Practice of Medicine

Claims Lesson

Obstetrician Faces the Perfect (on-call) Storm

November 26, 2013

The Case

This case involves a 22 y/o G2 P1 who presented to her obstetrician’s office at 39 weeks with decreased fetal movement. Electronic fetal monitoring (EFM) showed repetitive variable decelerations to the 60s, no accelerations and minimal variability. The defendant obstetrician’s partner sent the patient to the hospital for induction of labor around 5pm. The defendant obstetrician was on-call for both her practice’s OB/GYN patients and the Emergency Department that evening.

Electronic fetal monitoring began just after 5 pm. From the beginning the tracing had no accelerations, mostly moderate variability and continued variable decelerations down to 95. The remainder of the timeline evolved as follows:

6:30 pm The obstetrician wrote a progress note stating that she was aware that the patient had a non-reactive NST with variable decelerations in the office. She wrote orders for induction of labor. Apparently concerned about the EFM tracing, the patient’s primary nurse consulted the charge nurse.

8:00 pm Prior to heading to the OR, the obstetrician spoke with the L&D charge nurse. The charge nurse wrote a note stating the obstetrician was on the unit and told her that she was about to start an emergency gynecologic surgery and would not be available for 2 hours, and the patient would probably need a cesarean section. The nurse documented that she “questioned the obstetrician’s plan.”

The charge nurse informed the obstetrician that Pitocin would discontinued because it was against hospital policy to continue Pitocin when the obstetrician was not available.

Therefore the patient’s nurse discontinued the Pitocin and performed the appropriate intrauterine resuscitative measures (IVF bolus, oxygen, position changes).

The EFM tracing became more abnormal with minimum variability and more persistent variable decelerations. This information was recorded in subsequent nursing notes.

9:00 pm Another L & D nurse contacted the physician and informed her that the variable decelerations were becoming more repetitive. Since she was still in the OR, the obstetrician instructed the nurse to call another obstetrician on the unit if the patient’s condition worsened.

9:45 pm The nurses called an obstetrician from another group and informed her of the status of the EFM tracing. A prolonged deceleration began.

9:56 pm The second obstetrician ordered an emergency cesarean section.

10:00 pm The patient’s primary obstetrician finished her case in the OR and returned to the L & D. She scrubbed in to assist with the delivery of a baby girl. A nuchal cord X2 was encountered. There was no meconium.

10:06 pm The baby’s Apgar scores were 0, 1, and 5. Cord blood pH was 6.863; base excess was -17.3. The baby required CPR. She was transferred to the nursery with no spontaneous movement. The child was subsequently diagnosed with spastic diplegic cerebral palsy, microcephaly and developmental delay.

Allegations

Plaintiffs alleged that the on call (primary) obstetrician failed to:

  • recognize non reassuring fetal status or fetal distress
  • request assistance of another OB in a timely manner
  • order and/or administer intrauterine resuscitative measures
  • not order Pitocin in face of non-reassuring fetal status
  • She abandoned her patient.
  • She failed to do an emergency cesarean section

Plaintiffs further alleged that the nurses failed to timely discontinue the Pitocin, failed to perform intrauterine resuscitation, failed to carry out the obstetrician’s orders, and failed to implement the chain of command and bring in another obstetrician to care for the patient.

Disposition

MagMutual sought to defend this claim to the extent possible.

We had good expert support for the proposition that spastic diplegia is not associated with an intrapartum hypoxic injury, in accordance with the multidisciplinary publication, “Neonatal Encephalopathy and Cerebral Palsy” (available through the American College of Obstetricians and Gynecologists). Our experts opined that the neurological damage to the baby likely occurred before the patient’s office visit on the day of admission.

However our experts who reviewed the case were concerned about deviations from the standard of care by the primary obstetrician and the actions of the nursing staff. She was unavailable by her presence in the OR. The primary obstetrician did not arrange any back-up coverage. In fact, one expert reviewer even went so far as to say that the obstetrician abandoned the patient.

The actions and inactions of the obstetrician were going to be impossible to defend before a jury. Mediation of the claim was unsuccessful. Thus the claim was settled for a very large amount for the obstetrician paid by MagMutual. The co-defendant hospital made a very large payment to settle the case.

Other Concerns in Defending the Case

  • Before she went to the OR, the obstetrician was aware of the EFM tracing’s variable decelerations, decreased variability and absence of accelerations. She did not exclude hypoxia as a cause of the findings on the tracing.
  • Before she went to the OR there was a 1-1 ½ hour gap during which, experts testified, that he should have intervened with delivery because of the tracings.
  • The nurses’ notes suggested a conflict between the obstetrician and the nurses regarding the interpretation of the tracings and management of the induction.

Risk Management Commentary

Call coverage is imperfect, even in routine situations. It failed in this case.

In arranging proper on-call coverage, situations as occurred in this case must be anticipated. The dilemma of having to choose between managing problems in the labor and delivery suite or attending to business in the ED and OR must be mitigated by an appropriate system arrangement among the hospital and obstetrician gynecologists on staff.

Medical staff bylaws and policies often address on-call coverage. Failure to adhere to them is indefensible. EMTALA cases also arise from faulty on-call arrangements.

Health care systems conducting root cause analysis should clearly identify both active errors that are errors occurring at the point of interface between humans and a complex system; and latent errors that are the hidden problems within the health care system that contribute to adverse events such as the one discussed in this Claims Lesson.

Solutions to the failure that occurred in this case could include intra-and inter-group agreements and hospital initiated and funded agreements with the OB/GYN physicians on staff.

Please feel free to share your comments concerning any aspect of this claim and /or best practices in call coverage you, your group and hospital have implemented. Comments may be sent to gsamaritan@magmutual.com. Thank you.

Disclaimer

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