Brain injury allegedly caused by forceps

In 2004, a Kansas woman presented to the hospital for delivery of her baby. The nurse-midwife managing the labor, sought an obstetrician’s intervention when the head did not descend easily. The obstetrician used forceps to assist the delivery. She applied traction, pulling gently with a contraction 3 times, then removed the forceps, and an 8 pound 8 ounce infant was delivered. The parents sued the obstetrician after the delivery alleging the infant suffered a skull fracture, lacerated ear, bruising around his scalp, and bleeding in the brain as a result of the forceps. They attributed his cognitive impairment and epilepsy to the injuries he received at birth. The lawsuit claimed the obstetrician’s use of forceps was below the standard; the forceps were misplaced; and she should have delivered the infant by cesarean. The obstetrician countered that the fact of the baby’s vaginal delivery negated the claim that he was too large for such a delivery, also there was some question as to whether the baby actually suffered a skull fracture. She maintained that she used proper procedure for application of the forceps and understood the position of the fetal head. She further argued that the normal forces of labor could account for the infant’s injuries at the time of birth, and that the epilepsy is not related to his delivery. The defense also argued the child’s developmental issues were mild – he participates in sports and is in the same grade as others his age.

Verdict: The jury found in favor of the defense.

Analysis

In malpractice cases involving instruments used to assist with delivery of an infant such as vacuum and forceps, the 2 issues that come up are usually the actual use and placement of the instruments and the indication for their use. It is often difficult to prove that the instrument was negligently placed unless the injury is a skull fracture or some other head trauma, and it is then assumed that the instrument caused the injury. So, the case then focuses on the indication for using the device. With an appropriate indication for use of the instrument, it is possible to successfully defend a malpractice case. it is imperative that the indication for using vacuum or forceps for delivery be documented in the medical record along with any or no difficulty in placing the device.

Delay in timely delivery with placenta accreta

A Georgia woman was diagnosed with placenta accreta during her pregnancy. About 10 days prior to the planned delivery date for 39 weeks gestation, she collapsed and died at home. A lawsuit was filed and claimed the obstetricians made the decision to delay delivery to 39 weeks gestation instead of the standard of care, which required delivery no later than 36 weeks, and had she been delivered at that time it would have prevented her death. The case settled for $1.425 million.

Oxytocin overdose anddelivery delay blamed for CP

A Pennsylvania woman was admitted to the hospital in 2012 for delivery of her baby. Oxytocin was ordered to accelerate the uterine contractions. The fetal heart rate (FHR) progressively slowed over the next hour, dropping to 60 bpm. The obstetrician took steps to expedite the delivery and 20 minutes later the head was crowning. Another 10 minutes went by and the obstetrician then cut an episiotomy and delivered the infant. The baby developed spastic quadriparesis cerebral palsy (CP). He experienced impaired cognition, seizures, and global aphasia.

The parents sued those involved with the delivery and claimed the obstetrician mishandled the delivery; failed to properly monitor the labor; started oxytocin when it was not necessary as the patient was progressing and used it at an inappropriately high dose; and failed to discontinue it when the FHR dropped. They also maintained that the obstetrician should have delivered the infant with forceps or vacuum when it was crowning. The obstetrician countered that his treatment of the patient was proper, and he appropriately determined that vaginal delivery was the quickest route. He also testified that it was his practice to stop the oxytocin when the FHR dropped, but he had no independent recollection of stopping the oxytocin in this case. The obstetrician and hospital both argued that the infant’s CP stemmed from insufficiencies in the placenta, seizures, and meconium aspiration syndrome. The jury found in favor of the parents after a 2-week trial and a 4-hour deliberation, and they were awarded $14.48 million.

Bowel perforation during robotic hysterectomy

A New Jersey woman in her late 60s underwent a robotic sling procedure and hysterectomy, performed by her gynecologist. During the operation, she sustained a large perforation of the bowel outside the operative field. She developed sepsis and had multiple attempts at surgical repair. She ultimately required a colostomy. The woman sued the gynecologist claiming there was a failure to properly control the robotic device. She contended that she will require a permanent colostomy. The case settled for $6.25 million.

