Errors in obstetric and gynecological practice. Legal assessment of errors in obstetric and gynecological practice. Diagnosis of infectious and inflammatory diseases

SAFE MISTRY
Department of Obstetrics and Gynecology with a course of perinatology (head - Prof. V. E. Radzinsky) Russian University Friendship of Peoples, Committee on the Quality of Medical Care of the Russian
Society of Obstetricians and Gynecologists, Moscow

“Safe obstetrics” is a term that naturally replaces the expression safe motherhood. If in the last third of the last century the world community made efforts to unite humanitarian organizations, sociologists, educators, and doctors in the fight for a woman’s right not to die for reasons related to pregnancy and childbirth, then already in 1995 at the World Congress on Maternal Mortality there was not a single official representative of the UN, WHO, UNICEF or other international organizations. There are at least two reasons for this. It turned out that to transfer so-called home births to hospital births requires huge financial costs (up to 72 trillion US dollars). In addition, by the end of the 20th century, it became obvious that the WHO program (1970) to reduce maternal mortality by 2 times was not only not implemented, but by 2000 the situation had even worsened: instead of 500 thousand women dying annually due to pregnancy and childbirth, there were 590 thousand of them. There are many reasons for this, in particular, the priority of family planning turned out to be unrealized. However, the main reason is a change in attitude towards the family problem - it has been placed under the jurisdiction of national administrations. The consequences of this were not slow to be felt: there were significantly fewer program reports on the problems of maternal mortality at the last FIGO congresses (2003, 2006), and there was practically no unified interdisciplinary strategy at all.
The determination of maternal mortality by average annual per capita income (API) has long been proven. Thus, in Uganda the MDI is US$100, the maternal mortality rate is 1100 per

100,000 live births; in Egypt, the SOP is $400, maternal mortality is 100. Thus, the natural way to reduce maternal mortality is to increase the welfare of the state. This also applies to countries where there is no state system for the protection of motherhood and childhood.
Statistics show that more than half a million women around the world die every year without fulfilling the function intended by nature - reproduction. It should be noted that every tenth case of maternal mortality is, to one degree or another, a consequence of medical errors. It is medical errors (real or imaginary) that become a real danger for a doctor, who is subject not only to legal prosecution and sanctions from insurance companies, but also to “pressure” from society.
In general, the number of lawsuits against doctors has increased more than 5 times over the past 4 years. In this regard, two facts are interesting. First, there were no counterclaims from obstetricians-gynecologists against the plaintiffs at all. The second - in an anonymous survey of gynecologists in the Moscow region (A.L. Gridchik, 2000) to the question: how often were you a direct or indirect culprit of maternal mortality, the doctors answered very differently depending on their work experience. 15% of doctors with up to 15 years of experience, 43% with 16-25% years of experience, and 50% with more than 25 years of experience considered themselves guilty.
It is known that there are different types of medical errors. Firstly, these are gross violations of generally recognized norms, rules, protocols due to

low professional knowledge of medical personnel. Secondly, “strict” compliance with the same generally accepted norms, rules, protocols, etc. The situation is paradoxical.
Like any science, obstetrics is a dynamically developing discipline that constantly absorbs all the latest achievements of medical science and practice. This is typical for any scientific field, but it must be borne in mind that pregnancy and childbirth are a physiological process, and not a set of diagnoses. Therefore, any intervention in this area should be undertaken only as a last resort. However, in recent decades there has been a large information boom, which is manifested by the emergence of contradictory theories, ideas, and proposals for the management of pregnancy and childbirth. Under these conditions, it is difficult, and sometimes impossible, for practical doctors to understand the expediency and benefits of some provisions or, on the contrary, the risk for the mother and fetus of others: what is the effectiveness of certain methods of managing pregnancy and childbirth, what is the degree of their aggressiveness for the mother and fetus, how they affect the child’s health in the future.
On modern stage development of obstetrics, there are a number of erroneous, scientifically unsubstantiated ideas and approaches, the consequences of which in most cases can be characterized as manifestations of “obstetric aggression”. The latter sometimes becomes the “norm” for pregnancy and childbirth, unfortunately, not always with a favorable outcome. As an example, I would like to cite data from the Netherlands: the frequency of use of oxytocin during childbirth by doctors is 5 times higher than when childbirth is managed by nursing staff, and the frequency of caesarean sections is 3 times higher in medical hospitals.
In Russia, against the background of the most acute problem of population reproduction, in 2005 more than 400 women died from causes related to pregnancy and childbirth. The dynamics of the maternal mortality rate in the Russian Federation over the past decade inspires cautious optimism. As for the structure of the causes of maternal mortality, it fully corresponds to the global one, which is 95% “provided” by the countries of Africa and Asia (bleeding, abortions - 70%, sepsis, gestosis).
The reasons for such unfavorable outcomes of pregnancy and childbirth for the mother and fetus are, to a large extent, the so-called obstetric aggression.
Obstetric aggression is iatrogenic, scientifically unsubstantiated actions, supposedly aimed at benefit, but as a result bringing only harm to the mother and fetus. This leads to an increase in complications of pregnancy and childbirth, an increase in perinatal mortality, infant and maternal morbidity and mortality. In this regard, a natural question arises about the so-called safe obstetrics.
Safe obstetrics is a set of scientifically proven approaches based on the achievements of modern science and practice.

The overall goal of safe obstetrics is primarily to reduce maternal and perinatal morbidity and mortality. However, this provision is currently insufficient.
In recent decades, revolutionary changes have occurred in all spheres of life in our society. Modern socio-economic conditions put forward new requirements for the organization of healthcare. At the same time, such an indicator as the quality of services provided becomes one of the most important factors determining the activities of any healthcare institution.
The formation and development of the health insurance system and market relations also changed social behavior patients and contributed to the establishment of social control over the quality of medical services.
Therefore, the most important feature of modern healthcare is the strengthening of trends in the legal regulation of medical activities. One of the directions of legal reform in healthcare should be the determination of measures of responsibility for non-compliance or formal implementation of legislation for all healthcare authorities involved in ensuring the constitutional right of citizens to receive appropriate medical care, and in relation to a citizen doctor - ensuring his constitutional rights and professional activities, including liability insurance.
The risk of adverse outcomes of pregnancy and childbirth or the development of legal conflicts accompanies the “interested parties” - the doctor and the patient - from the first days of pregnancy, and sometimes extends to the period of pre-conception preparation.
Unobtrusive “aggression” often begins with the very first appearance of a pregnant woman at the antenatal clinic. This applies to unnecessary, sometimes expensive, research and analysis, as well as treatment. The prescription of a standard complex of drugs (vitamin and mineral complexes, dietary supplements, etc.) often replaces pathogenetically based therapy. For example, in case of threatening early termination of pregnancy, in all cases, without appropriate examination, progesterone drugs, ginipral and others are prescribed, which costs over half a billion rubles.
Separately, it should be said about the biotope of the vagina - the most unprotected area of ​​the reproductive system from medical actions. It has become common practice for doctors to identify the presence of any type of infection in the vaginal contents, while prescribing inadequate treatment (disinfectants, powerful antibiotics without determining sensitivity to them, etc.). No less a mistake is the desire to restore vaginal eubiosis. As is known, “nature abhors a vacuum,” therefore, after antibacterial therapy, the microbiological niche is quickly populated by the same microorganisms that, at best, were the target of treatment (staphylococci, streptococci,

