James M. Shwayder, MD, JD

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A 21-year-old G2P1001 was admitted on July 28 at 38 weeks, 4 days’ gestation for labor induction for a suspected large for gestational age (LGA) baby. The patient’s original estimated date of deliver was August 22. 

An ultrasound at 19 weeks, 6 days adjusted her date of delivery to August 7. The patient had a normal antepartum course, with normal antenatal screening, and normal glucose screening at 28 weeks’ gestation.

Two years earlier, the patient had given birth to an 8 lb, 10 oz male at term via an uncomplicated vaginal delivery with a three-degree extension.

During the current pregnancy, she was admitted at 33 weeks 0 days for possible preterm labor. Visual exam revealed a friable cervix, with 

. The patient was observed for approximately 21 hours, during which she received a dose of subcutaneous terbutaline, which led to diminished contractions, without significant cervical change. 

She was given a course of steroids and discharged on clindamycin and metronidazole.

On admission for labor induction on July 28, the patient’s diagnosis was advanced cervical dilatation and LGA. The admission history and physical documented a vertex presentation, with a cervix 3-cm dilated, 50% effaced, and a -2 station. The woman’s pelvis was described as “adequate.” 

Documentation did not include an estimated fetal weight (EFW). Induction proceeded with intravaginal prostaglandins, inserted at 7:30 am, with regular contractions beginning approximately 40 minutes thereafter. Fetal heart tones (FHTs) revealed a Type 1 pattern, with a baseline fetal heart rate (FHR) in the 140s. Augmentation of the patient’s labor with oxytocin was begun, at 2 mU/min.

Approximately 4 ½ hours later, at 12:05 p.m., the physician examined the patient. At that time, with oxytocin at 10 mU/min, her contractions were every 1 to 2 minutes, 60- to 70-mmHg in strength, with a continued Type 1 pattern. Her cervix was 4-cm dilated, 50% effaced, at a -2-3 station, with an occiput posterior position. Amniotomy revealed a small amount of clear fluid, and an internal FHR electrode was placed. 

An epidural was placed shortly thereafter. At 1:55 pm, with oxytocin at 12 mU/min, the patient’s cervix was 7- to 8-cm dilated, 90% effaced, at a 0+1 station. FHTs were in the 140s and, despite minimal variability, no decelerations were observed. At 3:45 pm, examination revealed a cervix with an anterior lip. 

No mention was made of the fetal station. The patient began pushing at 4:45 pm. FHTs were stable. The physician remained in the room while the patient pushed. Severe variable decelerations to the 60s started at 5 pm and the head was delivered at 5:10 pm and spontaneously rotated from right occiput posterior to occiput anterior position. The body did not immediately deliver. 

A McRoberts maneuver was used for 2 minutes and various maneuvers were performed to resolve a 6-minute shoulder dystocia. Fundal pressure was applied to assist with delivery of the body, which was accomplished at 5:18 pm. An 11 lb, 12 oz (5335 g) male was delivered with Apgar scores of 1, 6, and 8, at 1, 5, and 10 minutes, respectively. The arterial cord gases were pH = 7.19; pO2 = 23; pCO2 = 60; base excess = -7.0.

Then, and only then, first application of fundal pressure

Also described was an appropriate repair of a three-degree extension.

Subsequently, placental pathology revealed focal, mild, chronic non-specific chorionitis.

The newborn examination revealed bruising of the baby’s ears, face, chest, and right underarm. The right underarm bruising was consistent with traction to the armpit. There was no movement of the left arm. 

 while the pediatrician could not rule out a dislocation of the right shoulder. The left shoulder would have been the anterior shoulder at time of delivery. The baby had a low blood sugar at 37 and required an infusion of dextrox 10% in water.

The baby was transferred to an academic medical center. The admission physical revealed no movement of the left upper or lower arm. Radiologic studies revealed no dislocation of the left or right shoulder. 

revealed avulsion of the nerve roots on the left at C8 to T1, with mild displacement of the cord to the right. There was a possible subarachnoid hemorrhage. A cranial ultrasound was normal. Computed tomography of the head revealed no evidence of intracranial hemorrhage or displacement of the midline sutures. There was swelling on the right side of the face with minor asymmetry of the coronal suture.

