Ruptured uterus results in lengthy malpractice case

February 2, 2013

Looking at the legal issues surrounding a ruptured uterus, lack of a prompt diagnosis for placental abruption, uterine perforation during D&C, and what constitutes adequate fetal monitoring.

A Tennessee woman became pregnant in the summer of 1999 and received prenatal care from an obstetrician. She went into labor at term and was admitted to a hospital. At 1:30 pm, sudden fetal heart rate (FHR) decelerations were noted and the physician began an emergency cesarean delivery. The infant was delivered at 1:58 pm, and a ruptured uterus was diagnosed. The infant sustained an ischemic insult and profound brain injury.

A lawsuit was filed, claiming that there was a delay in delivering the infant and alleging that if the delivery had occurred even minutes earlier, the injuries would have been mild. The patient contended that the hospital nurses delayed calling the obstetrician for 15 minutes to report the FHR deceleration and that the physician should have delivered the baby sooner.

The hospital claimed that the obstetrician was notified as soon as the FHR tracing was concerning and that the delivery occurred within 30 minutes from decision to incision, although they faulted the doctor for any delay.

The obstetrician settled with the patient before trial and the hospital received a defense verdict in 2007.

Legal Perspective

After the 2007 trial, the patient filed a motion for a new trial, which was granted. The new trial was held in 2009 and ended in a directed verdict against the doctor. The jury was then asked to assign the amount of liability and found the physician to be 96.25% liable and the hospital to be 3.75% at fault. The award to the patient was for $4,528,454, which was reduced to $164,273.

The patient again moved for a new trial, citing error in directing a verdict against the physician and claiming that during deliberations, a juror had contacted her nurse mother regarding issues in the case and alleging that a quotient verdict had been reached. (A quotient verdict is an award based on each juror’s written opinion of what the amount should be. These amounts are totaled and then divided by the number of jurors. This is improper and grounds for setting aside the judgment.) Nevertheless, this new trial motion was denied, and the plaintiff appealed. An appellate court reversed both the denial-after finding several juror affidavits provided evidence of a quotient verdict-and the directed verdict against the obstetrician. A third trial was then held, and this jury found fault at 60% to the doctor and the remainder to the hospital. The award was for $13,623,000, which was reduced to $7,974,505 after allocation of fault. A posttrial motion by the hospital was still pending at time of publication.

Failure to promptly diagnose placental abruption

A pregnant Mississippi woman went to a hospital emergency department at 26 weeks’ gestation with a complaint of abdominal pain. An obstetrician examined her at 4 am, diagnosed premature labor, and arranged for transfer to a facility with a higher level of care. The patient was transferred at 6:48 am, and a placental abruption was suspected on arrival. A cesarean delivery was performed 28 minutes after her arrival. The infant suffered profound brain damage.

The woman sued the first obstetrician who saw her in the emergency department, alleging negligence in failing to diagnose the placental abruption promptly and to immediately deliver the infant.

The physician claimed that the patient’s presentation was initially consistent with preterm labor and that stabilization before transfer was appropriate. He also claimed that even with an earlier delivery, the outcome would have been poor, because the injuries were related to the prematurity, not the abruption. He also suggested that the child would not have survived if delivery had taken place at the first hospital. A defense verdict was returned.

Failure to timely diagnose uterine cancer

A Massachusetts woman in her 50s went to a gynecologist in 2004 with complaints of vaginal spotting. She returned to the doctor’s office several months later complaining of daily bleeding. An ultrasound (U/S) showed a 4-cm mass in the endometrial cavity that was consistent with a large polyp. A hysteroscopy was performed by the gynecologist 2 months later, and a biopsy revealed that the assumed polyp was actually uterine cancer. The patient underwent a hysterectomy and radiation therapy, but metastases were found in her lungs 8 months later, and she died 10 months after that.

A lawsuit was filed by her estate, claiming that the physician was negligent in failing to diagnose the uterine cancer in a timely manner.

The gynecologist claimed that the cancer was aggressive and that earlier diagnosis would not have changed the outcome. An $820,000 settlement was reached.

Claim of brachial plexus injury caused by excessive force during delivery

A Mississippi woman who was pregnant in 2001 was cared for by her obstetrician. An U/S in the fifth month of pregnancy showed that the fetus measured slightly large for gestational age. The infant was born at term, and the delivery required use of the McRoberts maneuver. The infant suffered a brachial plexus injury. Her left arm is shorter than the right, she cannot make a fist, and her fingers are not fully developed. She has scars from operative attempts to repair the injury.

The mother sued the delivering obstetrician, alleging use of excessive force during delivery and maintaining that she had symptoms of gestational diabetes, and therefore, a planned cesarean delivery should have been performed.

The physician maintained that the fetus was not large enough to be considered macrosomic and that the McRoberts maneuver was properly used without excessive force. A defense verdict was returned.

