January case summaries

Failure to offer C/S for suspected macrosomia

A California woman was receiving prenatal care from an obstetrician in 1999. She was scheduled for induction near term for "impending macrosomia," with an estimated fetal weight of more than 9 lb. A certified nurse-midwife monitored her induction, noted the indication as "macrosomia," and called an on-call obstetrician when she was not satisfied with the progress during the second stage. The physician used a vacuum to deliver the head and encountered a shoulder dystocia. He tried several maneuvers and delivered the infant after 5 to 7 minutes. The child has a brachial plexus injury.

The woman sued the hospital and physicians, alleging negligence in failure to inform the patient of the diagnosis of macrosomia and risk of shoulder dystocia and to offer her a C/S. She also alleged negligence in using a vacuum with a diagnosis of macrosomia, and failure to reduce the shoulder dystocia without injury.

Legal perspective

In shoulder dystocia cases, the typical issues are prediction and prevention of the dystocia and management during delivery. But in more recent cases-such as this one-other claims are being added. Here, the customary allegations were augmented with a claim of failure to inform the patient about the possibility of shoulder dystocia and injury and to offer the choice of a C/S. Both juries and judges are finding that kind of information should be included in a "consent for vaginal delivery" discussion, which is assumed to be a conversation about vaginal delivery with a choice for C/S. Such a discussion is particularly important in cases where "macrosomia" or "impending macrosomia" is written in the chart as a diagnosis or indication for induction. But even in cases with no risk factors or suspicion of shoulder dystocia, if there is an injury, informed consent can be an issue. Therefore, it's prudent to discuss risks of delivery with a patient and document the conversation in her chart, especially if there is any reference written in the chart of a potential for macrosomia.

Failure to timely diagnose ureteral injury after hysterectomy

A Massachusetts woman was referred by her primary-care physician to a gynecologist for assessment of a pelvic mass consistent with a uterine fibroid. Following evaluation, the physician recommended a total abdominal hysterectomy for removal of the uterine fibroids.

The patient underwent the hysterectomy in 2002 and immediately after complained of severe pain and had blood-tinged urine and decreased urinary output. She was discharged 3 days after the surgery and readmitted 2 days after that with left-sided abdominal pain radiating to the left flank, and nausea and vomiting. A CT scan was performed and a ureteral transaction was found during exploratory surgery. A urologist reimplanted the ureter and the patient was discharged about a week later. She continued to have complications, including a Clostridium infection, that required three more admissions with additional operations.

The woman sued, alleging negligence in injuring the ureter during the hysterectomy and in failure to diagnose the problem before closing. A $250,000 settlement was reached.

Forceps blamed for skull fracture

In 1990, a Kentucky woman had a forceps-assisted vaginal delivery. Within 12 hours, the infant had seizures, and an occipital skull fracture was diagnosed with a hematoma found consistent with the location of the fracture. The child has suffered seizures and other complications secondary to a brain injury, and is moderately retarded with an IQ in the 40s.

In the lawsuit that followed, the injuries were blamed on the delivering obstetrician, with the argument that the forceps caused the skull fracture and resulting brain damage, and the claim that a C/S should have been performed.

The obstetrician claimed the delivery was properly managed and the use of forceps was proper. The physician questioned if there was actually a fracture and contended that a hematoma was common from the labor process. A defense verdict was returned.