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cocci, Escherichia coli, fungi, etc.), but with a different antibacterial resistance.
High-quality PCR gives a lot of incorrect information, forcing the doctor to make certain “aggressive” decisions. Therefore, in the USA this research is carried out 6 times less often than in the Russian Federation, for the reason that it is “too expensive and overly informative.” In order to get rid of the desire to “treat tests,” since 2007 in the United States, even conducting bacterioscopic examinations of pregnant women without complaints was prohibited.
The study of the evolution of the composition of the biotope of the genital tract over the past decades gives the following results: in every second healthy woman of reproductive age, gardnerella and candida can be identified in the vaginal contents, in every fourth - E. coli, in every fifth - mycoplasma. If the CFU of these pathogens does not exceed 105, and the CFU of lactobacilli is more than 107 and there are no clinical manifestations of inflammation, then the woman is considered healthy and does not need any treatment. High-quality PCR does not provide this important information. It is informative only when detecting microorganisms that should practically be absent from the vagina (treponema pallidum, gonococci, chlamydia, trichomonas, etc.).
Another manifestation of so-called obstetric aggression in antenatal clinics is the unreasonably widespread use of additional research methods. We are talking about numerous ultrasound examinations, CTG in the presence of a physiological pregnancy. Thus, prenatal diagnostic methods should be used not to find something, but to confirm the assumptions that have arisen about the risk of developing perinatal pathology.
What is the way out of this situation? Risk strategy - identifying groups of women whose pregnancy and childbirth may be complicated by disruption of the vital functions of the fetus, obstetric or extragenital pathology. These risks must be assessed in terms of significance not only throughout pregnancy, but, very importantly, during childbirth ("intrapartum gain"). Many births that had unfavorable outcomes for both the mother and the fetus are based on underestimation or ignorance of intrapartum risk factors (pathological preliminary period, meconium fluid, labor anomalies, etc.).
The tactics of managing pregnant women at the end of the third trimester of pregnancy also requires revision: unreasonable hospitalization in sometimes extremely overloaded departments of pathology of pregnant women. In particular, this applies to dropsy in pregnancy. According to modern concepts, normal weight gain in pregnant women fluctuates in a fairly wide range (from 5 to 18 kg) and is inversely proportional to the initial body weight.
The majority (80%) of pregnant women in need of treatment can successfully use the services of a day hospital, saving material and

financial resources for the maternity hospital, and without separating the woman from her family.
A pregnant woman hospitalized in pregnancy pathology departments without convincing reasons at the end of pregnancy has one way - to the maternity ward. It is believed that in this pregnant woman, using various methods, first of all, the cervix should be prepared. This is followed by amniotomy and labor induction. It should be noted that amniotomy in the department of pathology of pregnant women is performed in more than half of the patients and is not always justified. This includes amniotomy when the cervix is ​​not mature enough, under the pressure of a diagnosis (dropsy, at best - gestosis, doubtful post-maturity, placental insufficiency with a fetal weight of 3 kg or more, etc.). It should be emphasized that amniotomy for an “immature” cervix significantly increases the incidence of complications during childbirth and cesarean section. Expert estimates show that every fourth caesarean section is the result of obstetric aggression.
The introduction of elements of new perinatal technologies does not find proper understanding: an excess of sterilizing measures (shaving, the use of disinfectants in practically healthy pregnant women) does not leave a chance for any biotope (pubic, perineal, vaginal) to perform its protective functions during childbirth and the postpartum period.
One cannot ignore what is supposedly solved, but at the same time eternal question- How long should labor last on average? This is a strategic question, and therefore incorrect answers to it entail a chain of incorrect actions.
According to the literature, the duration of labor for first- and multiparous women at the end of the 19th century averaged 20 and 12 hours, respectively, and by the end of the 20th century - 13 and 7 hours. Analyzing the time parameters of this value, we can assume that on average each decade the duration labor in primiparous women decreased by almost 1 hour, in multiparous women - by 40 minutes. What has changed during this time? Genetically determined, centuries-old physiological process of childbirth? Hardly. Anthropometric indicators of the female body, in particular the birth canal? No. A natural process of development of scientific thought? Without a doubt! Of course, most achievements in obstetric science and practice have a noble goal - reducing perinatal mortality, maternal morbidity and mortality. But an analysis of the current state of obstetrics shows that we often drive ourselves into a dead end. Why are the world averages for the duration of labor the starting point for making, most often hasty and in most cases, wrong decisions in a particular pregnant woman (the frequency of use of uterotonic drugs in the world reaches 60%, and this is only the data taken into account). Time, and not the dynamics of the birth process, became the criterion for the correct course of labor. Conducted studies indicate that women who begin labor in a maternity institution

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nii have a shorter duration of labor compared to those who present in the middle of the first stage of labor. It should be noted that in the 1st group of women in labor there are more difficult births, characterized by a large number of various interventions and a higher frequency of cesarean sections. No one knows the true figures for the use of prohibited benefits during childbirth (Kristeller’s method, etc.).
An assessment of the obstetric situation using the Kristeller manual was described by E. Bumm in 1917. E. Bumm emphasized that this method is the most aggressive and dangerous intervention in childbirth.
Currently, at the proposal of the French Association of Obstetricians and Gynecologists, the European Union is considering the issue of depriving a doctor of the right to practice obstetrics in all countries of the community if he declares the use of the Christeller benefit. Presented at the last World Congress of Obstetricians and Gynecologists (FIGO, 2006), this initiative was warmly welcomed by delegates.
A retrospective analysis of births that resulted in injuries to newborns, their resuscitation, including mechanical ventilation, revealed the main mistake: the use of the Kristeller method instead of surgical delivery that was not carried out on time.
Issues of providing obstetric care using episiotomy require strict restrictive frameworks. The desire to reduce the length of the incision leads to the exact opposite result: up to 80% of so-called small episiotomies turn into banal perineal tears. Therefore, instead of stitching up a cut wound, you have to stitch up a laceration. As a result, incompetence of the pelvic floor muscles occurs in young women. It has been established that episiotomy during fetal hypoxia is not a radical method of accelerating labor, and if the head is high, this operation does not make sense at all. Therefore, the growing number of cases of pelvic floor muscle failure is a consequence not only of poor restoration of the perineum, but also of the so-called sparing, and often unnecessary, dissection.
As you know, the leading cause of maternal mortality in Russia, as well as in the world, is obstetric hemorrhage. Discussions about the quantity and quality of infusion therapy when replenishing blood loss in obstetrics are still ongoing. Old views on this issue are now being critically assessed. Now there is no doubt that the priority of infusion therapy is the high-quality composition of transfused solutions. This is especially true for infusion therapy in women with gestosis, in which overhydration can lead to dire consequences. And refusal from such “aggressive” infusion media as gelatinol, hemodez, reopolyglucin, etc. significantly reduces the occurrence of disseminated intravascular coagulation syndrome. Hydroxyethyl starch, 0.9% sodium chloride solution, frozen plasma should be the main infusion media.

