthesia may provide an additional method of highlighting areas of clinical practice that could be improved. ⋯ A brief summary of each event is included along with a more detailed description from a sample of the reports. The advantages and disadvantages of untoward incident reporting are discussed, with recommendations made for a future survey.
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Intravenous nitroglycerin was used to provide uterine relaxation for cesarean delivery of a macrosomic infant. The procedure was complicated by uterine inversion, and subsequent uterine atony. While several other factors may have contributed to the uterine atony, nitroglycerin administration might have played a role. Further, while nitroglycerin was helpful in facilitating the delivery of the macrosomic infant, the risk of uterine inversion must be considered.