A 35-year-old woman was admitted to the hospital in labor at 41 weeks gestation. Nine hours later she was examined by her obstetrician who noted she was 8 cm dilated and -1 station. Three hours later an artificial rupture of membranes was performed, and 2 hours later an examination revealed no change in her cervix. The obstetrician reviewed the options, including epidural and a cesarean. It was decided that an intrauterine pressure catheter (IUPC) would be inserted and oxytocin augmentation started. Four hours later the patient was completely dilated and the head was at +1 station. An hour later she began pushing, and 2 ½ hours later the obstetrician noted no further progression and recommended a cesarean, but the patient wanted to push longer. An hour later no progress had been made and a cesarean was performed for delivery of a 9 1/2 lb infant. The uterus was closed with good homeostasis noted; however, uterine atony persisted which did not respond to multiple doses of medications or uterine massage, and hemorrhaging continued. Sutures were unsuccessful and the obstetrician called for assistance from another obstetrician. They performed ligation of the utero-ovarian ligaments, further suturing, and ovarian-artery ligation, which did not stop the hemorrhaging. The decision was made to proceed to hysterectomy. During the procedure, the left ovary tore and was removed. Following the hysterectomy, the patient recovered fully.
The patient and her husband sued the obstetrician, her practice, and the hospital involved with the delivery. They alleged the obstetrician was negligent in allowing the labor to continue too long, using oxytocin for an extended period, allowing the patient to push for several hours, and that she should have realized the infant was too large to deliver vaginally. The expert witness opined that stimulation of contractions for so many hours without progress created an unacceptably high risk of uterine atony and led to a non-reversible atonic state after delivery, causing the patient to lose her uterus and, thus, the ability to carry another pregnancy. At trial the patient and her husband talked about their intentions to have additional children and discussed how difficult it was that their only child would grow up without a sibling.
The obstetrician denied that she was negligent, and her expert witness testified that postpartum hemorrhage is a serious but frequently unavoidable complication of childbirth, and although the patient had an unfortunate outcome, the obstetrician met the standard of care in the management of her labor and delivery. According to the expert, the obstetrician was attentive, was present at appropriate intervals throughout labor, and there was no point where a different decision should have been made. The expert maintained that the obstetrician allowed the patient to have input in the decisions as to how her labor was managed, which is appropriate as long as the physician is comfortable that it is not compromising the safety of the mother or baby. The length of labor and the fact that the baby was large did increase the risk of postpartum uterine atony; however, in most cases this does not occur, and it can occur without these risk factors. The expert concluded that management of the complication was appropriate and prevented potentially life-threatening bleeding.
THE VERDICT: The jury returned a defense verdict.
In obstetric malpractice cases involving hemorrhage as a complication after delivery, the usual issues in the case are risk of the complication, informed consent, and, of course, recognition and management of the complication. While hemorrhage is always a risk in any delivery, some specific situations would require informing the patient of an increased risk, but most postpartum hemorrhages (PPH) are not predictable prior to labor and delivery. When it happens, however, it may become the subject of a medical malpractice lawsuit. Avoiding some of the common errors in management of PPH, as described in the article on hemorrhage in the March issue (“How to prepare for postpartum hemorrhage") and providing complete documentation of measures taken in managing this life-threatening complication can certainly aid in defending these cases.