In this study, the interviews were conducted were 25 participants, including Gynecologist, anesthesiologists, pediatricians, operating room and anesthesia experts, and midwives were interviewed. 1 participant was male and 24 were female. Participants' ages ranged from 29 to 47 years with an average age of 35 years. Participants' work experience of the participants was between 6 and 28 years with an average of 14.08 years (Table 1).
After coding by the first author, for each interview, 181 initial codes were extracted, and also after examining the similarities and removing the similar codes, 18 open codes were obtained. Then, by categorizing the related codes, 8 axial codes and 3 main themes of risk factors threatening the health of the mother, fetus, and newborn were obtained (Table 2).
3-1-1. Background factors
The main category of background factors related to the threats to the mother and fetus and newborn includes three subcategories of high-risk pregnancy, unusual fetus, and background risk factor along with sub-categories of each of them, which are discussed below.
3-1-1-1. High-risk pregnancy
Placenta accrete. It is the most common type of placental abruption. Improper diagnosis of this complication can have dangerous adverse effects such as severe and uncontrollable bleeding, the need for blood transfusions, increased need for surgeries like hysterectomy, and increased mortality. “A few days ago, during a night shift, we had a prima patient. When, the uterus was cut and the baby came out, we suddenly found a Placenta Accreta. Since, the residents do not usually conduct sonography for the primaries, before operation, they did not know that they had to reserve blood for her. The patient bled, I remember that we used 30 Langases and eventually led to a hysterectomy” (P1)
Deeply impacted fetal head. One of the causes of the difficult C-section is the condition in which the fetal head is packed in the birth canal and the position of the fetal head is inferior to the pelvis and normal delivery is not possible. This condition is associated with many maternal and fetal complications.“It once happened to me that the baby was stuck in the birth canal, i.e., the mother had to have a cesarean section during a normal delivery. We had to have one of the residents put her hand in the vagina and put the fetal head in my hand, so that I could bring out the baby. "Suddenly I saw that the uterus was torn towards the bladder and the bladder was hurt, so we immediately called an urologist to come to repair the bladder” (P5)
Placental abruption. It is the separation of the placenta from its junction before the onset of labor and is one of the most common known causes of fetal mortality and in cases with delayed treatment, even the mother's health is endangered.“We had a 39-week-old baby whose mother had a placental abruption. The fetus had an ischemia. I went up to him and saw that his Apgar score was less than 6, so I quickly revived him and the baby was intubated” (P24)
3-1-1-2. unusual fetus.
Malpresentation. It occurs when the fetal presenting part is other than the fetal vertex. It may prolong the labor and make the mother doubly upset. “During the cesarean section, I took out a mother-dentist's twin babies. The first one was in cephalic position. Then, when I tried to remove the second baby, it was in breech. As I was pulling it out, it broke from the thigh so I heard a bang” (P5 (
“Once the position of the fetus in the uterus was transverse, the doctor made an incision in the uterus .She tried to guide the fetus' head to make the cephalic position of the fetus easier to ejaculate. But she did not succeed. She had to make a more classic cut in addition to the first cut. The baby was difficult to remove it, but we faced a lot of bleeding” (P4)
Macrosomia. It is defined as weight at birth in a term baby above 4,000 g. It is a common complication in midwifery and can have side effects on the mother and fetus at risk. “We had a macrosomic baby, it weighed about 5–6 kilos and it came out very hard. When we took it out, after a few minutes, we saw that his hand was completely motionless and dizzy. Later, when taking a graphic, they said that he had a dislocated shoulder while bringing out” (P2)
3-1-1-3. Background risk factor.
Maternal obesity. Various conditions, including the mother's physical condition, can affect surgical and anesthesia conditions. One of the high-risk conditions is maternal obesity, which can increase the risk of pregnancy complications. Perinatal complications such as preeclampsia and gestational diabetes are higher in obese mothers. “A patient was too fat with a lot of belly fat. The pressure we put on the fundus to get the baby out and help it to give birth was lost in the abdomen. Because of this, another colleague was pressing the mother's chest from anesthesia with the palm of her hand, such as CPR. When pressure was applied, suddenly mother's lower rib fractured” (P3)
Previous cesarean section. Due to the continuous increase in the rate of cesarean section, the number of people with a previous cesarean section has also increased. Possible consequences of recurrent previous cesarean sections such as hysterectomy, bladder and bowel injury, blood transfusion, infection, and abnormal placental implantation should be considered. “It was a patient with a history of previous cesarean section. While making the incision on the uterus, but I cut the baby's head. The mother later told me, and I said," because you had a cesarean section before and your uterus was very thin ” (P5)
Intra-abdominal adhesions. Postoperative adhesions are one of the most important causes of postoperative complications such as intestinal obstruction, infertility, and intraoperative problems in a subsequent surgery. Adhesion during cesarean section increases the duration of surgery, intraoperative bleeding, maternal and fetal complications, and the need for assistance from other surgeons. “I was operating with one of the residents of the second year. When she gave the incision, I suspected that she had hit the intestine. At that moment, I did not say anything. She took the baby out and sew the uterus. She wanted to put the uterus and I said, "Let's check the intestine." We saw that it was perforated. We quickly called the general surgeon and the surgeon came and repaired the intestine” (P1)
3-1-2. Environmental factors
The main categories of environmental factors related to the threats to mothers, fetuses, and infants include the three subcategories of poor operating room facilities, lack of proper electro-surgery safety measures and excessive workload along with the sub-categories of each of them, which are discussed below.