But this is only part of the problem of successfully treating obstetric hemorrhage. The main points should include a correct assessment of the quantitative (volume) and qualitative (disturbance of the coagulation system) components of blood loss, timely and adequate infusion-transfusion therapy, timely and adequate surgical treatment(organ-preserving tactics) and constant hardware and laboratory monitoring of vital functions and homeostasis.
The main causes of mortality in massive obstetric hemorrhages are violation of the above points (delayed inadequate hemostasis, incorrect infusion therapy tactics, violation of the phasing of care).
Oddly enough, even such a trivial thing as assessing the volume of blood loss can play a decisive role in the outcome of the treatment of the bleeding itself. Unfortunately, the assessment of blood loss is almost always subjective.
Timely treatment of hypotonic bleeding using all necessary components allows you to successfully cope with the situation already at the conservative stage of obstetric care. Required condition is timely diagnosis of bleeding. Many legal cases brought regarding maternal deaths relate to this point. Then a thorough assessment of the volume of blood loss and calculation of the infusion-transfusion therapy program (depending on the woman’s body weight) and its correction during treatment are necessary. Great value has a multicomponent treatment that involves invasive intervention (manual examination of the uterine walls or bimanual compression - forgotten methods of Snegirev and Sokolov), the use of a system for intravenous administration of solutions, the introduction of uterotonics, monitoring hemodynamic and hemostasiological parameters and, importantly, constant assessment of blood loss (in the process treatment).
Recently, an intrauterine hemostatic balloon has been widely used to stop hypotonic bleeding. This method cannot be called new, since the first mention of the use of this kind of means dates back to the middle of the 19th century (1855). However, the use of modern materials and solutions has made it possible to once again turn to this method. Its effectiveness is 82%.
The next factor that often leads to dismal birth outcomes is the decision to switch from the conservative to the surgical stage of treatment of obstetric hemorrhage. To a greater extent, it concerns the psychology of the doctor: by any means to delay laparotomy and removal of the uterus. When 3,067 uteruses were promptly removed during childbirth in the Russian Federation in 2001, the number of lawsuits in the country regarding deprivation of the reproductive organ exceeded that for cases of maternal mortality. It shouldn't be this way. What options are there to stop bleeding during surgery?

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The sequence of actions is as follows:
- injection of prostenon into the uterine muscle;
- ischemia of the uterus by applying clamps and ligatures to the vascular bundles;
- application of hemostatic compression sutures B-Lynch and Pereira;
- ligation of the iliac arteries;
- angiographic embolization;
- and only then amputation or extirpation of the uterus.
The tactics for treating obstetric hemorrhage should always be based on the organ-preserving principle. It is unnatural if a woman admitted to a maternity hospital is discharged without a reproductive organ. Of course, there are exceptions to the rule, but today there is no doubt that organ-preserving tactics should become a priority in the treatment of obstetric hemorrhage.
Another cause of death in the Russian Federation is abortion, or rather its complications. Despite the decline in the absolute number of abortions over the past decade, they occupy 2nd place in the structure of causes of maternal mortality in Russia. There are reasons for this. Unfortunately, under the influence of socio-economic factors, abortion in the Russian Federation remains the main method of birth control (the frequency of use of highly effective contraceptive methods in the Russian Federation is 3 times lower than in economically developed countries; in addition, more abortions are performed in Russia than in European countries) .
To illustrate the complexity of the relationship between legislative decisions and the reaction of society, I would like to give an example of an ill-conceived decision to abolish a larger number (9 out of 13) of social indications for late termination of pregnancy, after which the number of criminal abortions increased by 30% (!), and not all of them ended well. Banning abortions without offering anything in return is pointless; a comprehensive solution to the problem is necessary.
Until now, the mystery of obstetrics is gestosis. Modern scientific research It would seem that we have already approached the last barrier in the pathogenetic chain of this pregnancy complication - genetics, but there is still no complete picture of the development of gestosis. The price of ignorance is the lives of thousands of women dying around the world, including in Russia. Strange as it may seem, gestosis is probably the most easily controlled cause of maternal mortality. The question is timely diagnosis and adequate treatment. Of course, we are talking about treatment conditionally - the only successful method of treating this complication is

The only way to prevent pregnancy is to terminate it in a timely manner. The main task is to prevent the occurrence of eclampsia, from which pregnant women actually die. The gold standard of treatment is oncoosmotherapy, therapy in accordance with the severity of the disease and delivery according to indications. But questions remain: how to determine the severity of gestosis, how long to treat, what method of delivery, etc. The correct solution to these issues is the safety of the patient and the doctor.
The fight against maternal mortality remains and, of course, will remain a priority in the work of the obstetric service, however, the formation and development of the health insurance system and market relations in the country have changed the social behavior and mentality of patients. Their awareness of modern methods obstetrics, paradoxically, sometimes embarrasses some doctors who do not bother to educate themselves. We are talking about modern perinatal technologies - a set of measures based on evidence-based medicine. Not introducing them where possible is, to put it mildly, short-sighted, and in some situations even criminal (outbreaks infectious diseases), The worse the sanitary and technical condition of an obstetric hospital, the more it needs mother and child to stay together, exclusively breastfeeding, and early discharge. Theoretically, everyone knows this; in practice, reluctance to change something gives rise to a pile of misconceptions.
We have already said above that every tenth case of maternal death in the world is due to the fault of a doctor. How can we protect the patient, as well as the doctor himself, from the consequences of incompetent actions? The cheapest but extremely effective way is to develop appropriate standards and protocols. In the modern information world, it is no longer possible to work without this. First of all, we are talking about protocols for the treatment of obstetric hemorrhage, management of pregnant women with gestosis, with prenatal rupture of amniotic fluid, management of childbirth in the presence of a uterine scar, etc., in the future - for each obstetric situation.
In conclusion, it should be noted that this report covers only a small number of current issues and problems of obstetric practice that are in dire need of solution, revision and critical evaluation. Further research into this acute problem will significantly improve the most important indicators of the obstetric service as a whole.

