A 38-year-old woman induced with cytotek delivered a stillborn baby following an emergency c-section.
This case involves a 38-y/o woman who was expecting her first child. At 41 weeks of gestation, she was induced with misoprostol. Five hours later, there was spontaneous rupture of membranes and the FHR was nl @ that time. Two hours later, there was a prolonged deceleration followed by recovery to the baseline. Five minutes later, there was another deceleration.
Thirty-five minutes following that, there was noted to be an unstable baseline. Twenty min. following that, the FHR was losing short term variability. For forty five minutes, there was no documentation in the progress note of any evaluation by a resident or attending physician.
Following a prolonged deceleration and bradycardia x 11 min., there was an unsuccessful attempt at forceps delivery followed. A cesarean delivery followed, and the baby was stillborn. There was a uterine rupture noted during the c-section. The mother required significant blood replacement.
The plaintiff alleged that a serious FHR pattern was either unrecognized, or if recognized, was misinterpreted. They stated that the FHR changes (loss of variability, decelerations and bradycardia) should have prompted members of the team to respond more aggressively.
This claim was settled in excess of $1 million.
To discuss the risk management implications of this case, Resource speaks with Dr. Ronald Marcus. Dr. Marcus is medical director of Obstetrical Services, Beth Israel Deaconess Medical Center.
Dr. Marcus, in a teaching hospital, where residents, anesthesiologist and nurses are always in attendance, who is responsible for management of the patients labor?
In this case, if a non- reassuring FHR is noted by the nurse and brought to the attention of a resident, that is typically the next step.
Dr. Marcus, you have conducted analyses of closed malpractice cases, looking for teamwork failures, and this case may contain issues that apply not only to obstetrics. What can you say about this case?
This is a case in which a number of providers were involved in the care of the patient. There is the primary nurse and residents both in anesthesiology and obstetrics as well as the attending physicians, and initially there appeared to be a lack of communication or miscommunication between the various providers. What started off as a relatively minor procedure, shall we say, escalated pretty quickly into a major problem with dire consequences for the baby and the mother as well. Had these communications taken place between the providers and had intervention been sooner, these problems might well have been obviated. In a teaching hospital, for example, you get the primary nurse looking after the patients, the resident anesthesiologists, the resident obstetricians, the attending physicians in all the specialties, and there has to be adequate communication between these providers in order for there to be a good outcome or rather to prevent a poor outcome, and therefore, teamwork, if it becomes the culture, if it is a culture in a particular setting, it can obviate these problems.
It’s always easy in hindsight to say that, in this case a non-reassuring pattern was not attended to promptly and that resulted in a poor outcome, but in looking at this case what would you suggest to an obstetrical team of clinicians that might have mitigated the outcome here?
One of the important things about teamwork is effective communications between the various providers and also what is known as cross-monitoring of clinical decisions so that a given provider who makes a decision, this decision can be monitored by other people to make sure that (A) the decision is correct or (B) the important information is not missed and that it has not been passed to other members of the team. During the time, for example, when there was a non-reassuring fetal heart rate pattern, this could have been diagnosed earlier, management of this particular pattern might have been affected earlier and instead of there being a sudden rush when the fetal xxxx cardio developed and a emergent situation with dire consequences, it might well have been easier to manage the case much earlier on before the pattern reached this terminal phase. In this situation a non-reassuring fetal heart pattern is noted by the nurse and brought to the attention of the resident. What’s typically the next step?
Well, first of all, there’s the clinical management of the non-reassuring fetal heart rate pattern: the changing position of the mother, the giving her of oxygen, maybe the increasing amount of fluids, but what is equally important in a broader sense is that this non-reassuring fetal heart rate pattern is communicated to everyone in labor and delivery for whom this becomes an important issue. That is to say that the resource nurse should know about it so that her staffing pattern may be altered or can be altered to accommodate a potentially emergency situation; the anesthesiology department should obviously be aware that their services may be required in a moment’s notice to treat the situation; the neonatologist should understand that there’s a non-reassuring fetal heart rate pattern and their services may be required to resuscitate a depressed infant. In certain hospitals where these staff are not necessarily present on the premises 24 hours a day, the team should be assembled so that when before the situation becomes emergent, so that immediate delivery be necessary, everyone is ready to handle the situation.
What are your recommendations for nursing staff or residents if they’re not receiving sufficient response from nursing leadership or their supervising physician?
Well, this is basically the conflict resolution, and every institution should have a conflict resolution tree whereby people…providers feel comfortable in order…if it is a conflict, that this may be taken up to the next level. This is very important not only from a teaching point of view where people can learn from their supervising providers, but also from a comfort point of view that people know that should they feel uncomfortable that this conflict resolution tree is in place and that they’re not going to be rejected in their feelings. What is very important is that these conflicts do not take place in front of the patient or equally important, if not more important, in the charts. These should be…this process should be evolved beforehand so that should the conflicts arise they can be resolved in the appropriate manner in the appropriate place.
