"Reckless" forceps use ends in disaster.
Ms Collins is an attorney specializing in medical malpractice in Long Beach, California. She can be reached at firstname.lastname@example.org.
A woman in her mid-20s was admitted to a Texas medical center for delivery of her baby at term. After she had labored most of the day, the nurses determined that the fetal heart rate (FHR) showed the fetus was in distress. The head labor nurse notified the obstetrician, who disagreed with the nurse that the FHR showed distress. That prompted the nurse to notify the supervisor, who confronted the obstetrician 2 hours later with the FHR strip showing fetal distress and told him it was a serious concern that required discontinuing oxytocin. The obstetrician again disagreed and ordered another nurse to increase the oxytocin dose. About 3 hours later, the FHR monitor showed severe decelerations and the obstetrician decided to deliver the patient. Thirty minutes later he attempted a forceps delivery with 3 attempts during the next 17 minutes, all of which were unsuccessful. The infant was delivered by cesarean and was limp, lifeless, and unresponsive. She was diagnosed with skull fractures and hypoxic-ischemic encephalopathy (HIE) and subsequently taken off life support. The autopsy found that the severe HIE was caused by bleeding in the brain due to the skull fractures.
A lawsuit was filed and alleged that the nursing staff should not have continued the oxytocin when the FHR showed fetal distress, and asserted that the supervising nurse should have contacted her supervisor and continued up the chain of command until the issue was resolved. The lawsuit also alleged that the obstetrician was so reckless in using the forceps because it caused the skull fractures, which compressed bone into the brain. It was alleged that a cracking sound was heard on the second forceps attempt and that on one attempt at delivery with forceps, the obstetrician had his leg on the bed to increase the force he was using and he attempted to rotate the fetal head with the forceps.
The obstetrician denied all allegations, blaming the traumatic skull injuries and bleeding in the brain on the patient’s pushing for hours and the long labor.
A $10.2 million verdict was returned, which included $575 for funeral and burial expenses, $100,000 for past pain, $3 million for past loss of companionship, $3 million for future loss of companionship, and $4.1 million for past mental anguish.
While the description of the obstetrician’s use of forceps in this case may indeed sound reckless, and may have been a contributing factor in the large jury award, the chain-of-command issue allowed the plaintiff to proceed against the hospital and nurses-and their “deep pockets”-as defendants. Most hospitals have a chain-of-command policy, and a good policy addresses the specific situations in which it is to be employed. Expert witnesses disagree about whether it should be employed when the doctor is at the bedside making decisions-the “captain of the ship” model. Others feel that nurses have an independent duty to go up the chain of command when there is significant disagreement in patient management that they believe may be detrimental to a patient’s well-being. The “captain of the ship” model, however, works only if it rescuses the hospital and nurses from any liability risk and holds the doctor solely responsible once at the bedside making management decisions. Since this is rarely the case, all caregivers should know what their chain-of-command policy requires.
A 30-year-old Wisconsin woman who weighed 300 lb was admitted to the hospital at 40 weeks’ gestation for induction of labor. Oxytocin was started, and within 30 minutes the baseline FHR increased, accelerations ceased, and late decelerations were noted. The dose of oxytocin was steadily increased throughout the day. In the early afternoon the FHR showed the fetus was not tolerating the contractions, so the nurse discontinued the oxytocin. The attending obstetrician ordered the oxytocin be restarted after giving the fetus an opportunity to recover. The patient requested a cesarean delivery, but the obstetrician felt that the patient’s excessive weight and prior heart surgery would make a cesarean risky and that it was unnecessary. His shift ended and his partner took over care of the patient. Early the next day the nurse notified the new obstetrician that the patient had made no progress in labor and that the FHR showed tachycardia. The obstetrician ordered terbutaline but did not examine the patient. An hour later a prolonged deceleration of the FHR was seen and the obstetrician immediately performed an emergency cesarean. The infant was severely depressed. Magnetic resonance imaging performed at 23 days of life showed that she had distinct hypoxic-ischemic injury. She was diagnosed with cerebral palsy (CP), and is non-ambulatory with significantly impaired cognitive abilities.