« Quod ribi fieri non vis, alteri ne faceris"
(“What you don’t wish for yourself, don’t do to someone else,” lat.)

Despite the well-known sacramental statement “Errare humanum est” (“To err is human”, Latin), the mistakes of medical personnel are very negatively perceived by the objects of our professional aspirations (patients), as well as by higher authorities. And the culprits (physicians of all specialties and ranks) add a lot of worries and gray hair...

Objective circumstances leading to an error include conditions under which it is not possible to conduct a particular study. It is also necessary to note the inconsistency of individual postulates and principles in the field of theoretical and practical medicine; In this regard, views on the etiology, pathogenesis, and understanding of the essence of many diseases change from time to time. In each individual case, the question of classifying a doctor’s actions as an error, especially when differentiating between ignorance due to insufficient qualifications and elementary medical ignorance, is decided based on the specific features of the course of the disease, duration of observation, examination capabilities, etc.

It is incorrect to always associate the subjective causes of diagnostic and tactical errors only with the qualifications of doctors. Undoubtedly, it is difficult to overestimate the importance of knowledge for correct diagnosis. But knowledge is not just the preparation of a doctor, it is also the ability to accumulate, understand, and use it, largely depending on the individual abilities, intelligence, character traits and even temperament of a particular specialist. “Life does not fit into narrow frameworks, doctrines, and its changeable casuistry cannot be expressed by any dogmatic formulas” (N. I. Pirogov).

Taking into account the specifics of obstetric and gynecological practice, in particular outpatient practice, as well as the fact that “Ignoti nulla curatio morbi” (“You cannot treat an unrecognized disease”, Latin), we have made an attempt to classify and consider the most “typical” errors.

A considerable number of them are associated with pregnancy diagnosis . The use of modern highly sensitive tests in combination with an ultrasound examination (preferably carried out by a qualified obstetrician-gynecologist, and not a “general ultrasound diagnostic specialist”) allows us to avoid gross errors. For example, a positive hCG urine test with an “empty” uterine cavity dictates the urgent need for urgent hospitalization of a patient with a well-founded suspicion of an ectopic pregnancy.

A form of ectopic pregnancy called cervical pregnancy , is quite rare, but very dangerous. Usually in the early stages it is accompanied by bleeding, which is associated with the destructive effect of chorion on the vessels of the cervix. The appearance of spotting or bleeding is mistakenly regarded by the doctor as an interruption of a normal intrauterine pregnancy, and only barrel-shaped cervix may serve as a sign of cervical localization of the fertilized egg. However, such changes in the cervix are sometimes considered as a manifestation of an incipient abortion, when the fertilized egg, upon being born, descends into the lumen of the distended cervical canal with an unopened external os. Indeed, in such cases the neck may also have a barrel shape. The existing hypertrophy of the cervix, as well as uterine fibroids in combination with pregnancy, greatly complicates the differential diagnosis. It is much better to suspect a cervical pregnancy where there is none and promptly send the patient to a hospital than to miss this extremely dangerous pathology or, even more so, to try to terminate the pregnancy in a day hospital at a antenatal clinic. The wrong tactics of the doctor can lead to the death of the patient.

In the work of an obstetrician-gynecologist, along with the so-called “gravid alertness” (see above), it is constantly urgently necessary cancer alertness . The frequency of errors during mass preventive examinations is still high. It has been established that without the use of cytological examination they are ineffective, since dysplasia and preclinical forms of cervical cancer are not detected visually, that is, with the naked eye.

The old and unshakable rule of thumb should always be kept in mind: any bleeding from the genital tract not associated with pregnancy in a woman any age should be considered as cancer (!) until this diagnosis is reliably and reliably excluded. Ignoring this rather ominous, although very correct axiom, leads to a lot of trouble. Just like the well-known traffic rules, but, unfortunately, not always followed by drivers and pedestrians, the diagnostic and tactical postulates of gynecological oncology are “written in blood.” In the figurative expression of E. E. Vishnevskaya (1994), “cancer “does not forgive” irresponsibility”! Long-term observation, hormonal examination, prescription of hemostatic drugs or even attempts at hormonal hemostasis, for example, in case of hyperplastic processes of the endometrium without the obligatory previous fractional therapeutic and diagnostic curettage with a thorough histological examination, which is still, unfortunately, sometimes observed in the practice of some colleagues - of course , are gross tactical and diagnostic errors.

Among tumors of female genitalia ovarian cancer It ranks second in frequency after cervical cancer, and first in mortality from gynecological cancer. The main reason is the extremely rapid, aggressive clinical course, manifested by an increase in the degree of malignancy of the tumor and the early onset of implantation, lymphogenous and hematogenous metastasis. The recognition of late-stage tumors is often based on medical errors; It is they who give rise to the neglect of the process, which is noted in 44% of newly diagnosed patients.

Timely recognition of such a formidable symptom as the appearance of free fluid in the abdominal cavity is important for the diagnosis of malignant ovarian tumors. The presence of ascites more often indicates the advanced stage of the tumor process, although this symptom accompanies the development of some benign tumors of the uterine appendages. For example, Meigs syndrome (ascites and hydrothorax) with ovarian fibroma. Gynecologists should know this well, so that patients with ascites are not mistakenly considered incurable, but promptly resort to a surgical method of treatment, which, after removing the tumor, leads to the rapid elimination of hydrothorax and ascites. By the way, even small ascites, the presence of which is sometimes very difficult to determine by conventional methods, especially in obese patients, is easily diagnosed with ultrasound.

As is known, uterine fibroids- one of the most common gynecological diseases. In-depth development of issues of pathogenesis and the study of endocrine and metabolic disorders confirm the need for maximum oncological vigilance to identify hyperplastic processes and malignant neoplasms of the endometrium in patients with uterine fibroids, which are often combined with atypical hyperplasia (7.6%), endometrial cancer (4%), sarcoma uterus (2.6%), benign (8.1%) and malignant (3%) ovarian tumors (Ya. V. Bokhman, 1989). Among the clinical symptoms of uterine fibroids, rapid tumor growth, recorded during clinical and ultrasound examinations, and acyclic uterine bleeding cause particular oncological suspicion. It is advisable to emphasize that “rapid growth” is considered to be an increase in the tumor per year by an amount corresponding to 5 weeks or more of pregnancy. It is necessary to actively identify precancerous diseases, cancer of the cervix and uterine body among patients registered at the dispensary for uterine fibroids, as well as timely determination of indications for surgical treatment.

