Table 6 Example of missed opportunities linked to care items for placenta previa

Case 2

A 36-year-old native mother, 2P, with two previous CS was admitted to hospital due to low back pain in 39 + 3 weeks of gestation. According to ultrasound examinations during antenatal visits, she had low-lying placenta previa. Emergency CS was performed two hours after admission on the night shift and the operation ended up with CS hysterectomy due to abnormal invasive placenta. More than 20 units of blood products were transfused, the mother was admitted at intensive care unit and had long-lasting intubation. Pathologic examination of uterus specimen revealed placenta increta.

Care items

Audit findings

Antenatal care

Despite two previous CS and low-lying placenta previa, examination of placental orientation for better obstetric plan during pregnancy was not conducted.

Despite repeat CS and previa, no elective surgery was planned.

Referral system

No timely referral from antenatal clinic to the hospital was made.

Initial assessment

Despite risk for abnormal invasive placenta, no assessment at hospital was performed.

Recognition

Recognition of abnormally invasive placenta in a high-risk mother was missed before operation room.

Care plan

No evidence was found indicating acute CS on the night shift for a high-risk surgery.

Documentation

Estimation of blood loss during operation was not documented.

Near-miss events such as the amount of administered blood, admission to intensive care unit, and long-lasting intubation were not documented in summary notes.

Preventability

The near-miss events could have potentially become less critical and traumatic for woman and her family by better obstetric practice (provider-related).