In the lawsuit that was filed following this delivery, the patient alleged she should have had a cesarean on the first day when she requested it. She faulted the nurses for not being more assertive in obtaining a cesarean for her. The expert pediatric neurologist opined that the infant’s injury occurred within 30 minutes of delivery, and that the injury could have been prevented had a cesarean been performed earlier.
The parties settled during mediation for $8.4 million.
A 32-year-old Arizona woman underwent an abdominal hysterectomy. She sued the gynecologist who performed the operation after a bladder perforation was discovered. She claimed the open procedure allowed all organs in the pelvis to be clearly seen, and alleged that the gynecologist failed to recognize and repair the 2-cm perforation in the back wall of the bladder. The patient required a second procedure to repair the bladder.
The gynecologist argued that a bladder perforation was a known complication of the procedure and that his care was not below the standard.
The jury returned a defense verdict.
An Illinois woman presented to the hospital in 2004 at 40 weeks’ gestation with a complaint of decreased fetal movement. She was placed on an external FHR monitor, which showed a non-reassuring tracing. The obstetrician decided to try an induction of labor and attempt a vaginal delivery. About 10 hours later an internal FHR monitor was placed and showed decelerations necessitating an emergency cesarean delivery. The infant suffered a hypoxic brain injury, resulting in CP. Twelve years later he has cognitive and physical limitations that require 24-hour care.
A lawsuit was filed against those involved with the delivery and alleged the physician should have performed a cesarean delivery immediately after FHR monitoring began.
The gynecologist argued that while the tracings were consistently non-reassuring, they were stable and there were no repetitive FHR decelerations or other indicators of fetal compromise that would preclude allowing her to attempt to have the safer vaginal delivery. He argued that the brain injury did not occur around the time of labor and delivery, showing that the infant’s oxygen level was normal and metabolic acidosis was mild. He further contended that an infection in the amniotic sac was present and caused the brain injury before the patient presented to the hospital, so an earlier cesarean would not have changed the outcome.
The jury awarded $53 million.
A lawsuit was filed in Illinois following the delivery of an infant who suffered a brachial plexus injury. The suit alleged that the obstetrician failed to read an ultrasound report from 5 days prior to delivery that showed the comparison of the fetal head and abdominal circumferences, which would have led him to be suspicious for macrosomia. Instead, it was alleged, he relied solely on the estimated fetal weight of under 8 lb when he decided to proceed with a vaginal delivery. A vacuum extractor was used to deliver the head and a shoulder dystocia occurred. The shoulder was successfully delivered but the infant sustained a permanent brachial plexus injury. The infant weighed 10 lb, 8 oz.
The patient contended that the obstetrician caused the injury by failing to diagnose macrosomia and allowing the dystocia to occur, then improperly using a vacuum extractor, which is contraindicated for macrosomia.
The obstetrician denied any responsibility for causing the injury and asserted that his reliance on the estimated fetal weight by ultrasound was within the standard of care.
A defense verdict was returned.
A Kentucky woman was 6 weeks pregnant when she called her obstetrician with complaints of lower abdominal pain. She went to the office and was seen by a partner of her obstetrician, who was off that day. The obstetrician in the office performed an ultrasound and could not find a fetus in utero. The patient’s β-HCG levels were suggestive of an ectopic pregnancy. The following day the obstetrician performed a laparoscopy but found no evidence of an ectopic pregnancy. She did remove the patient’s appendix. The obstetrician continued to be concerned about the possibility of an ectopic pregnancy and the following day recommended termination and prescribed methotrexate. A week later, an ultrasound revealed a gestational sac in the uterus and a heartbeat. Because of the methotrexate use and the possibility of birth defects the obstetrician again suggested terminating the pregnancy, which the patient did 1 month later.