Many diagnostic difficulties and, as a result, diagnostic errors cause malignant lesions vulva and vagina, despite the localization seemingly accessible to visual inspection. Vulvar cancer often develops against the background of degenerative processes, such as kraurosis and leukoplakia. However, a true precancer is dysplasia, which cannot be diagnosed without targeted biopsy and histological examination, which is not always done. Long-term conservative treatment of patients with dystrophic diseases of the vulva without histological examination is a very common mistake and leads to delayed diagnosis. Prescribing ointments and creams with estrogens, corticosteroids and analgesics relieves pain and itching and, feeling relief, patients stop visiting the doctor. 6-12 months pass, the symptoms resume, and a malignant tumor develops with metastases.

Diagnosis of such a seemingly easily accessible tumor as vaginal cancer, is still associated with a large number of errors, as a result of which more than 60% of patients are detected in stages II and III of the disease. The widespread use of the Cusco bicuspid speculum during gynecological examination plays a fatal role in late diagnosis. As a result of this, small tumors, especially those located in the middle and lower thirds of the vagina, being covered with a Cusco speculum, do not come into the field of view of the doctor (or midwife in the examination room).

As practical experience shows, many defects and diagnostic errors are often associated with insufficient knowledge or failure to comply with “some “secrets” of gynecological examination” (Mayorov M.V., 2005). It is not for nothing that it is said: “He who researches well diagnoses well.” An important condition for the information content of any medical examination is the presence of sufficiently intense local lighting. A powerful, directional light source allows visual diagnosis to be carried out properly, rather than at a glance.

Colleagues - gynecologists often forget about the urgent need for a rectal examination, and in all cases without exception, and not just in virgins. Bimanual recto-vaginal examination, somewhat forgotten by many practitioners, is very useful. His technique is quite simple: after a routine vaginal examination, the index finger is placed in the vagina, and a well-lubricated middle finger is placed in the rectum. In this way, it is much easier to palpate the uterus in a state of retroflexion, the uterosacral ligaments and the recto-vaginal septum, in particular, to determine space-occupying formations, for example, in retrocervical endometriosis.

Many errors occur in the diagnosis and treatment of infectious and inflammatory diseases of the genitals. Having received the result of a routine test informing that the patient has, say, trichomonas or fungi of the genus Candida, the doctor prescribes a certain specific treatment and often even notes some positive results (“It has become much easier!” the patient happily reports).

However, a complete cure does not always occur, since chlamydia, myco-ureaplasmosis and other urogenital infections often remain “behind the scenes”, reliable diagnosis of which is not possible only through conventional bacterioscopy of smears. But even when sufficiently reliable laboratory results are obtained to determine the type of urogenital infection, drug treatment is not always prescribed correctly and adequately. For example, in case of urogenital chlamydia and mycoplasmosis, it is advisable and effective to use antibacterial drugs of only three pharmacological groups: tetracyclines, macrolides and fluoroquinolones (Mayorov M.V., 2004). “Reliable and well-tested” sulfonamides, even in combination with trimethoprim (Biseptol), due to their low effectiveness in gynecological pathology, are currently only of historical interest. Often, when treating various urogenital infections, they forget that patients almost always have a concomitant anaerobic flora, and therefore the simultaneous use of drugs of the imidazole group (metronidazole, tinidazole, ornidazole, etc.) is indicated.

With regard to dosage, two extremes are observed: unreasonably exceeding the permissible ones or, conversely, prescribing unjustifiably low doses. For example, the prescription of doxycycline at a dose of 100 mg once a day for 5 days, acceptable for the treatment of, say, acute bronchitis, is completely insufficient for the treatment of acute salpingoophoritis; The WHO recommended dose is 100 mg 2 times a day for at least 10 days.

The use of hormonal drugs, in particular combined oral contraceptives (COCs), is far from simple and quite responsible. When so-called “breakthrough” bleeding often occurs while taking COCs, some doctors, instead of the necessary short-term increase in their dosage (until the bleeding stops), prescribe hemostatic therapy such as Vikasol and calcium chloride, and COCs are completely unreasonably canceled, which is a gross mistake. As a result, there is increased bleeding.

Combined oral contraceptives are widely used for the treatment of various gynecological diseases (endometriosis, polycystic ovary syndrome, uterine fibroids, etc.). But this applies only to monophasic COCs, since triphasic COCs are absolutely not suitable for therapeutic purposes. They do not completely suppress folliculogenesis, so they can contribute to the progression (!) of the pathological process in the above diseases. In particular, against the background of the use of three-phase COCs, glandular regression of the endometrium is not observed, which is contraindicated in its hyperplastic processes (Lakhno I.V., 2002).

Antiestrogens (clomiphene, clostilbegit, tamoxifen) are often used to stimulate ovulation. Careful (preferably daily) monitoring of the size of the ovaries (vaginal examination or ultrasound) is imperative, because, in some cases, hyperstimulation phenomena are observed, sometimes fraught with apoplexy.

When prescribing drug therapy, possible chemical and pharmacological incompatibility of individual drugs (for example, calcium and magnesium are antagonists), allergic history, the presence of extragenital pathology, and other significant factors are not always taken into account. This can contribute to the development of complications, because, unfortunately, “Graviora quedam sunt remedia periculis” (“Some medicines are worse than the disease,” lat.).

No machine can replace good training and creative thought of a doctor. Against the backdrop of a significant number of errors, from which not a single system of training doctors and not a single healthcare system in the world is guaranteed, this problem should be given much more attention. Even the ancient Romans quite rightly stated: « Bene facit, qui ex aliorum erriribus sibi exemplum sumit" (“He who learns from the mistakes of others does well,” Latin)

Medical deontology in obstetrics and gynecology is determined by the following factors:

medical activity in obstetrics and gynecology is inevitably associated with interference in the intimate sphere of the patient’s life;

the extreme importance of health issues related to childbirth;

unstable state of mental health of the pregnant woman (attitude towards pregnancy in the family, personality type of the pregnant woman, outcome of previous pregnancies, social factors, etc.), increased anxiety before childbirth (fear of upcoming suffering, outcome of childbirth, etc.), behavioral disorders women in labor due to an inadequate assessment of the situation (poor pain tolerance in emotionally unstable patients), a high probability of developing depression in the postpartum period.

When providing obstetric and gynecological medical care, many problems of an intimate, sexual, psychological, social and ethical nature arise, which significantly complicate the activities of medical workers. To establish good contact with patients, tact and caution are required during conversation and examination.

From the first minutes of contact with a woman, medical personnel need to correctly assess her emotional state, maintain appropriate tact, an attentive and kind attitude, conducive to frankness. Medical professionals need to be especially careful in their statements regarding the prognosis of the state of the sexual sphere and reproductive function of a woman.

