Description

Following a planned induction and successful vaginal delivery of the first twin, delivery of the second baby encountered complications requiring an emergency cesarean section. The severely brain damaged and quadriplegic second twin died six months after birth.

Key Lessons

Expecting everything will go smoothly does not pre-empt preparing for complications.
Team training can minimize the impact of a crisis.
Prevailing in court is not necessarily a win for the clinicians or organizations involved in an adverse event

Clinical Sequence

The 25-year-old mother of a three-year-old was scheduled for induction to deliver twin boys at her community hospital. Her pregnancy was uncomplicated, except that the non-presenting twin was in a breech presentation. In planning the delivery, the obstetrician requested portable ultrasound equipment and asked Anesthesia to be on hand.

Following induction via Pitocin, the first twin was delivered vaginally, without difficulty. When the obstetrician encountered problems delivering the second fetus, he re-confirmed that it was still a breech presentation. During an attempt to turn the baby via internal cephalic version, the obstetrician intentionally ruptured the membranes. The umbilical cord was wrapped around the baby’s feet and lower body. As the obstetrician further attempted to re-position the baby head-first for a vaginal delivery, the cervix contracted on his hand. The anesthesiologist, who had been called away, was called back to administer nitrous oxide to relax the uterus for further attempts to reposition the baby.

No ultrasound equipment was present in the delivery room, so the nurse monitored the fetal heart rate with a hand held device. At one point, while the obstetrician was attempting to reposition the second twin, the fetal heart rate dropped to 43 BPM. After eight minutes and no success at turning the fetus, the obstetrician called for a C-section.

The baby was born with very low Apgars, no gag reflex, and an EEG demonstrated severe brain damage. He was diagnosed with spastic quadriplegia, was blind, and died five months after birth.

Allegation

The parents sued the obstetrician, alleging negligent delays in delivery and treatment of fetal distress.

Disposition

Expert reviews for the defense were mixed, but the jury returned a verdict for the defense.

Analysis

Although the obstetrician prevailed at trial, defense experts cited a lack of adequate planning for untowards events as a problem in this case. Even though he requested Anesthesia and ultrasound just in case he would need them, they were not there when he actually needed them.
Planning ahead can be approached either from the perspective that “things usually work out well,” or “let’s prepare for what might go wrong.” If you focus on what is most likely to occur—what a reasonable person would do—you satisfy the letter of the law but miss the opportunity to go one level beyond that and prepare for the worst case scenario. Planning for what—and who—you expect to be in the room when a crisis “could” occur is the first level of vigilance. Systems and teamwork which make certain those things actually are present—with some form of redundancy—provide a second level of safety and piece of mind.
The decision to rupture the membranes, without access to ultrasound monitoring in the delivery room, was questioned by experts who reviewed this case. The obstetrician had requested it, but the nurse was unable to locate the portable machine.
When it is unreasonable to supply an often used piece of equipment in every room, the clinicians who use that equipment need to work out a policy or protocol that assures it is available when needed. Nevertheless, such equipment has to be someone’s responsibility and have a “home” or it will simply end up where ever it was used last and will not be readily available when needed most.
The obstetrician in this case proceeded on a course for a second vaginal delivery without seeking or receiving advice from another clinician. In the eyes of the jury, that was not substandard practice, but a team approach might have led to a different decision when the repositioning attempts were not succeeding.
The major attribute of team training is communication between various health care professionals on a level playing field. Communication among colleagues is respected as motivated by a common goal rather than competition or hierarchy. Asking for help, and offering advice and assistance, are seen ask acts of team strength, not individual faults.
In a medical malpractice lawsuit, the jury is asked to determine of the physician’s actions were reasonable for that specialty and time. The jury in this case decided the obstetrician acted reasonably in continuing to attempt a vaginal delivery of the second twin.
It is hard to judge judgment. Physicians are expected, by the court at least, to behave as other reasonable physicians would: not like the best physician, but not like the worst. But while a jury might fulfill its obligation with a judgment of “reasonable” (i.e., average), medicine owes it to the patient population to strive for better. Only when preventable injuries no longer occur does anybody actually win.