Alleged failure to respond to FHR results in CP

An Ohio woman filed a lawsuit against those involved in the 2010 delivery of her son. She originally presented to the hospital for delivery of her infant and the FHR tracings were reassuring. She claimed that, during the course of her labor, the FHR deteriorated and required intervention, but neither the obstetrician nor nurses recognized the need to expedite delivery. The infant was born not breathing and was then resuscitated. As a result of the lack of oxygen to his brain, he was diagnosed with CP. In the lawsuit, the parents claimed the child will need lifelong 24/7 care. The obstetrician settled with the parents for $1 million prior to trial. The case then proceeded against the nurse and hospital, and the jury returned a verdict for the child and parents, and $28.8 million that included $24.9 million in future care costs for the child, $2.9 million in lost earning capacity, and $500,000 each for noneconomic damages to the parents.

Neonatal death blamed on hypovolemia from double nuchal cord

In 2006 an Illinois woman was at 40 weeks gestation when she was admitted to a local hospital in labor. A nurse-midwife performed the vaginal delivery that evening. She noted a tight double nuchal cord as the head delivered and she reduced the cord at the perineum and delivered the rest of the infant. The baby was blotchy, limp, and extremely pale when she was placed on the mother’s chest. The nursing staff immediately realized the baby was not moving or crying and moved her to the warmer, initiated resuscitative measures, and called the special care nursery for assistance. The pediatrician immediately took charge of resuscitation and spent 38 minutes attempting to establish an airway and ventilation. Despite his efforts, the infant was pronounced dead at 40 minutes of life. The parents sued all those involved with the delivery and resuscitation on behalf of the infant’s estate. They contended the midwife was negligent for failing to have a neonatal team present at the delivery due to the maternal fever and variable decelerations of the FHR. They claimed the tight double nuchal cord prevented blood flow through the umbilical cord and the pediatrician was negligent for failing to replace the blood volume lost by the fetus due to complete umbilical vein occlusion, which caused hypovolemia, asphyxiation, and ultimately death. The court granted the midwife’s motion for a directed verdict at the close of the plaintiff’s case. The pediatrician asserted that he performed a rigorous textbook resuscitation, that it was improbable that the nuchal cord completely occluded the umbilical vein, that volume administration would have been frivolous without first establishing an airway/ventilation and heartbeat, and, finally, that the baby’s death was due to complications of chorioamnionitis and funisitis, which were present prior to delivery. The jury found in favor of the defense.

Ureter injury during hysterectomy

A 43-year-old South Carolina woman who suffered from multiple sclerosis (MS) underwent a hysterectomy performed by her gynecologist. During the operation the ureter was injured, requiring additional surgery and leaving her with permanent incontinence. The woman sued the gynecologist and claimed that he failed to notice that during the operation, he stitched around the ureter. She underwent a second surgery to remove the stitches and reimplant the ureter. She alleged it was the second surgery that left her permanently incontinent, and if the first surgery had been performed correctly, the second surgery would not have been necessary. She maintained the incontinence was not a part of her MS. The gynecologist asserted there was no violation of the standard of care and there was no stitching around the ureter. He claimed the ureter was damaged by kinking and the second surgery was performed to address that. He contended the incontinence was a result of her MS. The jury deliberated for 2 hours after a 4-day trial and returned an award of $700,000 for the woman. This included $500,000 economic damages and $200,000 in noneconomic damages.

Claim that episiotomy was unnecessary

A 28-year-old Missouri woman had a stillbirth at 38 weeks gestation and underwent a vaginal delivery. The fetus had been diagnosed with a genetic cardiac problem and the pregnancy was managed by a maternal-fetal medicine specialist who performed the delivery. An episiotomy was done and resulted in a fourth-degree laceration during the delivery. A breakdown later occurred, necessitating a repair and an ileostomy. A third operation was done to remove the ileostomy. The woman sued the physician who performed the delivery, claiming the episiotomy was unnecessary and that he failed to inform her of the risks of a fourth-degree laceration. The physician argued that the episiotomy was necessary and there was no need to obtain informed consent. The jury found in favor of the defense.