A neurology consult confirmed Erb’s palsy, with a significant avulsion injury and complete left brachial plexus palsy. The neurologist opined that other roots may be torn more distally. There was probable right Horner’s syndrome, right torticollis, and a hoarse voice suggestive of laryngeal paresis.

Despite intensive physical therapy, there was no recovery of the function of the left upper extremity over 5 months, associated with mild ptosis of the left eyelid and ipsilateral pupil, consistent with Bernard-Homer Syndrome. 

The baby was referred to a pediatric neurosurgeon at another academic institution and underwent left brachial plexus exploration and external and internal neurolysis approximately 11 months after birth. Nerve grafting was not performed, as intraoperative electrical stimulation of the musculocutaneous nerve produced some visible and palpable contractions of the biceps brachii, and stimulation of the accessory nerve produced a similar response of the left deltoid muscle. 

Six weeks after surgery, the child was able to partially extend the elbow and flex his fingers. 

, there was no flexion at the elbow or extension of the fingers. Neurosurgery follow-up 4 months later (5 months postoperatively) identified no further recovery. The child continues with physical therapy.

Negligence in not offering the patient a primary cesarean delivery

Negligence in management of the shoulder dystocia

Damages including long-term care of the child, required long-term physical and occupational therapy, current and future pain and suffering, loss of future earnings, as well as emotional distress of the parents, and loss of consortium.

Following discovery, the defense elected to proceed with trial, as the case was deemed highly defensible.

At trial, the plaintiff’s experts noted that induction of labor for a LGA baby is not recommended by the American College of Obstetricians and Gynecologists (ACOG). Lack of an estimated fetal weight, either clinically or with ultrasound, was a breach of the standard of care. Had the physician estimated the weight as at least 5000 g, 

a primary cesarean delivery should have been pursued

Even with an estimated fetal weight > 4500 g, the risk of shoulder dystocia is up to 50%. The baby suffered permanent irreversible injuries that will require long-term physical and occupational therapy. The child will never have a normal life.

The defense experts testified that shoulder dystocia cannot be accurately predicted or prevented. None of the risk factors for macrosomia were present in this case, including preexisting diabetes and gestational diabetes, maternal obesity, excessive gestational weight gain, or abnormal antepartum glucose screening. 

The patient’s first baby weighed 8 lb, 10 oz or 3934 g and was delivered vaginal without difficulty. There was no clinical evidence of macrosomia, noting that the fundal height at 38 weeks was 39 cm.

Although an estimated fetal weight was not documented, the obstetrician deemed that the mother’s pelvis was adequate, evidence that there was consideration of the estimated fetal weight. 

Clinical and ultrasound estimates of fetal weight are poor indicators of actual fetal weight. Ultrasound is, at best, accurate to within 10% in estimating weight, and worse with larger babies.

Induction of labor is controversial. Earlier studies show an increased cesarean rate without a significant reduction in shoulder dystocia. Recent studies show induction of labor results in a four times reduction in the rate of shoulder dystocia. 

 even a primary cesarean delivery does not eliminate the risk of birth trauma and neonatal brachial plexus injury associated with macrosomia.

Further, most macrosomic babies do not experience shoulder dystocia. Finally, brachial plexus injuries can occur as a result of intrauterine positioning, not just a result of a shoulder dystocia.

The patient rapidly entered active labor following induction. She did not experience a prolonged labor, a prolonged second stage, nor was operative delivery required. Once the shoulder dystocia was encountered, all maneuvers were appropriate. The shoulder dystocia lasted 6 minutes, which is not an extended time. 

The umbilical cord gases were normal, evidence that the baby did not suffer any hypoxic compromise. The clinician’s contemporaneous documentation was excellent.

During rebuttal, the plaintiff’s experts again criticized the care, particularly the lack of documentation of an estimated fetal weight. If the estimated fetal weight had been less than 5000 g, attempting a vaginal delivery could have been justified. 

However, had the estimated fetal weight been 5000 g or greater, according to ACOG, a primary cesarean delivery should have been performed. The baby weighed 5335 g and thus, a cesarean delivery should have been performed. 

