January Case Summaries

The mismanagement of oxytocin

In 1997, a Florida woman delivered a child by emergency cesarean section at 42 weeks' gestation. He was subsequently diagnosed with dystonic cerebral palsy. The parents sued those involved with the delivery. They claimed that the physician had ordered oxytocin during labor and they had refused, but the nurse administered it anyway, despite the parents' objections. They alleged the patient's contractions did not meet the requirement for the use of oxytocin as described in the hospital's protocol and that it was increased even after adequate labor was reached. They noted that the contractions became hyperstimulated, but the oxytocin was not discontinued, again as required by the hospital's policy. The parents also claimed the obstetrician failed to see the patient until the time the C/S was performed.

The physician countered that there was no negligence in the use of oxytocin or the management of the patient and that the infant's condition was due to the sudden prolonged deceleration of the fetal heart rate that necessitated the emergency C/S, which could not have been anticipated. A jury returned a $30,817,966 verdict.

The alleged misuse and mismanagement of oxytocin are at the center of many lawsuits brought against caregivers in malpractice cases that involve FHR monitoring and labor and delivery. In these cases, the plaintiff's attorney usually subpoenas all the protocols and policies in effect at the time of the delivery and combs the chart to see if there are any deviations. So whether the patient in this case really refused oxytocin-and while the experts argue over whether there really was hyperstimulation that caused fetal hypoxia or whether it was the prolonged deceleration leading to emergency delivery that caused damage-what is made clear is that the caregivers did not follow their own protocol for oxytocin.

When jurors hear that the physicians and nurses did not even adhere to their own policies or did not know what they were, they immediately become suspicious and assume the care was below the standard-at least below the protocol-regardless of whether it had anything to do with the outcome or injury. That, combined with the fact many attorneys read the entire oxytocin package insert to the jury, leads them to believe that it is always a dangerous drug to use in pregnancy. Be sure to know what your policies and protocols require and follow them. If there is deviation from the protocol, this should be documented in the record along with your rationale for doing so.

Ureteral injury during removal of ovarian mass

A 49-year-old Texas woman went to the hospital in 2004 for removal of an ovarian mass. The ovarian mass was thought to be at least 10×12 cm. She had had a previous hysterectomy and after the incision for the removal of the ovarian mass, she was found to have severe pelvic adhesions. The ovarian mass was not visible until after exploration of the cavity, when it was found at a point low in the pelvic cavity and close to the ureter. The mass was removed. The ureter was damaged and part of it removed without the physicians realizing it before closing. The patient complained of pain in the back and flank area for several days before the problem was diagnosed. When blockage of the ureter was discovered, the patient demanded transfer to another hospital. After transfer and 5 days after the original operation, she underwent the placement of a nephrostomy tube and was discharged 3 days later. The woman was told that the repair could not be done at that time due to inflammation in her abdomen. She was readmitted a few weeks later for 6 days for a severe tube-induced infection, which was treated. She then underwent several procedures to change the nephrostomy tube and was readmitted for repair of the ureter a few months later. She again had an infection that was treated; 4 days later, she had ureteral reimplantation and placement of an indwelling ureteral stent. She had a nephrostomy tube for 2 more months.

The woman sued the original gynecologists, claiming the mass was cut out without first identifying and excising out the path of the ureter or checking the postoperative site to ensure the ureter had not been damaged.