Legally Speaking

September 1, 2005

No ob available for C/S with prolapsed cord

No ob available for C/S with prolapsed cord

A pregnant woman who had received prenatal care from a family practitioner was admitted to a Hawaii hospital in 1999 for the birth of her child. Within 1 to 2 minutes after artificial rupture of her membranes, the fetal heart rate revealed a significant prolonged deceleration to 60 bpm. The physician performed a vaginal examination and discovered a loop of cord along the left side of the infant's head, which he described as a prolapsed umbilical cord. He then manually elevated the infant's head, reducing the cord. The deceleration continued for about 4½ minutes.

The physician then instructed the mother to push and allowed her to labor for almost a half hour, during which there were several significant FHR decelerations. The infant was born with the umbilical cord along the left side of the head and had a fractured right humerus and a small subdural bleed with an intracerebral contusion. He had severe brain damage due to profound anoxia and now receives 24-hour care in a nursing home.

The physician claimed that he had not diagnosed a prolapsed cord before delivery and that the records indicating a prolapsed cord were written in retrospect and were not a comment on what he knew at the time of delivery. The hospital claimed that its on-call policy was appropriate for a community hospital. They also argued that the child's injuries were not due to anoxia from a prolapsed umbilical cord. A $10.9 million settlement was reached.

Legal perspective

During the lawsuit described here, the parties discovered that on the evening in question, the physician had made two telephone calls to the primary and back-up obstetricians on call for the hospital. The primary obstetrician was unavailable because he was doing a procedure at another hospital, and the back-up obstetrician was more than 45 minutes away.

Cases like this one can be problematic for all involved with a patient's care, including the back-up obstetrician. The family practitioner and hospital are at risk for liability by not providing emergency obstetric back up equivalent to what is required of all hospitals that offer obstetric services. That is, they must offer emergency C/S within a 30-minute decision-to-incision time frame. When obstetricians agree to back up family practitioners, they often face rapidly deteriorating situations and must be available for emergent procedures. If an ob/gyn can't be available in timely fashion, he or she will be at risk for liability. And even if the obstetrician does execute the delivery in a timely fashion, he or she may still be tied to liability for prior delay that results in a bad outcome.

Asherman's syndrome after D&C

A 36-year-old Virginia woman gave birth to her first child in 2002. A month later, she was admitted to the hospital with heavy active bleeding and hypotension. The delivering obstetrician saw her in the emergency room and suspected that retained products of conception remained in her uterus. The patient's consent was obtained and she had an emergency dilation and curettage. The physician used a suction curette, followed by a large, sharp postpartum curette to stop the bleeding. The procedure successfully controlled the bleeding and the patient was discharged several days later.

Unfortunately, the woman thereafter developed amenorrhea and was referred to a fertility specialist, who diagnosed Asherman's syndrome. She underwent surgery for lysis of the adhesions with placement of a balloon catheter to promote healing. This did not result in a normal uterine cavity and subsequent studies revealed recurrence of scar tissue in the uterus.

The woman sued her obstetrician, claiming that the sharp curettage aspect of the D&C was done in a manner inappropriate to the medical facts and circumstances of her presentation. She alleged that the methods, techniques, and instruments (particularly the sharp curette) caused the scarring and the development of Asherman's syndrome.