Practice of Medicine
Specialty Focus: Obstetrics and Gynecology
June 2, 2017
A 28-year-old G1 P0 female presents in active labor after an uncomplicated pregnancy. She progressed adequately in labor, getting an epidural at 6cm dilatation. After delivery of the fetal head, the head partially withdraws back into the birth canal (turtle head) and this was immediately noted. A modified McRoberts’ maneuver was done with suprapubic pressure without success. This was followed by a Woods’ corkscrew maneuver. Ultimately, delivery of the posterior arm was successful with delivery of the shoulders and trunk of the infant. The infant was noted to have brachial plexus palsy which was ultimately found to be permanent. Because it was a very difficult delivery, the physician wrote a quick note and went to the nursery to check on the baby. Unfortunately, the documentation by the physician did not include the procedures that were done and in what order, and did not mention which shoulder was anterior.
The patient is a 76-year-old Caucasian female with a history significant for hypertension. She was diagnosed with a pelvic mass measuring 10x9x8cm and uterine fibroids. One month later she had an open hysterectomy and bilateral removal of ovaries, fallopian tubes and pelvic mass. This surgery was thought to be uneventful. Over the next four days, the patient progressed but remained without flatus or bowel movement. She was given Milk of Magnesia and Dulcolax. On post-op day number 4 she complained of constipation, but had minimal flatus and a small bowel movement. She was moderately distended and a three-way X-ray revealed “moderately extensive free intraperitoneal air,” presumably secondary to the surgery. The patient’s condition did not improve significantly and CT scans of the pelvis, abdomen, and chest were done. Ultimately, the patient was diagnosed with a perforated bowel with peritonitis and sepsis. She was hospitalized for two months due to additional complications.
These two cases demonstrate common allegations against MagMutual OB-Gyn providers. Events in the peri-natal and peri-operative period can be complex and poor outcomes will likely lead to close inspection of physician and nursing documentation of pertinent events. Fortunately, there are strategies physicians can employ to both provide their patients with optimum care and protect themselves should an unanticipated outcome occur.
Case #1 Discussion
Almost half of all dollars paid out for defense and indemnity for OB-Gyn physicians are a result of care in labor and delivery. Unfortunately, poor documentation can make it difficult to tell if the standard of care was met, as illustrated in the first case. To support documentation, a delivery note addendum checklist may have helped in this case. This would have captured the chronological details of what happened during the procedure to support the decisions that were made.
If this is relevant to your practice, we encourage you to download this material and share it with other practitioners in your setting as well as other members of your staff.
Case #2 Discussion
Slightly more than 25% of dollars paid out in OB-Gyn medical liability cases relate to technical performance and complications of gynecologic surgery. The most common allegation, as illustrated in Case #2, is the failure or delay in recognizing a post-operative complication. All procedures have known complication rates. The occurrence of a complication is not, in and of itself, evidence that a procedure was performed poorly. The provider's duty is not to guarantee a complication-free procedure, the provider's duty is diligent surveillance for any possible complications during the post-operative course.
Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.
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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.