Further, in managing the shoulder dystocia, the documentation states, “the slightest amount of downward traction” was applied. Avulsion of the nerves does not occur without the application of excessive, improperly directed force. Avulsion injuries are not a result of intrauterine positioning. 

The baby has permanent injuries with paralysis of the left arm and distortion of his face, which will result in lack of social acceptance in the future. 

Defense experts testified that ACOG only states that a scheduled cesarean delivery may be beneficial and does not mandate that it be performed. The ACOG recommendations are based on expert opinion, not randomized trials. 

During the reparative surgery, there was evidence of some nerve conduction, thus the current disabilities may still respond to therapy in the future.

After 6 hours of deliberation, the jury found for the plaintiff, awarding $3.5 million.

This case was defensible, except for two major issues

: the lack of a pre-induction estimated fetal weight and the resulting nerve avulsion. The lack of an estimated fetal weight is not uncommon in shoulder dystocia cases resulting in litigation. Even though inaccurate, a clinical or ultrasound-based estimated fetal weight should be included in the initial assessment of all patients, whether for induction or in labor. Documentation of an estimated fetal weight, even if inaccurate, renders cases more defensible. 

Lack of such documentation, as in this case, is a major obstacle to successful defense. Avulsion of the nerve roots on the left at C8 to T1 was an additional impediment to successful defense. Plaintiff attorneys who frequently litigate shoulder dystocia cases often pursue only cases with nerve avulsion, as the forces required to cause avulsion have been shown to exceed the forces associated with the typical maneuvers used to manage shoulder dystocia. 

Further, avulsion injuries rarely recover spontaneously and require early surgical intervention, which if not successful, result in permanent disabilities. 

, the presence of the child in the courtroom throughout the trial was a constant visual reminder of his life-long disabilities.

Articles

This case involves induction of labor for a suspected large for gestational
age (LGA) baby in a mother with a normal antepartum course.

Shoulder dystocia: The unpredictable nightmare

A 39-year-old G3P2012 presented to the Emergency Department (ED) with a complaint of 2 weeks of worsening low back and abdominal pain and more recent-onset nausea and vomiting. She had been seen in an urgent care center 4 days earlier with lower back pain, which was treated with naproxen.

Her history included hypertension, which was well-controlled with a single medication, bilateral tubal ligation, subsequent ruptured ectopic pregnancy, and exploratory laparotomy with extensive adhesiolysis, performed for pelvic pain.

The patient was afebrile, with stable vital signs. She had a tender, palpable mass extending into the lower abdomen from the pelvis. Pelvic ultrasound revealed a 14-cm left ovarian cyst with multiple septa and possible hemorrhage. A review of her records revealed a similar-sized mass on an ultrasound performed 5 years earlier. The only laboratory abnormality was an elevated white blood cell (WBC) count of 15,100 cells/µL.

Surgery was pursued on an urgent basis. A laparotomy was performed due to the size of the mass and the extensive adhesions documented on prior laparotomy. A large, cystic pelvic mass was encountered, but it could not be completely removed because of extensive, dense adhesions. Therefore, it was aspirated, returning 750 cc of serosanguinous fluid. A portion of the cyst wall was excised and sent to pathology. A peritoneal drain was placed

On postoperative Day 1, the patient had a temperature of 99.2º F; blood pressure 162/76 mmHg; pulse 108 beats per minute (bpm), and respirations 15 per minute. Her abdomen was soft, with bowel sounds present. The peritoneal drain had a total of 115 cc of serous fluid over 24 hours, with no drainage over the most recent 8 hours.

Urine output since the surgery was 1450 cc. The patient’s hemoglobin and hematocrit were stable at 9.8 g/dL and 29%, respectively, with a WBC of 12,400/µL. On postoperative Day 2, her temperature was 98.5º F, with a maximum temperature of 101º F over the past 24 hours. Her blood pressure was 144/82, with a pulse of 102 bpm. The intraperitoneal drain had 40 cc of serous drainage over 24 hours.

The patient complained of increasing pain, nausea, and epigastric pain. Examination revealed a distended abdomen, with no bowel sounds identified. An abdominal x-ray revealed an ileus. A nasogastric tube was placed, offering some relief. 