3-1-2-1. poor operating room facilities.
Worn out equipment. The existence of defects and problems in the operation of the equipment can harm the patient. By contacting the medical equipment unit, their correct operation can be ensured. “A few months ago, we had a baby. At birth, Apgar was a little low and the midwife put the baby under oxygen. A little later, she saw that the baby had apnea. We found out that the device was failed and the oxygen line was not working well, so we intubated the baby” (P24)
Shortage of proper equipment. Providing the necessary equipment and tools before the start of surgery is one of the factors that can ensure the safety of the patient during surgery. Also, in some surgeries, a special set of tools and equipment is needed to perform the surgery in its best form. “Yesterday, we had a patient. When she brought to recovery, we had low pulse oximeter. I used a pulse oximeter of another patient who was to be transferred to the ward. I said myself, "she is newly brought to recovery ward. I saw that her heart rate is going down and dropped to 48, 45 and 40. I asked for atropine, we talked to her, we gave her oxygen, and her heart rate went up” (P20)
3-1-2-2. Lack of proper electro-surgery safety measures
Accompanying jewelry. The patient's rings and other jewelry carry the risk of burns to the patient due to the creation of an alternative current due to the use of monopolar electrosurgery.
“We had a patient who came into the operating room with a bracelet. We explained to the patient that if you do not take them out, you will get burns. The patient was not satisfied to remove the bracelets. We asked her to sign the commitment form. Then, we covered the bracelets with glue and latex gloves to reduce the possibility of burns; we checked after the operation and saw that the patient's hand had a superficial burn” (P1)
Wetting the junction plate of the cutter during operation. Wetting the junction plate of the cutter during operation due to spillage of fluids or excessive sweating can cause burns to the patient. Burns and problems caused by the electro cautery can cause many problems for the patient and the surgical team. “We had a mother of twins, they have two amniotic sac as you know. After the babies were born, the operation field was so wet that it caused a piece of plate to get wet and separated from the mother's leg. After the operation, we saw that some part of the leg had burned” (P11)
3-1-2-3. Excessive workload.
Night shift fatigue. Night work can cause fatigue, negligence, and distraction at work by causing sleep deprivation. Fatigue significantly impairs the performance of the treatment team and seriously affects their ability to care for the patient effectively. “It happened to a midwife in a night shift several years ago. Now maybe the midwife was sleepy when she cut the umbilical cord in tangent to the skin. Actually, instead of cutting the umbilical cord from above the clamp, it was cut from under the clamp close to the skin. If we did not care the baby quickly, the baby would really die” (P2)
Staff shortage. The shortage number of personnel compared to the number of surgeries always leads to errors due to negligence, forgetfulness, or improper performance of tasks. “The number of personnel in the recovery ward is low and the recovery is very busy and the workload is very high. An anesthesia nurse with all those patients is really hard job. She must complete the whole files, additionally. This makes us unaware of the disease, once the uterus of one of the patients in Aton recovery, she was bleeding profusely, which we found out too late, and the mother returned to the operating room”(P11)
3-1-3. Human Factors
The main category of human factors related to the risks threating the health of mother, fetus, and newborn includes two subcategories of the lack of medical team skills and by an individual error of the medical team along with the sub-categories of each of them, which are discussed below.
3-1-3-1. lack of medical team skills.
Use of inexperienced personnel. Adequate experience and skills are very important factors contributing to the rate of human error. The probability of error in the performance of experienced personnel is generally much lower and novices are trying to make medical and pharmaceutical errors. “One night I was circular Nurse and the scrub nurse was a novice. After the baby came in, we saw that it smelled very bad. I found that the novice resident did not recognize the bladder tissue and cut it. We called in the midnight. An urologist came to repair” (P1)
Improper abdominovaginal delivery. During a cesarean section, an abdominovaginal procedure is performed to remove the fetus from the uterine incision in a low-lying position. In this procedure, the assistant inserts her hand through the vagina and places 2 or 4 fingers around the head, applying gentle pressure to the packed fetal head and pushes it up so that the surgeon can remove the head from the uterine incision.“A repeat cesarean section in which the mother herself was late to the hospital and her baby was in the birth canal. During the cesarean section, a novice person introduces her finger into the vagina and pushes the head up. And the pressure on the fontanelles was high, causing the baby's skull to break” (P14)
3-1-3-2. by individual error of the medical team.
Incorrect identification of mother and baby. Lack of proper identification of the patient is one of the cases that cause irreparable mistakes in the health care system. For this reason, patient authentication is an important factor in patient safety in the operating room. “I witnessed that a baby's bracelet was written incorrectly, and the parents would accept the baby's gender and that the baby is theirs; because they had changed the bracelets and they were suspicious” (P2)
Excessive hurry during surgery. There is always the possibility of error due to negligence, forgetfulness, or improper performance of tasks due to hurry and lack of time.
“Once, one of the surgeons was opening the mother's abdomen in a hurry. She punched the bladder with a scalpel so that all the urine came out” (P15)
“It was early in my job, when the scrub nurse wanted to cut the umbilical cord. She was in hurried so that he cut the baby's little finger. Fortunately one of the surgeons save it” (P1)
3.2. Conceptual framework