Legally Speaking: Why was this cesarean delivery delayed?

February 1, 2008

Given the increased risks inherent during VBAC, ob/gyns must take great care to ensure that all of the caregivers involved in the trial of labor are on the same page.

Key Points

• THE FACTS

The patient, a 27-year-old G5, P1, was admitted to the defendant hospital center at approximately 3:15 PM on September 27. Her prior pregnancy had ended 18 months earlier with a cesarean delivery (CD) via transverse uterine incision for nonreassuring fetal heart rate tracings.

IN THE CURRENT PREGNANCY she had been followed by the chief resident in obstetrics, who had been involved in the prior CD. Although her prenatal course had been uneventful, the patient was admitted for induction because of oligohydramnios, which had been confirmed during an ultrasound evaluation that morning. A prenatal progress note by the chief resident on June 7 specifically documented that the patient wanted a trial of labor after prior CD. The note also documented the fact that the risks of such a trial of labor, including the risk of uterine rupture, had been discussed with the patient.

The chief resident involved in the previous CD (#1) was called by the intern and arrived at the hospital some time after 5:00 PM to evaluate the patient, although the resident was not part of the regular labor and delivery team that evening. At 5:45 PM, she documented that the patient was "well known to her and desired a trial of labor," and that the case would be discussed with the second obstetric attending who, along with a maternal-fetal medicine (MFM) specialist, would be assuming care at the shift change. The MFM specialist, however, authored no consult or progress note regarding an evaluation of the patient or discussions with the attending, or chief resident (#1). The chart, however, reflected that the patient consented to a trial of labor and was informed of the risk of uterine rupture.

The chief resident (#1) then left the hospital sometime after her note of 5:45 PM with instructions to the junior resident to call her when the patient was near delivery. The responsible on-call attending for the evening wrote no notes in the chart with the exception of a postdelivery note. Between 11:00 PM and 2:30 AM there is no documentation of the attending having seen the patient or been consulted by residents concerning the patient's care. The resident documented the evaluations at 9:15 PM, 10:30 PM and 12:30 AM as to the reassuring fetal heart rate tracings and describing the oxytocin augmentation, which never went above 8 mU.