Decreased Fetal Activity and Inaction Prior to Stillbirth

Description

A 40-year-old woman, G5, P3, who was admitted for premature rupture of membranes at 32 weeks reported decreased fetal activity hours before labor was induced, and a stillborn infant delivered.

Key Lessons

Concerns of decreased fetal movement need to be recognized and evaluated in a high -risk patient.
Cross monitoring and effective communication between clinical providers increase the likelihood for timely intervention.
Minimizing or dismissing patient concerns can weaken the physician-patient relationship and increase the likelihood of legal action following a catastrophic outcome.

Clinical Sequence

A 40-year-old obstetrical patient, G5 P3 (smoker), with a past medical history of bilateral tubal ligation, and pregnant via IVF, was admitted for premature rupture of membranes at 32 weeks. She was treated with antibiotics and IV steroids for fetal lung maturity. The biophysical profile was 6/8 (-2 for fluid volume) on admission. Fetal monitoring tapes show intermittent variable decelerations of the fetal heart rate (FHR) as low as 90-100 as well as a decrease in the baseline fetal heart rate from 140-150, down to 110-120. The patient complained of decreased fetal movement. A non-stress test (NST) was reactive and reassuring.

The next day, the mother again complained of decreased fetal movement. The nurse and resident told her not to worry, and advised her to eat her dinner to raise her blood glucose level and then do kick counts; FHR was 150 per Doppler. No monitor strip was done, nor was a NST performed. After dinner, the patient reported no fetal activity and staff notified the obstetrician, who confirmed no FHR. Labor was induced, and a stillborn infant was delivered with a nuchal cord x1. A small clot on the placental surface was noted, with possible abruption. Autopsy was consistent with placental bacterial infection as the possible cause of fetal demise, although there were no clinical signs of infection. The other strong possibility for the cause of death was the nuchal cord.

Allegation

The mother sued the attending, the fellow, the resident and all three nurses involved in her care while she was an inpatient, for failure to provide a timely intervention to rescue the fetus.

Disposition

A jury found the attending and one nurse negligent, without causation. The remaining four defendants were found not negligent.

Analysis

Clinical Perspective

When the patient complained of no fetal movement, the nurse told her to do her own kick counts and then returned two hours later.
In a high-risk patient, the doctor should be informed of decreased fetal activity. Nurses who have an independent responsibility for the patient need to understand when and how to activate the chain of command. This responsibility should be supported by training in an environment that enables them to do so.
Due to the ruptured membranes, the risk of cord compression was elevated.
Amniotic fluid acts as a cushion, and when it is lost the walls of the uterus can close in and compress the umbilical cord. Using a Doppler is not enough to fully evaluate maternal complaints of decreased fetal movements. Daily NST’s provide reassurance to both patient and clinicians. According to American College of Obstetricians and Gynecologists (ACOG) standards, this needs to be done whenever the mother reports a decrease in fetal movement. Fetal surveillance, including, but not limited to NST and BPP, help to identify fetal compromise and provide an opportunity to intervene prior to intrauterine fetal demise.

Patient Perspective

The patient believed that she should have been more closely monitored and possibly delivered, and that the decision not to do so resulted in fetal demise.
Failure to educate a patient on the progress of labor and delivery and discuss the concerns one has about the fetal status can leave the impression that the labor team is not serving her best interest. Patients need to know why doctors are resistant to deliver a baby due to risks associated with a premature delivery, such as immature fetal lung development. Blanket reassurances, followed by a catastrophic outcome, often lead to mistrust and a sense that the caregivers dismissed a patient’s legitimate concerns.

Risk Management Perspective

Communication between the providers and the patient was inadequate.
Patients need to understand their care plan and its clinical basis. Such conversations must be documented in the patient’s chart. Comfort is valuable, but discussion should never dismiss or minimize patient concerns.

Legal Defense Perspective

The plaintiff argued that clinical signs indicated the need for closer monitoring and that an earlier delivery would have rescued the baby, an argument that was not successful at trial despite findings of negligence.
Negligence is only one important element necessary for a finding that the defendant in a medical malpractice lawsuit is liable. The patient’s attorneys must also prove that the negligence caused the adverse outcome and that damages resulted. Even when a defense is successful at trial, malpractice litigation is an ordeal best prevented. Showing the patient that his or her concerns have been heard and taken seriously may help preserve the relationship and reduce the motivation to pursue a lawsuit after a tragic outcome. Documented communication with a patient about the care plan is vital to discouraging plaintiff attorneys from taking on expensive litigation.