MALPRACTICE
Risk management in obstetrics and gynecology

Failure to perform a timely repeat C/S

In 1998, a California woman presented to the hospital in the very early morning with a term pregnancy and was admitted in early labor. She previously had consented to a repeat cesarean section and not a vaginal birth. The obstetrician was called at home by the nurses and advised of the woman's presence in the labor unit, her ongoing contractions, and the fact that she was to have a repeat C/S. He ordered a tocolytic agent and stated that he would be in later.

When he did not appear after about 1 ¹/₂ hours, the nurses called the physician again. He then informed them that he had a scheduling problem and would get someone else to cover this patient. About 20 minutes later, the physician called back and gave the nurse the name of the obstetrician who would cover for him. Soon after this, the second physician telephoned the labor nurses and was told of the patient's condition and the need for a repeat C/S. He informed the nurses that he was going to another hospital first to see his other patients, and instructed them to prepare the woman for a C/S in 2 hours.

About 30 minutes later, the fetal heart rate strip showed a prolonged deceleration and the new physician was paged. He responded that since there seemed to be recovery from the deceleration, according to the labor nurse, he would still plan the C/S for the same time. The nurse then left the patient's room and did not return for 30 minutes. The centralized FHR monitoring system was not working that day, so no one could evaluate the monitor strips unless they were at the bedside. About 10 minutes after the nurse left, an unobserved prolonged deceleration occurred without recovery. No one was aware of this until the nurse returned. At that time, the nurse requested emergency help, but she did not call for the perinatal fellow or the obstetric resident on the unit. The perinatal fellow was eventually paged and delivered the infant by emergency C/S. At surgery, a ruptured uterus was found, with the baby floating in the abdominal cavity. Apgars were 0 and 1; cord pH was 6.68. The child remained in the hospital for 5 weeks and eventually had a gastrostomy and tracheotomy placed. The child is severely compromised, with a life expectancy of another 2 years.

In the lawsuit that followed, the woman claimed that one of the obstetricians should have performed a repeat C/S after her admission, as she did not desire a vaginal birth. She claimed further that the obstetricians should have come to the hospital and maintained that the labor nurse should not have left the bedside after the first prolonged deceleration, since the remote monitor was not functioning. The woman argued that if the nurse had been in the room, the uterine rupture would have been detected promptly and the baby would have been delivered sooner.