MALPRACTICE
Risk management in obstetrics and gynecology

Failure to perform a timely repeat C/S

In 1998, a California woman presented to the hospital in the very early morning with a term pregnancy and was admitted in early labor. She previously had consented to a repeat cesarean section and not a vaginal birth. The obstetrician was called at home by the nurses and advised of the woman's presence in the labor unit, her ongoing contractions, and the fact that she was to have a repeat C/S. He ordered a tocolytic agent and stated that he would be in later.

When he did not appear after about 1 ¹/₂ hours, the nurses called the physician again. He then informed them that he had a scheduling problem and would get someone else to cover this patient. About 20 minutes later, the physician called back and gave the nurse the name of the obstetrician who would cover for him. Soon after this, the second physician telephoned the labor nurses and was told of the patient's condition and the need for a repeat C/S. He informed the nurses that he was going to another hospital first to see his other patients, and instructed them to prepare the woman for a C/S in 2 hours.

About 30 minutes later, the fetal heart rate strip showed a prolonged deceleration and the new physician was paged. He responded that since there seemed to be recovery from the deceleration, according to the labor nurse, he would still plan the C/S for the same time. The nurse then left the patient's room and did not return for 30 minutes. The centralized FHR monitoring system was not working that day, so no one could evaluate the monitor strips unless they were at the bedside. About 10 minutes after the nurse left, an unobserved prolonged deceleration occurred without recovery. No one was aware of this until the nurse returned. At that time, the nurse requested emergency help, but she did not call for the perinatal fellow or the obstetric resident on the unit. The perinatal fellow was eventually paged and delivered the infant by emergency C/S. At surgery, a ruptured uterus was found, with the baby floating in the abdominal cavity. Apgars were 0 and 1; cord pH was 6.68. The child remained in the hospital for 5 weeks and eventually had a gastrostomy and tracheotomy placed. The child is severely compromised, with a life expectancy of another 2 years.

In the lawsuit that followed, the woman claimed that one of the obstetricians should have performed a repeat C/S after her admission, as she did not desire a vaginal birth. She claimed further that the obstetricians should have come to the hospital and maintained that the labor nurse should not have left the bedside after the first prolonged deceleration, since the remote monitor was not functioning. The woman argued that if the nurse had been in the room, the uterine rupture would have been detected promptly and the baby would have been delivered sooner.

The obstetricians argued that the problem was entirely the hospital's fault since no one attended to the patient during the critical time period. The hospital contended that it was appropriate for the labor nurse to leave the room, since neither she nor the obstetrician was concerned about the monitor tracing at that time. A $2.2 million cash settlement was reached, which was paid by the hospital. The obstetricians were dismissed without prejudice. A second case against the obstetricians is possible if the child survives.

Legal perspective

This case illustrates the danger in not having uterine rupture foremost in mind when caring for a patient in labor who has previously undergone a C/S. While the judgment is questionable regarding delaying the C/S for convenience of the physicians' schedules and treating the patient with tocolytic drugs to promote that delay, the physicians' complete reliance on the nurse's assessments and reports allowed them to avoid responsibility in the case at this point. There is a caveat in their dismissals that allows for another suit against them if the child survives longer than anticipated.

In the case described, the hospital was held completely responsible for payment of the damages to this child. The issues brought out by the plaintiff's attorney were: (1) the nurse's assessments of the FHR strip and the delay in the recognition of uterine rupture, most likely at the first prolonged deceleration of FHR; and (2) the delay in securing other qualified personnel who were in the hospital in this emergency situation. Although this patient had previously consented to a repeat C/S, nevertheless, she was admitted in labor with a previous uterine scar. In such a situation, the American College of Obstetricians and Gynecologists' VBAC guidelines, modified in July of 1999, require the immediate availability of a physician who can perform an emergency C/S. While the hospital had physicians on site, it was the nurses' responsibility to summon them in an emergency situation. Both physicians and nurses have the responsibility to anticipate and recognize uterine rupture in patients who are at risk.

One twin with cerebral palsy

In 1991, a woman pregnant with twins, both in breech position, was admitted to a hospital in labor 1 day before her scheduled C/S. FHR monitor strips on one of the twins revealed decreased short-term variability, and her obstetrician ordered a C/S "ASAP," which was not a declared emergency. One hour later, an epidural was administered and the first twin was delivered approximately 1 ¹/₂ hours after the decision for C/S. Apgar scores were 6 at 1 minute and 9 at 5 minutes and the cord pH was 7.07. That twin was diagnosed at age 9 months with developmental delay and spastic triplegic cerebral palsy.

The obstetrician, the anesthesiologist, and the hospital were sued. The plaintiff contended the obstetrician was negligent for failing to perform adequate prenatal testing and an elective C/S sooner, despite the mother's high-risk history of prior stillbirths, and failure to recognize and declare an emergency at the time of admission. The plaintiff further blamed the hospital for failing to timely respond to the "ASAP" order and the anesthesiologist for choosing epidural anesthesia, which contributed to the delay in delivery.

The defense contended that appropriate prenatal testing was done with normal results, standard of care permitted waiting until the due date to assure fetal maturity, fetal monitor abnormalities were not sufficient to require an emergency C/S, and since there was no emergency, defendants did not cause a delay. The defense also argued that various tests proved brain damage had occurred before labor began and most likely as much as 2 to 3 weeks before delivery. This Illinois case resulted in a defense verdict.

Cardiac arrest during hysteroscopy

A 21-year-old Missouri woman presented to her physician with dysfunctional uterine bleeding. The doctor recommended and performed a diagnostic hysteroscopy. During the procedure, the woman had cardiac arrest due to a gas embolus. She sustained brain damage, resulting in permanent motor and cognitive defects, inability to work, and permanent disability.

The woman and her husband sued the hospital, the physician, and the medical group, alleging past and future medical damages totaling $2.8 million, as well as past and future wage loss of $775,000. She contended the physician's negligence during the procedure caused the heart attack and resulting brain injury.

The defendants denied negligence, contending that hysteroscopy is a safe procedure and that the patient's complications during the surgery were attributable to an operative error by the anesthesiologist, not by the surgeon. The jury returned a verdict of $3 million for the woman, but apportioned all fault to the hospital, which settled with the plaintiffs before the trial, and no fault to the other defendants. The plaintiffs' post-trial motions were denied and an appeal has been filed.

Department editor Dawn Collins, JD, is an attorney specializing in medical malpractice in Long Beach, Calif. She welcomes feedback on this column via e-mail to DawnCF@aol.com.

Many times, the factual information available about the cases presented here is incomplete. Thus it may not always be possible to discuss all of the elements of negligence or nuances involved in a given situation. The outcomes described also may not reflect the current standard of care or the best practice in obstetrics and gynecology. What these cases do represent are the types of clinical situations in the specialty that typically result in litigation and the variation in jury verdicts and awards across the nation. Some of the cases described have merit but many do not.

— Dawn Collins, JD

Dawn Collins. Malpractice.

Contemporary Ob/Gyn

2000;7:138-141.