The patient sued the obstetrician involved and alleged she rushed to advise the patient to terminate the pregnancy, and was negligent in not waiting for the pathology from the appendix and not repeating the ultrasound to assess the normally implanted pregnancy.
The obstetrician argued that she acted reasonably based on the patient’s symptoms.
A defense verdict was returned.
A Michigan woman was diagnosed with polyhydramnios and underwent weekly non-stress tests until the fluid level became normal. Near the end of her pregnancy she noticed a decrease in fetal movement (FM) and called her obstetrician’s office. She was told to perform fetal kick counts and go to the hospital if the count was abnormal. The patient fell asleep and in the morning she presented to the office with decreased fetal movement and was sent immediately to the hospital. She was admitted and 2 ½ hours later an emergency cesarean was performed. The infant was severely depressed and died 8 hours later.
The patient sued the obstetricians involved and their group, alleging that they should have continued the weekly testing even after the fluid measured in the normal range, should have sent the patient to the hospital when she initially called about decreased FM, and should have performed the cesarean immediately upon arrival at the hospital.
The obstetricians argued that further testing was not necessary once the amniotic fluid was normal, that the phone advice regarding kick counts was appropriate, that any delay in performing the cesarean was out of their control and the outcome would have been the same regardless of their actions.
A defense verdict was returned.
A 39-year-old New Jersey woman was admitted by her gynecologist to a surgical center to undergo urethral sling surgery to alleviate symptoms of incontinence. The patient later sued the gynecologist and the surgery center, claiming that during the operation she was negligently burned on the inside of her left thigh after her skin came into contact with the heat source of a cystoscope, causing a third-degree burn.
The gynecologist denied any liability and argued that if the patient’s burn was caused by the cystoscope, it would have been the fault of the nurse. He asserted the cystoscope was not giving off intense heat when he was using it and that he was not using it near the thigh.
A defense verdict was returned.
A gynecologist performed a hysterectomy on a 45-year-old Illinois woman. During the operation the patient’s bladder was perforated, which led to another operation, prolonged hospitalization, pneumonia, and incontinence.
The woman sued the gynecologist and alleged that the original surgery was unnecessary.
The gynecologist argued that the patient was properly advised of the various alternatives for treatment based on her physical findings and diagnostic test results, and was told of the risks and benefits of each alternative. He further argued that the patient made an informed choice to have the hysterectomy, which was properly performed, and that the patient suffered a known complication.
A defense verdict was returned.
An Alabama woman was pregnant with her fourth child and discussed with her obstetrician her desire to labor and deliver in any position other than on her back. The obstetrician agreed to her request. When the patient went into labor and presented to the hospital in 2012, she informed the nurse that her preferred position for labor was on her hands and knees. The nurse informed the patient she had to lie on her back as that was necessary for monitoring the fetus. The patient informed the nurse that her doctor had agreed that she could labor in any position and could be mobile during the monitoring process.
The patient began having hard contractions and turned over onto hands and knees, and informed the nurse she could not labor on her back. The nurse flipped the patient onto her back by taking her wrists and pulling her hands out from under her. The nurse then delayed the delivery by putting pressure on the fetal head until the doctor could arrive. A second nurse then forcibly pressed the patient’s left knee back toward her chest, leaving her legs in an asymmetric position at the moment of delivery. The obstetrician arrived in time to deliver the baby. Two months later, the patient complained of chronic severe pelvic pain. She was diagnosed with pudendal neuralgia and underwent nerve blocks and took pain medication.
The patient sued the hospital and alleged her condition was the result of tension and compression due to malpositioning of her legs during delivery. She also alleged the condition could be the result of a laceration on the left side of her vaginal wall.
The nurses denied any breach of the standard of care. They argued that the patient’s injuries, if any, had not been caused by the delivery.
The jury awarded the woman $16 million in damages.