Lack of presence on L&D critical to outcome

Facts
A 17-year-old G1 presented to labor and delivery at 12:30 PM, at 35 weeks 0 days of gestation, with complaints of a gush of blood, nausea, and vomiting, with intermittent and constant abdominal pain. She reported good fetal movement. The patient was clearly uncomfortable on the bed. Contractions were occurring every 2 minutes, lasting 30 to 40 seconds, and were moderate in intensity to palpation. Fetal heart tones (FHTs) were initially in the 120-130 beats per minute (bpm) range, with adequate variability without accelerations. Two subtle decelerations were noted at 12:50 PM and 12:53 PM. The obstetrician’s examination at 1:00 PM revealed a tender uterine fundus, cervix 1- to 2-cm dilated, 50% effacement, and a vertex presentation at a -2 station. At 1:30 PM, the FHTs were in the 140s with decreased variability, and a possible deceleration to 100 bpm. (There was difficulty continuously identifying the fetal heart rate [FHR] on the external monitor.) There was a moderate amount of blood in the vagina. It was elected to admit the patient with the diagnosis of early labor versus placental abruption. Vaginal cultures were obtained prior to starting Group B streptococcus prophylaxis. No tocolytics or steroids were ordered.

Bedside ultrasound revealed a single fetus in a vertex presentation, AFI = 6, with no obvious placental abruption or previa. Following this evaluation, at 2:15 PM, the physician left the hospital with instructions to notify him if the patient’s clinical status worsened. The nurse’s notes documented that the patient remained very uncomfortable. At 2:30 PM an IV was started and the patient remained on continuous monitoring. A nurse’s cervical exam at 2:50 PM revealed that the cervix was 1- to 2-cm dilated, thick and high, with a moderate amount of blood again noted in the vagina. Although the patient’s contractions spaced out slightly, she remained very uncomfortable between contractions. At 4:00 PM, antibiotics were ordered, without accompanying documentation. FHTs at this time were in the 150s with a spontaneous variable deceleration noted in the nursing notes. At 4:20 PM, morphine and promethazine were ordered to help reduce the patient’s pain. At 5:00 PM, the FHTs were in the 170- to 180-bpm range, with poor variability and no accelerations or decelerations. At 5:20 PM, the nurses documented that the physician was notified of the fetal tachycardia, now with late decelerations. The physician arrived at 5:50 PM and ordered a cesarean delivery for non-reassuring fetal heart tracing. The patient was transferred to the operating room shortly thereafter. A spinal block was inserted at 6:00 PM. The FHTs were 87 after the spinal. The baby was delivered at 6:22 PM, with the findings of a Couvelaire uterus. Because there was difficulty delivering the baby, vacuum assistance was required. Apgars were 0 and 0, at 1 and 5 minutes, respectively. The baby could not be resuscitated. There was a 200 cc subchorionic clot identified. Cord gases revealed an arterial pH of 7.06, with a base excess of -13.9. The venous pH was 6.97, with a base excess of -17.1

Autopsy revealed changes consistent with an intrauterine stress episode, with associated changes in the skin, adrenal glands, pulmonary congestion and hemorrhage, acute tubular necrosis of the kidneys, and a small subdural hematoma. The placenta was small, with uteroplacental vasculopathy and villus information. There was extensive decidual necrosis, hemorrhage, and a marginal abruption. A suit was filed for negligence and wrongful death.

Chart review revealed no contemporaneous physician documentation after the initial assessment. Two late entries were documented at 10:00 PM. One timed at 4:20 PM indicated that it was unclear if the pain was due to an abruption or labor. Thus, morphine was ordered. This was confirmed by a nurse’s later entry, which also included the statement that the physician was notified of fetal tachycardia in the 160s, with decreased variability and spontaneous decelerations. A second late note by the physician documented that, upon the decision for cesarean delivery, it was felt that the situation was urgent but not emergent, thus there was time for a spinal block.

Deposition
At deposition the nurse stated that the physician went home after evaluating the patient. She testified that other physicians also manage their patients from a distance. She also stated that she was not worried by the rising baseline FHR, going from the 120s to the 160s.