Uterine perforation and iliac artery injury during D&C

A 47-year-old Wisconsin woman underwent a dilation and curettage (D&C) performed by her gynecologist at a hospital. She subsequently sued the physician, claiming that her uterus was perforated, her iliac artery was punctured, and the artery injury caused her to suffer a heart attack. She argued that the doctor had failed to open the cervix with the appropriate dilators to gain access to the cervical and endometrial cavity and then failed to use the proper instrumentation in the uterus. She also maintained that the doctor had failed to correctly assess the shape of the uterus. She maintained that she suffered cognitive and emotional damages and that she would require surgery in the future. A $350,000 settlement was reached.

Failure to provide adequate fetal monitoring during labor

A pregnant woman at 32 and 4/7 weeks’ gestation was admitted to a Massachusetts hospital with preterm premature rupture of membranes (PPROM). She was managed for 10 days with a plan to induce labor at 34 weeks. She began to have cramping and contractions on the morning of the scheduled induction. FHR monitoring showed a normal tracing, and the patient had no fever. The fetus was noted to be a compound presentation, with the chin presenting first. The patient progressed to 6-cm dilation by 1 pm. The FHR began to show some recurrent mild variable decelerations that became increasingly deeper. The patient later claimed that the technical quality of the external FHR tracing was poor, but no internal monitor was placed, and that the interpretable tracing showed severe variable decelerations.

At 4 pm the patient was fully dilated, the baby’s head was at +1 to +2 station, and the patient began pushing. The interpretable part of the FHR showed minimal variability with significant decelerations and tachycardia at 190 bpm. The residents and nurses noted the FHR, but the attending physician was not present until the last half hour of labor. Meconium was noted, and the infant was delivered at 6:47 pm. The Apgar scores were 1 at 1 minute, 5 at 5 minutes, and 7 at
10 minutes, and the arterial cord pH was 6.85. An initial head U/S was normal, but subsequent magnetic resonance imaging showed subdural and intraventricular hemorrhage and evolving profound hypoxic ischemic injury. At just over 1 year of age the child had a seizure disorder, cortical blindness, and severe developmental delays.

After this delivery the patient’s attorney contacted the hospital and alleged negligence in the failure to respond to the FHR abnormalities, failure to insert an internal lead to obtain a better tracing, and failure to expedite delivery in the face of significant and worsening FHR abnormalities.

The hospital’s insurance carrier began settlement discussions when the infant was about 8 months old, which resulted in a $4.2 million settlement before filing a lawsuit.

CP following failure to prevent premature delivery after PPROM

In 1995 a New York woman who was pregnant with twins was admitted to the hospital with PPROM at
25 weeks’ gestation. Eight days later she reported pain. Although medication was administered for several hours, it was determined that she was in labor, which was allowed to progress and resulted in a vaginal delivery. One child was subsequently diagnosed with cerebral palsy (CP) and requires assistance with many daily activities, although her cognitive function is not impaired.

The woman sued those involved with the management of the pregnancy and claimed that the CP was caused by a failure to prevent the child’s premature delivery. She alleged negligence in the failure to recognize that she was in labor. She argued that timely recognition of contractions would have allowed for administration of a drug that would have delayed delivery. She maintained that contractions had been successfully stopped twice before. The patient also claimed that the infant suffered trauma during passage through the vagina that could have been prevented by an episiotomy or a cesarean delivery.

The physicians denied any negligence, and the hospital contended that monitors did not suggest any contractions initially. The jury found fault only as to the hospital, with the physicians being found not liable, and awarded $103,075,617.82 to the child.

Complications after cystocele-rectocele repair

A 51-year-old Virginia woman went to her gynecologist after noticing a bulging in her vagina. The doctor diagnosed a cystocele and rectocele. An anterior and posterior colporrhaphy repair using tension-free vaginal tape obturator (TVT-O) was recommended. The physician stated that a urologist would be on hand during the procedure because a bladder lift was involved. The surgery was performed in 2008. The patient awoke after the procedure in excruciating pain and was told that she had lost a lot of blood and that “sometimes you can do everything right but things can still go wrong.” At the first postoperative visit the doctor told her that the stitches had not yet been absorbed and were causing an abrasion and that she would need to use a lot of lubricant for sexual intercourse because more vaginal tissue was cut than had been planned.

About 2 weeks later the patient could not see a vaginal opening because of severe stenosis. She continued to have severe groin pain and muscle spasms, and the physician found that the TVT-O was creating a ridge of tissue in the anterior portion of the vagina. Dilators were required to expand the vagina, and it was determined that there was entrapment of the dorsal clitoral nerve from the TVT-O. The woman continued to have dyspareunia and pain in her groin from nerve entrapment.

The patient sued the gynecologist, claiming that he failed to inform her that 2 months earlier the FDA had issued a public health notification regarding complications associated with transvaginal placement of surgical mesh during repair of prolapse and urinary incontinence. She also claimed that she was not informed that the doctor had just completed training in TVT-O surgery, was not fully credentialed to perform the procedure, and was being proctored on the procedure. A $390,000 settlement was reached.OBG

Ms collins is an attorney specializing in medical malpractice in Long Beach, California. She welcomes feedback on this column via e-mail to dawncfree@gmail.com.