A 38-year-old woman induced with cytotek delivered a stillborn baby following an emergency cesarean section.

Key Lessons

  • Critical information has to be available to all members of the care team.
  • An established conflict resolution process serves to keep critical patient information flowing.
  • Contemporaneous documentation is necessary for maintaining patient safety.

Clinical Sequence

In the 41st week of her first pregnancy, a 38-year-old woman arrived at Labor and Delivery at 6:30 a.m. for a planned induction of labor due to mild, pregnancy-induced, hypertension.

6:45 a.m.

After intra-vaginal placement of misoprostol, the nurse observed her briefly and, at 11:00 a.m., discharged her from the unit. She went for a walk with her husband in a park next to the hospital.


Patient's membranes spontaneously ruptured and she returned to the labor and delivery unit. A recently hired, new graduate, nurse admitted the patient, took her vital signs, and checked the fetal heart rate. The mother's blood pressure was 176/95 but the nurse thought this was related to nausea, vomiting, and discomfort from the contractions.

12:10 p.m.

The resident examined the mother, determined that her cervix was 5-6 cm, 90 percent effaced and the vertex was at 0 station. An internal fetal heart monitor was placed because The mother's vomiting and discomfort caused her to move around too much in the bed, making it hard to record the fetal heart rate with an external monitor. The internal monitor revealed a steady fetal heart rate of 120 and no decelerations.

2:05 p.m.

The mother continued to complain of painful contractions and requested an epidural. Shortly after placement of the epidural, the monitor recorded a prolonged fetal heart rate deceleration. The heart rate returned slowly to the baseline rate of 120 as the nurse repositioned the mother, increased her intravenous fluids and administered oxygen by mask.

2:15 p.m.

An epidural analgesia infusion pump was started. The fetal heart rate strip indicated another deceleration that recovered to baseline. The nurse informed the resident who checked the tracing and told her to "keep an eye on things."

2:45 p.m.

The primary nurse noted in the labor record that the baseline fetal heart rate was "unstable, between 100-120" but she did not report this to the resident.

3:05 p.m.

The nurse recorded that the fetal heart rate was "flat, no variability." As the nurse was documenting this as a non-reassuring fetal heart rate pattern, the patient expressed a strong urge to push and the nurse called for an exam.

3:20 p.m.

A resident came to the bedside, examined the mother and noted that she was fully dilated with the caput at +1. A brief update was written in the chart, but the clinician who had performed the exam was not noted.

3:30 p.m.

The mother was repositioned and began pushing.

4:05 p.m.

The fetal heart rate suddenly dropped and remained profoundly bradycardic for 11 minutes. The resident was called and attempted a vacuum delivery since the fetal head was at +2 station, The attending then entered and attempted forceps delivery.

4:35 p.m.

An emergency cesarean delivery was performed; the baby was stillborn. The physician identified a uterine rupture that required significant blood replacement.


In a claim filed against two attendings, two obstetrics residents, and the primary nurse, the plaintiffs alleged that a serious fetal heart rate pattern was either unrecognized or misinterpreted. They further alleged that the FHR changes (loss of variability, decelerations and bradycardia) should have prompted members of the team to respond more aggressively.


The case was settled for more than $1 million against the attending.


Clinical Perspective

  1. Junior members of the mother's care team, in this case a nurse and physician, shied away from voicing their concerns or challenging decisions made by more senior clinicians. Quite possibly, the delays in performing a cesarean-section were related to their inability to convey their concerns.

    All members of the care team should be encouraged to speak up if they disagree with a management plan or they're seriously concerned about their patient's care. When there's disagreement with a management decision then there should be a clearly defined way of resolving the conflict. Every institution should have a conflict resolution tree to help all providers feel comfortable in taking a concern up to the next level. This is important from a teaching point of view-creating a system that allows providers to learn from each other; and from a comfort point of view-reassuring every member of the care team they're not going to be rejected or alienated for expressing their disagreement with a management plan.

Patient Perspective

  1. At least six individuals were involved my care over the nine hours following induction. Two attendings, two residents, my primary nurse, and one or two other nurses. I would expect that, with all those doctors and nurses watching out for me and my baby, the fact that we were both in trouble would have been recognized and addressed. Why didn't everybody know what was happening to me?

    Achieving a good clinical outcome requires effective communication, and coordination among all the caregivers involved, with adequate documentation of the management plan. A bad outcome is often the result of one or more missteps in having the right information shared with the right individuals at the right time. The communication culture in a given care setting often influence how patient safety risks are identified and resolved. When everyone involved-even the newest nurse on the night shift-shares a common set of behaviors and routinely brief, share and review clinical information in a timely fashion, then there are greater opportunities to ensure safe patient care.

Risk Management Perspective

  1. Although the care team-nurse, resident and attending, responded to the fetal bradycardia, there was no indication that other resources were promptly alerted to the emerging crisis.

    The impact of certain clinical events or information often extends beyond the obvious problem. A situation that demands greater monitoring may impact staffing, thus the resource nurse should know about it. The potential for emergency surgery, anesthesia, and neonatal care should be known to those who need to be prepared, before the situation is in crisis mode. Experienced and cooperative clinicians can decide what to do with the patient information they receive; obviously they cannot make optimal decisions when they lack critical details.When conflicts arise then be sure to move the discussion away from the patient and family members. Equally important is to clearly document maternal-fetal health status and keep the conflict-emotions and feelings of the providers involved out of the patient's chart.

Legal Defense Perspective

  1. The fact that the fetus had a "non-reassuring" heart rate pattern was not shared among team members and the situation was not promptly addressed. The record mentions no efforts-e.g., changing the mother's position, giving her of oxygen, increasing her fluids-made in response to subsequent fetal decelerations and bradycardias. When the situation eventually became critical, the care team was insufficiently prepared.

    The defense of care provided during a crisis benefits from evidence (i.e., documentation) that the providers a) were prepared for contingencies, and b) followed an established protocol once things heated up. The absence of such evidence leaves patients (and if they pursue a malpractice lawsuit, jurors) to conclude otherwise.

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