On the morning of postoperative Day 3, the patient complained of increasing pain, despite passing some flatus. Her vital signs were essentially unchanged, with a temperature of 98.2º F, BP = 145/80, pulse = 100 bpm, and respirations of 22 per minute. The peritoneal drain had 50 cc of serous drainage over 24 hours. The woman’s abdomen was soft but distended, with some sluggish bowel sounds.

Later in the morning on postoperative Day 3, the pathologist personally notified the gynecologist that the biopsy specimen was consistent with a ruptured colonic diverticulum with adjacent abscess and smooth muscle with associated colonic mucosa. A surgical consult was obtained, and an abdominal computed tomography (CT) scan revealed a partial small bowel obstruction, an amorphous 4 x 6-cm left-sided pelvic mass containing fluid and gas, with possible diverticular disease.

The patient underwent surgical exploration with findings of a large, inflammatory mass encompassing the entire left side of the pelvis. There was a 1-cm hole found in the lateral portion of the sigmoid colon, as well as a residual ovarian cyst, densely adherent to the surrounding structures. Neither the left ovary nor the ovarian cyst could be excised in total; thus, the ovarian cyst was aspirated and biopsied.

The surgeon performed a segmental sigmoid colectomy and created a colostomy. During a 2-month postoperative course, complications included a small bowel obstruction, with multiple surgeries. Ultimately, the colostomy was reversed months later.

The patient filed a suit against the gynecologist, alleging misdiagnosis and negligently performed surgery.

At trial, the plaintiff’s experts included a gynecologist, who opined that the preoperative work-up was incomplete and should have included a pelvic exam and a CT scan, which would have established the diagnosis of a diverticular abscess. The elevated WBC count should have alerted the gynecologist to a potential infectious process, warranting further work-up prior to surgery.

Further, this expert testified that the operating gynecologist breached the standard of care by failing to properly identify the anatomic structures before excising tissue. The failure to recognize the bowel perforation and inability to remove the ovarian cyst resulted in major postoperative complications and multiple surgical procedures.

The plaintiff’s surgical expert echoed this opinion, further stating that the ultrasound did not demonstrate how much colon or rectum was involved, nor the location of any potential anastomosis or colostomy, precluding an appropriate preoperative informed consent. In addition, emergent surgery was not required, with better management being the placement of a percutaneous drain and antibiotics.

A general surgeon should have been consulted to establish the correct diagnosis, prior to surgical intervention. As a result of the complications and multiple surgeries, the patient is at risk for additional adhesion formation, bowel obstruction, and need for future surgery. Neither plaintiff’s expert was critical of the postoperative care.

Defense experts, including a gynecologist and general surgeon, testified that both the ED physician and the treating gynecologist thought the mass was ovarian in origin, supported by the abdominal and pelvic ultrasound. Further, the radiologist did not recommend a CT scan to further clarify the sonographic findings. The patient had no history of diverticular disease or long-term bowel-related symptoms. 

Thus, a diverticular abscess was unlikely. Thus, surgical consultation was not required before proceeding with surgery, which was a reasonable option in management. For further support, a defense medical expert testified that diverticular disease is uncommon in young individuals, again making the diagnosis of a diverticular abscess very unlikely. The elevated WBC could be consistent with either torsion or partial rupture of the ovarian cyst.

The defense experts testified that the large mass encountered at surgery was consistent with the preoperative diagnosis of an ovarian cystic mass. The markedly distorted anatomy and inability to excise the ovarian mass completely rendered aspiration and biopsy an appropriate management option. Postoperative management was appropriate, with a surgical consultation obtained in a timely manner when the pathology findings were known.

It was further noted that, at surgical re-exploration, the operating surgeons were not able to remove the ovarian cyst or ovary, and therefore pursued aspiration and biopsy. Regarding the potential for future surgery due to abdominal adhesions, the defense experts testified that the patient had significant adhesions prior to the incident surgery, even requiring a prior exploratory laparotomy and extensive adhesiolysis. Thus, the patient was already at risk for future surgical procedures due to the adhesive disease

After an 8-hour deliberation, the jury return a defense verdict.

Ostensibly, this case appeared to be a certain victory for the plaintiff. The ultimate result, a defense verdict, underscores the importance of excellent legal representation and the critical nature of expert witness selection, not only for their credibility, but also for their ability to engage the jury.