If a woman does not consider it necessary to inform her husband about the state of her “female” health, then the doctor should not interfere in such cases.

During the treatment of incurable diseases, medical workers must in every possible way maintain the patient’s confidence in the successful outcome of the disease, instill in the emerging improvement at the slightest favorable symptom, which is noted by the patient herself.

A medical professional should be especially careful and tactful in relation to women with infertility (primary infertility, miscarriage, pathology in previous births, etc.).

When adopting children by infertile couples, disclosing the secret of adoption, informing the adoptive parents about the real parents and, conversely, informing the real parents about the family that adopted the child, is a violation of medical confidentiality. If a woman in a second marriage does not want her husband to know about previous pregnancies in her first marriage, the doctor should not disclose such information during a conversation with her husband.

An important condition for maintaining a secret is proper educational work in a team. It is known that it is often not doctors who disclose medical confidentiality, but nurses, nannies and other employees of hospitals and clinics, and therefore, carrying out appropriate work and suppressing any attempts to unnecessary inform relatives, acquaintances of the patient or roommates will help maintain medical confidentiality.

Each woman has her own characteristics, including in relation to reproductive health. Many women during menstruation experience nagging pain in the abdomen, lower back, and discomfort in the genital area. There may be increased irritability and tension. In girls, under the influence of long-term psychogenic disorders, some gynecological diseases (dysmenorrhea, uterine bleeding, premenstrual syndrome) can occur. Severe mental trauma can cause amenorrhea in women. The natural onset of menopause often causes women to fear the onset of old age, fear of losing femininity, attractiveness and the ability to marry.

Medical workers who know the above features well enough can successfully use this knowledge when working with patients. In this case, appropriate tact, an attentive and kind attitude, conducive to frankness, must be observed. Often, women often tell nurses what they don’t tell the doctor. Data obtained through a frank conversation contribute to more accurate diagnosis and selection of adequate treatment.

Much psychotherapeutic work should be carried out with a woman before major operations (caesarean section, uterine amputation, ovary removal, etc.). It is necessary to assess the woman’s personal characteristics and the nature of family and marital relationships. A conversation with the patient regarding the upcoming operation is extremely important; it is necessary to explain the essence of this surgical intervention and instill confidence in a favorable outcome.

Pregnancy and childbirth are one of the most pressing psychological problems that arise in a woman’s life. Mental disorders during pregnancy depend, first of all, on the woman’s personality traits, social and living conditions and other factors, about which the doctor and nurse at the antenatal clinic should have a certain understanding and promptly refer such women for consultation with a psychotherapist.

Particularly difficult psychological experiences of a woman arise during pregnancy from an extramarital affair (prejudices, the problem of raising a child without a father, etc.). These women require special attention from antenatal clinic workers. Forming a belief in a favorable outcome of pregnancy, childbirth and future life is a humane and noble task of a doctor and midwife at a antenatal clinic and obstetric hospital.

The problem of labor pain has always been one of the difficult problems of obstetrics. Psychoprophylactic preparation, developed in our country in the 20-30s of the last century, for painless childbirth is based on the principles of the teachings of I.P. Pavlova. The main goal in preparing for a painless birth is to eliminate the fears of pregnant women associated with the upcoming birth. For this purpose, women are given lectures, coursework, individual or group interviews are held, films about childbirth are shown, etc., and gymnastic exercises are shown to normalize breathing and help relax muscles. In addition, various methods of psychoprophylaxis are used: autogenic training, rational psychotherapy. It is necessary to explain to the woman that she will provide significant assistance during childbirth to herself if she follows all the instructions of the doctor and midwife. Obstetrics and gynecology as a field of medicine requires doctors to have certain knowledge, not only medical, but also psychological. It is not for nothing that in modern maternity hospitals, psychotherapists and psychologists work together with gynecologists and help create a favorable psychological climate in the hospital.

Analysis of the causes and errors in treatment measures that led to commission forensic medical examinations in obstetrics and gynecology in 2003

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Analysis of the causes and errors in treatment measures that led to commission forensic medical examinations in obstetrics and gynecology for 2003 / Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

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/ Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

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Analysis of the causes and errors in treatment measures that led to commission forensic medical examinations in obstetrics and gynecology for 2003 / Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

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/ Kirpichenko V.I., Chekmarev A.I., Chernyshev A.P. // Selected issues of forensic medical examination. - Khabarovsk, 2005. - No. 7. — P. 34-39.

In 2003, the regional bureau of forensic medical examinations carried out 25 commission examinations, involving an obstetrician-gynecologist as an expert.

• From Khabarovsk - 20 examinations
• From the districts of the Khabarovsk Territory - 4
• From other regions - 1

The main questions asked by the prosecutor's office and the police in almost all cases were the following:

• Were there any violations in the provision of medical care to the patient?
• Whether there was a violation of current instructions and orders during the provision of medical care.
• Was the disease diagnosed correctly and timely?
• Medication and other treatment was carried out correctly and in accordance with the established diagnosis.
• What is the cause of death, is there a direct causal relationship between the outcome of the disease and the actions of the doctor and medical staff? personnel, performance of their professional affairs.

At the same time, the experts had medical histories, individual records of pregnant women, birth histories, and outpatient records of patients at their disposal.

After examinations, in some cases, defects in the treatment of victims and organizational errors were identified. It was noted that in a number of medical documents there was careless maintenance of them, some of the records were not readable.

The largest number in 2003 (12) was carried out regarding complications arising as a result of parenteral administration of a 5% glucose solution in a number of medical institutions in Khabarovsk. All cases, with the exception of one, resulted in a favorable outcome for the patients. At the same time, some organizational errors were identified. Having received an emergency notification, the older nurses destroyed in most cases the solutions from this series, leaving a small amount for examination. Violations of the sanitary and epidemiological regime were identified; solutions were stored on the floor, without pallets, near the entrance. No defects or disorders were identified regarding treatment, diagnosis, treatment.

Of particular interest is the examination sent from area A. In the case, in addition to the questions raised about the quality of treatment, questions were raised about compensation for material and moral damage. The experts were asked questions about the causes of traumatic damage to the pelvic joints, which, according to the plaintiff, arose from the unprofessional actions of the doctors who delivered the child. During the examination, the experts decided whether the patient really had a rupture of the pubic and sacroiliac joints.

Based on a thorough analysis, submitted documents, X-ray studies, literature on this issue, the commission came to the conclusion that the woman did not have a rupture of the symphysis pubis (that is, there was no injury at all), but symphysiolysis that developed as a result of physiological processes and the accompanying inflammatory process of the pubic symphysis (symphysitis) and the sacroiliac joint (sacroiliitis). The commission also found that there was no connection between the doctor’s actions (pressure on the stomach with hands).

