Fatal Team Failure to Widen the Diagnostic Focus for OB Patient

The following case study is based on closed malpractice claims in the Harvard medical system. Some details have been changed to mask identities.

A 26-year-old patient in her third trimester, at 41 weeks, with a high body mass index (BMI) was admitted to Labor & Delivery, dilated 3 centimeters (cm) with complaints of a sore throat. Her prenatal history included a positive Group B Strep test. The initial external FHR, fetal heart rate tracing, was Category 1. The nurse noted that the FHR recording was complicated by the patient’s elevated Body Mass Index.

Twelve hours later, the patient’s temperature was 100.5°. Ampicillin was administered, and the nurse midwife consulted with the on call obstetrician (OB) via telephone regarding a potential viral syndrome. The patient was not examined by the OB.

Six hours after that, the patient had progressed to 4 cm and Oxytocin was administered. Her temperature remained at 100.5° and she was given anti-flu medication. 

Forty-one hours after her admission, the patient was fully dilated at 10 cm. Meconium-stained fluid was noted, and the FHR tracing was now Category 2 with decelerations. An hour and a half later, chorioamnionitis was diagnosed and treated with antibiotics.

A baby girl was delivered vaginally with Apgars of 1/3/5, and she died shortly after birth. Her cultures were negative; autopsy confirmed hypoxic ischemic encephalopathy. The patient sued the care team, including the midwife, the OB, and the nurse, alleging that a delay in the treatment of fetal distress and improper management of the patient’s labor led to her baby’s death.

Expert review on the case concluded that a more aggressive response to non-reassuring FHR tracings, such as a 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.

To discuss the risk management and patient safety implications of this case, we are joined now by Dr. Thomas Beatty. Dr. Beatty is Chair of the Department of Gynecology and Obstetrics at Newton Wellesley Hospital, and Associate Medical Director for Obstetrics and Gynecology at CRICO.

CRICO: Dr. Beatty, thank you for joining us.

Thomas Beatty MD: Thank you very much for having me.

CRICO: We can talk about the quality of the consultation in a minute. We can set that aside for a moment and talk more about what is going on with the patient and mother. What was the status, what were the indications the baby and mother were in serious trouble? It seems like the initial discussion was limited to concerns about a viral syndrome.

Thomas Beatty MD: So, I think let’s start and set the stage with this is a patient who’s coming in at 41 weeks, so one week past her due date. Whose care is complicated by her morbid obesity or very high body mass index. That can often make caring for the patient more challenging and require a heightened level of surveillance during labor. Additionally, she was known to be group B strep positive, and therefore require antibiotic prophylaxis during pregnancy. And then the complicating factor that she came in with a sore throat. And as we know, during respiratory season, many patients come in with congestion, sore throat, or cough. That needs to be taken into account, but taken into account within the context of the patient’s overall condition and progress during labor and delivery.

CRICO: When you think about this case in particular, are there features of this that made it sort of unusual, or unusually difficult, or is this kind of what is always happening, or what you should always expect?

Thomas Beatty MD: No, I think there are some features. I think first, when we care for patients with a very high BMI, their care can often be more challenging in terms of assuring that we have the appropriate equipment to take care of them, and often in terms of being able to effectively and continuously monitor the fetus during labor when it’s appropriate. When, for example, this patient had oxytocin start during labor, we know it’s critical to continuously evaluate the fetus. But that means assuring that we have a continuous interpretable fetal monitor trace. That’s more challenging for someone with the high BMI, and at times will require moving from external fetal monitoring to internal fetal monitoring using a scalp electrode.

I think the other factor is that the patient came in with a fever. We know that fever in labor is defined as 100.4 or higher, so she came in, had a fever and still had the same fever 6 hours later. During respiratory season, as I said, patients will come in with upper respiratory symptoms and may have a low-grade fever, but anytime we have a patient with a fever and labor, it’s incumbent upon us to broaden the diagnosis, to think about amniotic infection or chorioamnionitis as a possibility, and to evaluate that. Evaluate in terms of evaluating the mother’s heart rate, the fetal heart rate, the white blood cell count, and to have a heightened index of suspicion that the fever could be more than just the upper respiratory tract infections. Patients, in fact, can have both, especially during respiratory season.

CRICO: What’s the best way to think about these kinds of consults and relationships? Are there certain rules of thumb that help ensure that they’re timely and that they’re thorough?

Thomas Beatty MD: Well, all clinicians are encouraged to seek additional medical advice whenever they have concerns about a diagnosis or a course of treatment, or when the expertise or comfort level of the attendant clinician is exceeded. So calling a consult is certainly encouraged and appropriate. It’s important for both parties to understand that a consultation, whether it’s in person or remote, in this case by phone, is still a formal consultation. And that a consultant might be contacted about a specific question in the patient’s care, but it’s essential for the consultant to have enough context and information about the patient’s overall condition to give an appropriate opinion regarding the patient’s ongoing care.

CRICO: The issues of reassessment and care plan adjustments in real time seem ripe for extra training or even simulation. Do you agree with that?

Thomas Beatty MD: Yes, I do. So we know that labor will unfold over hours, and that during that time, there are often handoffs from one team to another, and as well as other competing interests that can occupy a clinician’s time. For example, other patients are being cared for and leave. So it’s very important to have the situational awareness about the patient’s progress and the patient’s lack of progress during labor. And when there are handoffs, to be certain that the adequate information, comprehensive information, is being given to the clinician who will assume responsibility for the patient. And those are activities that we can all practice in drills and in simulation. Unlike acute event simulations, like a shoulder dystocia or a postpartum hemorrhage that most often take place in a finite and relatively short period of time, this type of labor course can be a little more challenging to simulate. But it is feasible and important for us to simulate.

CRICO: Well, thank you, Dr. Beatty, for a great discussion about some important patient safety risk issues in OB. Dr. Thomas Beatty is Chair of the Department of Gynecology and Obstetrics at Newton Wellesley Hospital, and Associate Medical Director for Obstetrics and Gynecology at CRICO.
I’m Tom Augello, for MedMal Insider.

This has been a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.