Case Study
Sent Home Twice Before Birth of Compromised Baby
Key Lessons
- Early recognition of signs and symptoms of fetal distress require appropriate intervention.
- Engaging the chain of command without hesitation in difficult situations can lead to less error and earlier, more effective intervention.
- Use of clinical guidelines, including CRICO Obstetrical Guidelines can aid the decision making process.
Description
A 21-year-old obstetrical patient at term was sent home twice by L&D during a 10-hour period after spontaneous rupture of membranes, before presenting a third time in active labor; the baby had APGAR scores of 1, 3, underwent a 25-minute resuscitation, and later developed profound neurological deficits.
Allegation
The patient’s parents sued the nurse midwife, the L&D RNs, and the responding pediatricians, alleging that mismanagement of labor and delivery and the aftermath led to profound neurologic defects of the baby.
Clinical Sequence
A 21-year-old female, G1 P0, had been being followed at a community hospital for an unremarkable prenatal course. At 39 weeks gestation, she spontaneously ruptured membranes at 7:45 a.m. and presented to the emergency department about an hour later. She was transferred to Labor and Delivery for evaluation and was seen by the nurse midwife on-call. The patient was deemed to not be in labor, and fetal well-being was thought to be assured. She was sent home at 9:45 a.m., having been advised to return when her contractions were closer together.
At about 11:30 a.m., the patient returned to Labor and Delivery with her husband, where she was re-evaluated by the same obstetrical provider. The patient’s cervix was 1 cm dilated, 90% effaced, and the fetal head at -1 station. The fetal heart was monitored via electronic fetal heart monitor (EFM) for 13 minutes; the nurse midwife deemed the fetal heart rate pattern as unremarkable, gave the patient Benadryl, and sent her home, instructing her to return if her contractions did not increase by 7:00 p.m.
The patient returned by wheelchair to L&D at 6:45 p.m., grunting and bearing down. Her cervix was 9 cm dilated, 100% effaced and fetal head at +1 station. EFM revealed a fetal heart tracing with marked variability in the baseline heart rate, fluctuating between 120-180, and notable for repeated decelerations to 90 bpm. The patient labored for about two more hours before delivery occurred, during which time there were persistent, recurrent deep variable decelerations to 80-90bpm. The nurse midwife delivered a baby boy at 9:01 p.m. with Apgars of 1 at one minute and 3 at five minutes.
The baby initially appeared floppy and had an umbilical artery cord blood gas pH of 6.74. Resuscitation by the on call pediatrician was successful after 20 minutes and the baby had his first spontaneous movement at 30 minutes of life. The baby was then transferred to a tertiary care facility where he experienced seizure activity. A brain MRI confirmed findings consistent with hypoxic-ischemic encephalopathy., The baby developed additional symptoms of profound, permanent neurological deficits, including blindness and a severe seizure disorder.
Analysis
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Clinical Perspective
- When the patient returned the second time, electronic fetal monitoring was performed for 13 minutes before the patient was sent home again.
Care standards suggest that the minimum time frame required to monitor the fetal heart rate and assess for fetal well-being is 20 minutes. Hospital policies should address minimum monitoring times and the need for evaluation by an obstetrician following rupture of membranes.
- When the patient was finally admitted to Labor and Delivery, the fetal heart rate tracing was notable for repeated decelerations to 90bpm. No other steps were taken to assess fetal status and the patient was allowed to labor for more than two hours with a persistently abnormal fetal heart rate tracing.
Timely recognition of an abnormal fetal heart rate pattern is critical to providing optimal L&D care. When an abnormal pattern with persistent, recurrent, deep variable decelerations occurs, an obstetrical consult is appropriate to take measured steps that assure fetal well-being and delivery of the baby as expeditiously as needed.
Risk Management Perspective
- The nurses responding to serious developments may have been uncomfortable with the decisions by the clinician in charge and hesitant to initiate the chain of command and call for assistance.
Obstetrical nurses have an independent responsibility for the patient, and need to understand when and how to activate the chain of command. This responsibility must be supported by an environment that enables them to do so when: there is a significant change in the FHR baseline; the midwife or physician fails to provide care in accordance with the accepted standard; the nurse disagrees with midwife or the physician’s interpretation of the fetal heart pattern; or the nurse has concerns about the treatment planned by the midwife or physician. Once the nurse activates the chain of command, failure to continue up the chain until the issue of concern is appropriately resolved jeopardizes the patient's safety and adds to the clinical team's liability.
Legal Defense Perspective
- After delivery, the EFM tracings were lost and never found, removing a key aid for defense experts who could not defend the midwife’s decisions.
Legal requirements for maintaining electronic fetal monitoring strips vary by jurisdiction. In Massachusetts, Department of Public Health-licensed facilities are required to keep a record of electronic fetal monitor tracings for at least five years (CRICO/RMF recommends 30 years). The tracings should include the patient’s name and hospital number; date and time at the beginning of the tracing; and date and time of delivery. EFM tracings need not be stored with the medical record, but should be readily retrievable, whether stored electronically or in hard copy/paper files. Documentation in the medical records of relevant information contained in EFM tracings is helpful; however defense experts may find it impossible to support a delivering caregiver without having the tracings for their expert review and evaluation.
- When the patient returned the second time, electronic fetal monitoring was performed for 13 minutes before the patient was sent home again.
Disposition
This case was settled against the nurse midwife for more than $1 million.
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