Nevertheless, the experts identified shortcomings in the management of childbirth: the degree of perinatal risk was not noted, the condition of the symphysis pubis before birth (divergence of the pubic bones during pregnancy) was not noted in the clinical diagnosis, and the diagnosis: Diastasis of the rectus abdominis muscles was not made. There were discrepancies in determining the timing of pregnancy and fetal weight. The commission noted that when providing medical care in the second stage of labor, techniques were used that were not regulated by orders of the Ministry of Health of the Russian Federation; the question of a planned caesarean section was not raised (taking into account the course of pregnancy, the condition of the fetus and other data).

Of particular interest is the examination of the development of severe purulent-septic complications, which led to the development of severe iatrogenic complications and worsening of the disability group (according to the preliminary investigation). Based on the study of medical documents, the expert commission came to the conclusion that the patient’s clinical diagnosis of “fast-growing fibroids” was beyond doubt; the patient needed specialized gynecological medical care. assistance (surgical treatment). At the same time, the commission believes that the patient’s severe pathology of the left lower limb (osteogenic sarcoma of the left thigh) can veil clinical manifestations other diseases or pathological conditions, or complications. The commission believes that this clinical case is extraordinary and dictated the need for a medical consultation (consisting of gynecologists, traumatologists, surgeons, pharmacologists and the administration of the medical institution) to develop a consensus on the plan for managing the patient, which should be reflected in the medical history. When planning surgical treatment of the patient, a complete special gynecological examination was not performed (colposcopy, RDV, followed by histological examination of scrapings, no smears for cytology). The Commission emphasizes that in any institution, the attending physician is responsible for conducting examinations and treating the patient. Planning the scope of surgical treatment is decided by the attending physician together with the head. department or department employee responsible for work in the department.

The commission believes that the temperature reaction that arose in the postoperative period and the absence of changes during vaginal examination could lead to the idea that the patient’s temperature in the postoperative period was related to the patient’s disease of the left thigh.

Based on the documents submitted for examination, the commission believes that the diagnosis made after examination by a surgeon and an infectious disease specialist: peritonitis with symptoms of severe intoxication required emergency surgical treatment. Suturing the defect of the sigmoid colon with purulent peritonitis is a mandatory stage of surgical intervention.

The commission also believes that postoperative complications are primarily due to the patient's severe oncological disease (hip sarcoma), accompanied by immunodeficiency, which was a favorable background for the development of the inflammatory process in the pelvis. The Commission believes that there is no direct cause-and-effect relationship between the incomplete scope of diagnostic measures before elective surgery, the selected volume of surgery on the one hand, and the development of postoperative complications on the other hand.

From the point of view forensic medicine complications of operations or complex diagnostic methods used in the absence of defects in their implementation resulting from other reasons (severity of the patient’s condition, unforeseen features of the patient’s reaction, etc.) are not subject to forensic medical gravity of harm to the patient’s health.

The next examination is about death in the postpartum period. Based on the submitted medical documents, the commission identified errors and omissions of both treatment and organizational plans.

At the stage of the antenatal clinic, the algorithm for examining and monitoring the pregnant woman was not followed, no measures were taken to prevent and treat gestosis, and there was no continuity between the antenatal clinic and hospitals. In the maternity ward, the patient was not assessed for the severity of gestosis, and blood and urine tests were not performed for emergency indications. When foul-smelling green amniotic fluid is discharged, a diagnosis of chorioamnionitis is not made, antibacterial therapy is not prescribed, and chronic DIC is not treated. When massive postpartum hemorrhage (more than 4,500) developed, no blood or blood products were transfused. Surgical treatment was prolonged for one hour and was carried out on an agonizing patient. The commission recognized that the woman in labor, against the background of prolonged gestosis, chronic disseminated intravascular coagulation syndrome, which was not treated at all stages of pregnancy and medical care during delivery, experienced massive postpartum unrepaired bleeding (more than 4,500), which led to the development of stage 3 hemorrhagic shock - the immediate cause of death . Analysis of medical documents, as well as re-examination of pathohistological material internal organs corpse shows that in a woman in labor who suffered from long-term and untreated gestosis and intrauterine infection, the birth took place with severe complications - infection of the placenta, amniotic fluid and the fetus itself, which led to its bacterial death as well as the development of necrotic purulent endometritis and postpartum sepsis, morphological the signs of which were: focal interstitial myocarditis, acute reactive hepatitis (with acute fatty hepatosis), septic hyperplasia of the splenic pulp, necronephrosis, necrosis of the adrenal gland. The expert commission believes that there is a direct cause-and-effect relationship between the quality of medical care for pregnancy with violations of the observation and treatment algorithm at all stages of its course and during childbirth, on the one hand, and an unfavorable (lethal for the mother and fetus) outcome. The Forensic Medical Expert Commission considers it appropriate to point out organizational and tactical defects made by the head of the childbirth department (failure to follow instructions and job responsibilities), there is a lack of control on the part of the administration over the work of the maternity ward and the blood transfusion station. The department is not provided with modern infusion equipment, there is no control over the reserves of blood and its components, as well as lists of reserve donors.

Cases concerning complications that arose during the pre- and postpartum period, surgical and other medical measures, rape, and treatment of inflammatory diseases were submitted for consideration by experts. An analysis of documents and findings of commission forensic medical examinations shows that in most cases, the provision of medical care corresponds to the modern level and the outcomes of diseases are not in a direct cause-and-effect relationship with this care. But in a number of cases there were defects in treatment and organizational events and the outcome was in direct causal connection with this. The most common reason for the initiation of cases and inspections carried out by the prosecutor's office and the police were complaints from relatives and the victims themselves about the actions of medical staff and deontological aspects were a frequent reason for this.