The physician’s deposition raised several important issues. He admitted the hospital and that nothing prevented his return. He stated that a persistent non-reactive FHR raises concern for fetal oxygenation and uteroplacental insufficiency. While stating that a nurse cannot be expected to be as well trained in interpreting fetal heart tracings, the physician relied on the nurse’s interpretation. He testified to only receiving two calls throughout the day, despite nursing documentation to the contrary. He testified that the nurse failed to notify him of repetitive decelerations, despite nursing documentation to the contrary. Had he known there was fetal tachycardia and a loss of variability, he said that would have given him concern for a worsening placental abruption. In review of the FHR, the physician admitted that it reveals a period of time with worsening decompensation stating, “It’s easy to see that now.” Subsequently, the physician testified that he was notified by the nurse of fetal tachycardia lasting for approximately 25 minutes, with no variability, which was unresponsive to oxygen. In addition, the nurse also stated that the patient was in a great deal of pain, with a maternal pulse of 110 bpm. Under oath, the physician then stated, “I’m not going to come in for that kind of phone call.” Later in his deposition he admitted that placental abruption was the proximate cause of the fetal demise. Further, had he been in the hospital evaluating the FHR strip prospectively, he would have made the decision to do the cesarean delivery sooner. He admitted that the FHR was okay on admission and suspected that had he intervened sooner, the outcome would have been better.

Outcome
Following these depositions, the suit was settled for an undisclosed amount.

Learning Points

1. Preparation for testimony.
Physicians should meet with their attorneys to prepare for any testimony. It is critical to advise the attorney of potential management concerns and how to address those issues. In this case the physician’s deposition admissions regarding the worsening fetal heart tracing, delay in proceeding with a cesarean delivery, and the probable cause of the fetal demise rendered the case indefensible. 

2. Ultrasound diagnosis.
The sensitivity of ultrasound in detecting a placental abruption is approximately 50%. Thus, it cannot be relied upon to rule out such a diagnosis in patients presenting with the signs and symptoms suggesting a placental abruption. Further, vaginal ultrasound may be required to visualize an abruption at the lower margin of the placenta. Thus, one’s diagnosis of a suspected placental abruption should integrate clinical symptoms and objective findings, and not exclude the diagnosis based on a normal ultrasound. 

3. Documentation discrepancies. There were discrepancies between the nurses’ documentation and the physician’s recollection and documentation. Particularly in cases with adverse outcomes, it is critical that physicians and nurses debrief prior to final documentation, particularly late entries. Discrepancies in documentation raise concerns for a lack of honesty and forthrightness. 

4. Lack of physician presence.
The physician attempted to manage the patient from home. Increasingly, physician groups are assigning a physician to in-house Labor and Delivery coverage. Hospitals may pay a stipend to encourage in-house ob/gyn physician call coverage for the hospital. Alternatively, hospitals are establishing “laborist” programs. These allow on-site physician presence, with the ability to consult and even manage patients, in the absence of the patient’s primary physician. 

5. Physician and nurse relationships.
It is clear that competent nurses are critical to quality patient care, particularly on labor and delivery. However, a physician cannot transfer ultimate responsibility to nurses. This is particularly important when concerns arise for fetal or maternal status, such as with a suspected placental abruption. It is the physician’s responsibility to personally evaluate the FHR tracing in critical situations. Electronic systems allow remote access to such records in real-time. If not in the hospital, one must avail oneself of this capability and be in a location that offers such access. Alternatively, personal presence on Labor and Delivery is ideal. As discussed previously, a “laborist” program can provide physician presence for urgent or emergent situations. However, such a program is relatively expensive and may not be a realistic option for some hospitals. 

6. Lack of physician documentation during labor.
The lack of physician presence on labor and delivery contributes to the lack of contemporaneous documentation. However, electronic health records allow documentation when accessed remotely. Thus, it is possible to document one’s assessment and treatment plans remotely. However, when critical issues arise a physician’s immediate presence on Labor and Delivery is recommended.