Passive Response to Mother’s Status During Labor

Description

A newborn died shortly after her birth, which was complicated by prolonged labor and a delayed diagnosis of chorioamnionitis.

Key Lessons

• Determination for consultation in-person versus remote should be criteria-based.
• Prolonged labor without significant progress must trigger assessment by a (clinical) third-party.
• Unresolved concerns (e.g., maternal fever, fetal tracings, stagnant dilation) have to be regularly assessed and the care plan adjusted accordingly.

Clinical Sequence

A morbidly obese 26-year-old in the 41^st week of her first pregnancy was admitted to Labor & Delivery 3cm dilated and complaining of a sore throat. Her prenatal history included a positive Group B Strep test. The initial external fetal heart rate (FHR) tracing was Category 1; the nurse noted that FHR recording was complicated by the mother’s size.

12 hours later, the patient’s temperature was 100.5°; she was given Ampicillin and her nurse midwife consulted with the on call obstetrician (by phone) regarding a potential viral syndrome. The patient was not seen by the obstetrician.

• 6 hours later, the patient had progressed to 4cm; her temperature remained at 100.5° and she was given anti-flu medication (oseltamivir). Oxytocin was also administered.
• 5 hours later, the patient had progressed to 6cm dilation.
• 8 hours later, no cervical change.
• 4 hours later, the patient had progressed to 8cm and her membrane was artificially ruptured.
• 6 hours later (41 hours since her admission), the mother was fully dilated. Meconium stained fluid was noted; the FHR tracing was Category 2 with decelerations.
• 1.5 hours later, chorioamnionitis was diagnosed and treated with antibiotics.
• 1 hour later, a female infant (3700g) was delivered vaginally; her Apgars were 1/3/5, and she died shortly after birth. Her cultures were negative; autopsy confirmed hypoxic ischemic encephalopathy.

Allegation

The mother sued the OB care team (midwife, obstetrician, nurse) alleging that a delay in the treatment of fetal distress and improper management of her labor led to her baby’s death.

Disposition

Experts who reviewed the case for the defense team concluded that a more aggressive response to non-reassuring FHR tracings (i.e., conversion to cesarean delivery) would have been appropriate. Coupled with a delay in the diagnosis and treatment of chorioamnionitis, the case was settled in the high range.

Discussion Points

The nurse midwife’s outreach (by phone) to the obstetrician’s was limited to the potential viral syndrome. The obstetrician was not asked, nor opted, to see the patient in person.

Consultation is essential when a provider’s experience, expertise, or comfort level is exceeded. The determination of whether or not the consultant needs to see the patient in person should be based on standard criteria rather than intuition or a heat-of-the-moment judgment.

The infant’s heart rate was being monitored throughout a long labor without adequate focus on changes in the tracings or special attention due to the mother’s obesity.

Women with high BMI present challenges (e.g., beds, monitoring equipment, positioning) that Labor & Delivery units must be prepared for and staff trained on. Criteria for converting from external to internal fetal monitoring can reduce the duration of monitoring gaps.

Relevant signs and test results were underappreciated.

Failure to appreciate and reconcile relevant signs and test results (team dynamics around discontinuous FHR in 2^nd stage, prolonged labor, fever) speak to the need for team training via simulation and drills.

Strategies to Prevent Similar Incidents

1. Team training:
   • To promote active communication among providers for all significant findings &/or changes in patient status
   • To establish a culture of safety and improve speaking up
   • To improve patient safety
   • To effectively utilize resources
2. Routine interdisciplinary safety rounds/huddles
   • Review all relevant sources of information: FHR, maternal and fetal assessment
   • Routine at shift or team change
   • At least once during the patient’s labor, for example
3. Defined triggers for reassessment
   • Prolonged labor
   • Concern expressed by any team member
   • Changes in maternal vital signs, mental status
   • Coordinated educational efforts:
   • Multidisciplinary FHR training
   • Strip rounds to review and learn from FHR tracings
   • Debriefing after events
   • Multidisciplinary M&M’s