The defendant was prepared to explain the thought process underlying the probable diagnosis, the decision for surgery, and the management decisions during the incident surgery. Further, the defendant clearly explained the sequence of findings in the postoperative period and the associated decision processes.

The plaintiff’s experts were somewhat dogmatic in their opinions, rejecting the value of ultrasound and even the probability of the preoperative diagnosis of an ovarian cyst. Further, they dismissed that there are multiple approaches to management, particularly when unexpected findings, such as extensive adhesions, are encountered.

Contrasting this were the defense experts who discussed the value of various diagnostic modalities and the reasoning behind selecting specific modalities, such as ultrasound, CT, and magnetic resonance imaging. They supported the preoperative diagnosis of a large ovarian cyst. They expressed the difficult decisions one makes when encountering unexpected findings, which often lead to alternative treatment options.

The plaintiff’s experts seemed somewhat aloof and tended to “speak above the jury,” rather than at a level understood by the jury. In contrast, the defense experts were engaging and explained complex medical terms and decisions in simple terms, almost teaching the jury.

As a result, the defense opinions had greater impact and influence on the jury. The defense counsel was credited for excellent preparation of all defense witnesses for trial testimony. The selection of an excellent attorney and expert witnesses definitely impact the ultimate outcome of a case.

The outcome in this case underscores the importance of excellent legal representation and scrupulous expert witness selection.

Legally Speaking: Unrecognized bowel injury during surgery: How important are your attorney and the expert witnesses?


	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.


	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.


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


	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. 


	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. 

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. 


	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. 


	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. 

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.

Physicians should meet with their attorneys to prepare for any testimony, especially in cases with documentation discrepancies and unreliable physician-nurse communication.

Lack of presence on L&D  critical to outcome

A 32-year-old G5P4004 with four prior cesarean deliveries underwent an ultrasound at 12 weeks’ gestation, which revealed a pregnancy in the lower uterine segment with a probable placenta previa. An ultrasound at 20 weeks’ gestation revealed a definite placenta previa, with lacunae and hypervascularity suggestive of a morbidly adherent placenta (MAP, now called placenta accreta spectrum). Magnetic resonance imaging (MRI) confirmed the ultrasound findings. 

Although the mother was a long-term patient of the obstetrician, she was transferred from a community setting to a regional perinatal center 40 miles away. Her care continued at the perinatal center with a plan for cesarean hysterectomy at 34 to 35 weeks’ gestation. The patient was instructed to call the perinatal center immediately if she experienced any bleeding or significant contractions prior to the planned delivery date.

At 32 weeks’ gestation, the patient awoke in the night with severe pain and bleeding. She called 911 and was brought by ambulance to the local community hospital at 11:00 pm, where, fortuitously, the original referring physician was on call. Although the physician had not cared for the patient for several months, regular communication had been from the perinatal center. The physician was aware of the plan for cesarean hysterectomy. Although the patient’s vital signs and fetal heart monitor readings were stable, the degree of pain and bleeding necessitated urgent delivery at the community hospital. Anesthesia was consulted, multiple sites of intravenous (IV) access were established, and the blood bank was prepared for possible massive hemorrhage. The patient underwent a low transverse cesarean under general anesthesia and delivered a viable male infant who weighed 1845 g and had Apgar scores of 5 and 7 at 1 and 5 minutes, respectively. The baby did well. The placenta separated “normally,” but significant bleeding was noted at delivery and the estimated blood loss was not documented. Although bleeding initially was brisk, the uterus was deemed “dry” following primary closure. 

Over the next 6 hours, the patient had multiple episodes of hypotension and bleeding. She did not leave the operating room (OR), nor could she be extubated. She received multiple uterotonics, 12 units of packed red blood cells and 10 units of fresh frozen plasma. The community obstetrician consulted with the regional perinatal center, as well as intensivists and hematologists at the community hospital. Subsequently, the patient developed disseminated intravascular coagulation (DIC). She was ultimately transported by helicopter to the regional perinatal center, where she was moribund on arrival and died upon admission to the hospital. Autopsy concluded that death was due to the obstetrical hemorrhage and DIC from a placenta accreta. 

