Obstetrician-gynecologists are frequently exposed to malpractice claims. Approximately 77% of the ob/gyns surveyed by the American College of Obstetricians and Gynecologists (ACOG) in 2012 said they had been named in a malpractice suit during their careers and the average number of claims per respondent was 2.64.1 Of those claims, 42% were a result of care rendered during residency.
The most common reasons for obstetrical claims were birth of a neurologically impaired infant (28.8%), stillbirth/neonatal death (14.4%), and delay in diagnosis/failure to diagnose (11.1%). In 2014, the Risk Management Committee of the Society for Maternal-Fetal Medicine (SMFM) reported similar data for maternal-fetal medicine (MFM) subspecialists: 67% of those who responded to a survey had experienced a legal claim and 54% had faced 3 or more claims.2
As a practicing MFM specialist with more than 30 years of expert witness experience in cases of suspected obstetrical negligence, I have observed certain patterns that increase risk. Here I will review selected case patterns, offer tips for recognizing certain high-risk situations, and offer suggestions for ways to lower risk and improve outcomes.
1. Learn to trust the laws of physics: You can’t be in two places at the same time
A physician with a patient in early labor is also performing an abdominal hysterectomy and providing emergency department (ED) coverage for his group.
Earlier in the day, a fetal heart rate (FHR) tracing on the laboring patient had demonstrated moderate variability and accelerations. While in the operating room, the physician is called by the labor and delivery (L&D) nursing staff and told that the FHR tracing is beginning to show minimal variability and a lack of accelerations. He advises them that he is almost done with his surgical case, he will come right up to evaluate the situation, and it is not necessary to call one of his partners.
Approximately 1 hour later, the physician comes to L&D, reviews the monitor strip, and feels that the labor can continue. He informs the nursing staff that they should keep watching the strip and notify him if it deteriorates.
The ob/gyn next goes to the ED to evaluate a woman with an incomplete abortion and determines that she needs a dilation and curettage (D&C). During the next 90 minutes, the FHR pattern in L&D worsens, and the L&D team contacts the OR to tell the doctor to come to L&D as soon as he is done. This message is not conveyed or heard by the physician until he receives a STAT page while in the recovery room.
On arrival in L&D, he sees notes repetitive decelerations and absent variability on the FHR, and makes plans for an emergency cesarean delivery because the patient is only 7 cm dilated. He delivers an infant with a cord pH of 6.95.
The pressure to be more efficient and to overextend our clinical responsibilities creates an environment in which an ob/gyn may not be able to provide each patient with the attention she needs. It’s often possible for a physician to multitask throughout the day, but finding yourself in situations in which you need to be two places at once increases the risk of adverse outcomes.
To avoid these cases, it’s critical to have clear back-up plans if you need to leave L&D or are committed to caring for another patient. Also, giving nurses the authority to call partners or other physicians in the event of an emergency and stop oxytocin infusions when a FHR strip becomes nonreassuring helps to minimize the frequency of these situations.