AS EVERYTHING WAS. Anna Gorodnova (name and surname have been changed) is only 25 years old, but she has already known the bitterness of losing a child. The woman lost her daughter during childbirth, and she herself miraculously made it out of the other world... Anna’s pregnancy was difficult, the young woman was kept in hospital more than once. “I felt my first contractions at 38 weeks of pregnancy,” she says. “I immediately called my local gynecologist, and she invited me to an appointment. After examining me, she said that the first stage of labor had begun. But, despite the fact that from the very beginning of my pregnancy I was in danger of miscarriage, the doctor did not hospitalize me. In the evening, pushing began, I called the gynecologist again. She replied that she needed to go to the maternity hospital as soon as the pain intensified. But she had to go earlier because signs of bleeding suddenly appeared. The woman was placed in the prenatal ward and the baby’s heartbeat was listened to. All readings were normal. That day, Anna’s local gynecologist was on duty at the maternity hospital. At 11 at night, having examined the woman in labor, she said that if she did not give birth by the morning, then Anya would be prescribed stimulating injections, and left. The woman in labor suffered all night. And in the morning, despite the fact that she started bleeding, Anya was transferred to the general ward. The young woman tried to draw the attention of the medical staff to her deteriorating condition, but the doctors assured that nothing terrible was happening. - The pain intensified, blood was flowing. “I was incredibly scared for my child,” continues Anna. - I called my doctor again. She sent me for an ultrasound. The specialist gave an updated gestational age of 37 weeks 2 days. And the doctor explained that I would remain under observation for another five days and only then give birth. On the same day, Gorodnova was examined by the head of the hospital’s maternity ward and left in the general ward. All this time the woman was injected with painkillers. At two o'clock in the morning she repeated her attempt to attract attention: the pain intensified. She was finally transferred to the prenatal ward. By lunchtime, Anna’s condition had deteriorated sharply: her blood pressure was 80 over 40, there was a lot of blood loss... Gorodnova was again taken for examination to the manager. A terrible diagnosis was made in his office: the child had cerebral edema. They began to urgently prepare the operating room. HOW IT ALL ENDED. “While they were preparing the operating room for about 25 minutes,” continues Anna, “I had already stopped feeling the child’s movements. After the operation, the doctors did not tell me that my girl had died. I found out later... Anna herself at that time was between life and death. The loss of more than two liters of blood led to a sharp drop in hemoglobin levels. Fortunately, Anna’s mother prevented another medical mistake. The woman in labor was prescribed a system with blood from a donor of the second positive group, but she had the first (!). The mother noticed this at the last moment... Among the medical staff they were able to find two donors from whom Anna received a direct blood transfusion. However, she became even worse. Doctors urgently called from the Republican Clinical Hospital for Sanaviation brought fresh blood. And when this didn’t help, they took me to the intensive care unit of the Republican Clinical Hospital. They fought for Anna Gorodnova’s life here for ten days. I CAN'T BE SILENT! At first, Anna came to her daughter’s grave every day. The pain of loss tore my heart. What burned even more was the understanding that no one was responsible for the death of her baby. The woman contacted the prosecutor's office and Investigative Committee RT, wrote letters to the President of Tatarstan, the Ministry of Health of the Republic of Tatarstan and Russia. The Ministry of Health of Tatarstan seemed to side with the victim. “In the maternity ward, an expert has determined that the diagnosis of your condition and your child by obstetricians and gynecologists was inaccurate,” the official response said. - And as a consequence, a delayed choice of the correct delivery tactics in the form of a caesarean section. The doctors' mistake was accepted with reservations. Experts concluded that the baby was doomed due to pathology of internal organs. It would seem that we could put an end to this. But Anna, a lawyer by profession, decided to move on. She turned to a medical expert from the neighboring Udmurt Republic for help. The conclusion received from him moved the matter forward. The prenatal department of the Nurlat Central District Hospital was charged with Part 2 of Article 293 of the Criminal Code of the Russian Federation - “Negligence, negligent attitude towards service, improper performance official their duties, which through negligence resulted in the death of a person.” “After the death of my daughter, the doctors, even before the autopsy, began to tell my relatives all sorts of lies,” says Anna. - That the child has a two-chamber heart. That I had infections, late abortions, pathologies, prematurity... All this was refuted by the conclusion of our forensic experts. According to him, my daughter was full term and healthy, just like me. PUNISHMENT. All this time the investigation was ongoing. In November of this year, the 51-year-old head of the maternity ward was convicted of improper performance of his professional duties, as a result of which the fetus died. Initially, the doctor was charged with committing crimes under Part 2 of Art. 293 of the Criminal Code of the Russian Federation (“Negligence resulting through negligence in causing serious harm to health or death of a person”). However, later it was reclassified by the court under Part 2 of Art. 109 of the Criminal Code of the Russian Federation (“Causing death by negligence due to improper performance by a person of his professional duties”). The district court sentenced the obstetrician-gynecologist to 1 year and 6 months of restriction of freedom. In addition, during the year, a doctor does not have the right to hold positions and engage in medical activities in the specialty “Obstetrics and Gynecology.” COMMENT by lawyer Tatyana Chashina: - The case is certainly outrageous. And although the doctor who committed criminal acts that resulted in the death of the fetus and the serious condition of the mother in labor was nevertheless punished, this does not give confidence that in the future this person will perform his duties properly. In a particular case, the situation with the punishment of the perpetrator of the crime was resolved through the efforts of the victim herself. It is very unfortunate that her legal education was useful to her only in resolving serious consequences, but did not help her avoid it. The first thing every patient should remember is that he has the right to choose not only the treating institution, but also the doctor, taking into account his consent. This opportunity is provided to us by Article 21 Federal Law “On the fundamentals of protecting the health of citizens in the Russian Federation.” To exercise the right of such a choice, the order of the Ministry of Health and Social Development of Russia dated April 26, 2012 No. 406n approved the Procedure for a citizen to choose a medical organization when providing medical care within the framework of the program of state guarantees of free medical care to citizens. Responsibility for exercising the patient’s right to choose a doctor and (or) medical institution lies with the chief physician. When choosing a doctor and a medical organization, a citizen has the right to receive information in an accessible form, including posted on the Internet, about the medical organization, the medical activities it carries out, doctors (level of education, qualifications and experience). Despite the fact that the law provides us with the opportunity when choosing a treating institution and a doctor, do not forget about basic forethought, and when in the future you are going to visit a medical institution, it is necessary to collect all available information about what kind of institution it is and what kind of specialists there are. It wouldn’t hurt to look at the relevant Internet forums, “Google” the names of doctors and the names of medical organizations. View reviews from patients who have already sought medical help. And if you feel that something has gone wrong, you can always refuse treatment in this institution. In this case, you will be forced to write a corresponding receipt - at your responsibility. How many medical errors are there in Russia? The global statistics of medical errors are terrifying. In the United States, 50-100 thousand people die annually from medical negligence. Every 15 minutes in this country, five patients die due to the fault of doctors. In Russia there are no official statistics on this problem. After all, the inspectors and the audited are part of the same structure. According to the chief pulmonologist of Russia, academician Alexander Chuchalin, the number of medical errors in Russia is significant - more than 30%. For example, out of 1.5 million cases of pneumonia, no more than 500 thousand are diagnosed. The main reason is our lack of a system for monitoring the quality of medical care. Every year, 50 thousand people die from medical errors in Russia, reports the public organization Patient Defense League. Nobody in the country keeps official statistics on medical errors that lead to the death of patients. However, according to unofficial data, the carelessness and miscalculations of doctors kill more Russians than road accidents. Doctors themselves admit that every third diagnosis is wrong. At the same time, it is almost impossible to prove a medical error in court, writes Rossiyskaya Gazeta.