September Case Summaries

When the patient claims negligent repair of a third-degree perineal laceration

The pregnancy of a 27-year-old Georgia woman in 1998 was uncomplicated, other than an episode of premature contractions treated with bedrest. A clinical examination in early pregnancy concluded that her pelvis was adequate, and she went into labor at term. She was placed on an electronic fetal monitor, given an epidural, started on oxytocin, and she progressed to complete and began pushing. The on-call obstetrician examined the patient after she attempted to push with little effect, and since her epidural had been rebolused, she was allowed to rest and let the baby descend naturally. Eventually the head was noted to be +2 station and was brought down further with a vacuum extractor. The infant spontaneously delivered after the vacuum was removed and weighed 8 lb, 5 oz. The total duration of the second stage of labor was about 4½ hours. The patient had a third-degree perineal tear that was immediately repaired. She did well after delivery and was examined in the hospital by both physicians and nurses before discharge, with no problems noted at the site of the repair.

At some point, the patient began to suffer intermittent episodes of fecal incontinence, although the onset, extent, and frequency were disputed at trial. At her 1 month postpartum visit, the repair was examined and found to look good, but she did complain of some fecal incontinence. The physician instructed her to keep her updated on the problem. When the patient called the office several weeks later and reported the problem had not resolved, she was immediately referred to a rectal surgeon. She eventually underwent surgery to repair a defect in the rectal sphincter and subsequently went to other physicians because she was dissatisfied. She was eventually referred to a pelvic floor specialist and underwent more surgery. She still complains of an incomplete cure and continuing intermittent bouts of incontinence. The patient had a second child by cesarean section.

The defense countered that the standard of care was met and a defense verdict was returned.

Legal perspective

Malpractice suits making the claim that an episiotomy repair was performed negligently because it broke down or the patient eventually developed complications are becoming more and more frequent. They typically allege negligence in the management of the second stage, the failure to perform a C/S, and as in the case above, improper use of any device used for delivery. Of course it is made to seem obvious that the repair was inadequate since the patient now has problems.

In order to defend these cases, documentation in the chart must cover all these allegations, including medical judgments made during the second stage, proper indications and use and application of any device assisting delivery, and complete description of the repair. But just as important is documentation of the postpartum care, including any patient complaints or symptoms both at visits and phone calls, any instruction and response to these, and timely corrective measures or referral if needed.

Should this nuchal cord have been handled differently?

A Washington woman was pregnant with her first child in 2006. She had mildly elevated blood pressure at term and no other complications. The patient requested an elective cesarean delivery, a request that the first-year family practice resident caring for her conveyed to the attending several times, including 4 days before delivery. The attending declined the request, and no obstetrician was consulted.

The patient complained of decreased fetal movement. A non-stress test was nonreactive, and a biophysical profile found decreased tone and low amniotic fluid. She was hospitalized for induction of labor with oxytocin. Because the FHR showed intermittent decelerations and decreased variability, the resident requested the attending come in. He was on the way when the head delivered. The chief resident was called and found the head delivered and a nuchal cord that the first-year resident clamped and cut. The chief resident delivered the rest of the baby within 2 minutes, although no FHR had been recorded on the monitor for 20 minutes prior. The infant was resuscitated and intubated at 4 minutes. The child suffered hypoxic-ischemic encephalopathy and has brain damage.

The patient sued those involved with the delivery and claimed the brain damage occurred during the delivery and a $3.2 million settlement was reached.