The patient’s family sued for wrongful death of the woman. They sued the community physician for: 

Not offering pregnancy termination at 12 weeks’ gestation, when the placenta accreta first was suspected; 

Not referring the patient to the perinatal center until after 20 weeks, after the time when termination would have been available;

Not transferring the patient to the regional perinatal center after initial stabilization on the night of delivery; 

Not executing the delivery plan, specifically performing a cesarean hysterectomy at the time of delivery; and 

Not reopening the patient while in the OR to perform a life-saving hysterectomy. 

The family also sued the perinatal center for not admitting the patient at 30 to 32 weeks for in-patient observation. They also sued the perinatal center for not recommending a hysterectomy during consultation shortly after delivery, while the patient was in the OR. 

The community physician stated that the patient was happy with the pregnancy and termination was never an issue. Upon admission she was not stable enough for transfer. The cesarean was performed in a timely manner, with delivery of a healthy infant who required only a short stay in the Level II nursery. Further, despite the diagnosis of MAP, the placenta delivered easily, and thus, a cesarean hysterectomy, with its increased morbidity, was not necessary. None of the consultants recommended further surgery. The anesthesiologists opined that the patient was not stable enough for further surgery, throughout the 6 hours that she remained in the OR. Everything possible was done and, despite that, the patient succumbed.

The perinatal center physicians stated it was not the standard of care to admit patients with MAP prophylactically at 30 to 32 weeks’ gestation. Further, although they recommended earlier transfer and hysterectomy, the community physician felt the patient was too unstable for either further surgery or transfer. 

Prior to trial, a large settlement was made on behalf of the community obstetrician. The perinatal center was dismissed from the claim. 

Risk factors for MAP (placenta accreta spectrum) include previous cesarean delivery, with likelihood increasing from 0.3% for one previous cesarean delivery to 6.74% for five or more cesarean deliveries. Placenta previa further increases risk for MAP. Ultrasound remains the mainstay of diagnosis, although there exists significant interobserver variation. In this case, the diagnosis was made by the community physician, confirmed with MRI, with appropriate referral to a higher level of maternal care-the regional perinatal center-although not early enough for pregnancy termination to be considered. For previa pregnancies, counseling for pregnancy termination for material indications should be documented. In this case, the planned timing and location of delivery comported with recommended management.

Regional perinatal centers have multidisciplinary teams, which may include MFM specialists, gynecologic oncology, urology, vascular surgery, trauma surgery, interventional radiology, hematology, intensivists, and a fully functional blood bank with extensive resources. Further, these centers have substantial support services and staff, including more extensively trained nursing staff and OR personnel. This environment enhances favorable outcomes.

This community obstetrician was clearly placed in a difficult situation, which occurs when delivery plans are disrupted by clinical circumstances. The obstetrician could have considered asking for surgical assistance from a general surgeon, trauma surgeon, urologist, or even surgical oncologist. Because the patient was not stable enough for transfer, proceeding with the cesarean delivery was appropriate. Several management options were available following the delivery, including leaving the placenta attached, with subsequent methotrexate, or removing the placenta and using prophylactic or therapeutic tranexamic acid, insertion of a Bakri balloon, or uterine artery embolization. The obstetrician also could have left the placenta attached, closed the uterus, and proceeded with hysterectomy. Alternatively, assuming the patient was stable after leaving the placenta attached, transfer to the regional perinatal center for further care could have been considered. 

In cases refractory to uterotonics, massage, and tamponade, hysterectomy is recommended. Unfortunately, the delay in responding to the ongoing bleeding, e.g. not proceeding with hysterectomy in a prompt fashion, contributed to the patient’s demise. Although the ultimate result may have been unchanged, proceeding with the hysterectomy in a timely manner would have enhanced defensibility in this case.

Dr. Shwayder is extremely grateful to Steven Warsof, MD, who shared this case from his files. The case also appears in a book they coauthored,

Legal Concepts and Best Practices in Obstetrics: The Nuts and Bolts Guide to Mitigating Risk

Did this community physician act accordingly after the patient was diagnosed with MAP?

Author | James M. Shwayder, MD, JD

Articles

Shoulder dystocia: The unpredictable nightmare

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Lack of presence on L&D critical to outcome

Disrupted delivery plan leaves OB in difficult situation