A 26-year-old woman presented in labor at full term with symptoms of fetal distress, and was delivered by emergency C-section; however, the baby sustained permanent neurological brain injury due to ischemic encephalopathy.
- Incomplete communication between clinicians regarding patient status can impair treatment decision-making.
- Early recognition of signs and symptoms of fetal distress, critical to fetal well being, require baseline measures to assess trends.
- Perception that a pregnancy is low-risk must not be allowed to diminish probing for risk assessments in the moment.
- Specific instructions to other clinicians and the patient help maintain a timely and appropriate response to worrisome signs.
A 26-year-old female, G3-P0-Tab2, with a full term uncomplicated pregnancy, experienced pain and leaking fluid. She was unsure if she was in labor, and called her obstetrician, who advised her to use a peripad, rest, and call back if the symptoms increased. About two hours later she went to the ED in severe pain. She was admitted to the Labor & Delivery unit at 8:15 p.m., presenting with leaking green/brown fluid.
The L&D nurse placed an electronic fetal monitor (EFM). The patient was 1-2cm dilated and 50 percent effaced. Per EFM, the fetus was showing heart rate decelerations to 90 and decreased beat-to-beat variability. Meconium was present on the patient’s peri-pad. The patient requested analgesics for pain, and the RN called the obstetrician. She advised him that the EFM strip looked good, and requested an order for Nubain IM for pain, which was administered shortly thereafter.
The obstetrician arrived at 9:20 p.m. Meconium was still present, and the EFM strip showed some decelerations and decreased variability. The obstetrician questioned if it might be due to either the Nubain or to the EFM picking up the maternal pulse. He decided to treat her conservatively with hydration and oxygen. The patient was 3cm dilated, and she received an epidural.
At 10:50 p.m., as the EFM showed late decelerations and decreased variability, the RN called the obstetrician to the patient’s room. The patient was now 5cm dilated. Fetal scalp PH tests were performed by the obstetrician, and results were abnormal at 7.15. The obstetrician determined the fetus was in distress, and ordered an emergency C-section.
An infant girl was born at 11:24 p.m., weighing 2940 grams, with Apgar scores of 1 at 1 min., 5 at 5 min. and 7 at 10 min. Her heart rate was less than 80, and she required vigorous resuscitation. Upon admission to the neonatal ICU, the baby’s hematocrit was noted to be only 12; the retic count was 12.3, and cord PH was 7.001. A Kleihauer-Betke test revealed significant feto-maternal bleed. The infant ultimately developed seizures and was diagnosed with hypoxic ischemic encephalopathy. She suffers neurological sequelae from CP, such as: right sided hemiparesis, cognitive difficulty and speech delays.
The parents sued the covering obstetrician and the nurse, alleging failure to appropriately assess fetal status and perform a C-section in a timely manner.
Following a negative arbitration finding for the defense, the case was settled for more than $1 million.
- The RN did not accurately communicate the maternal-fetal status to the obstetrician, affecting the physician’s treatment decisions and causing a delay in the diagnosis of fetal distress.
When the decision-maker is not with the patient, communication from the clinician on site becomes paramount for seeing the whole picture. Assessing the ability and experience of a junior clinician on the phone can help determine whether and when to examine the patient in person. Specific significant results, such as EFM tracings must be shared during the phone consult. An incomplete status report may lead the physician in charge to miss important clues necessary to understand what is needed next.
- Administration of an analgesic (Nubain) without a baseline EFM may have misled the obstetrician, who initially failed to recognize fetal distress, delaying performance of an emergent C-section.
New medications initiated at the hospital can complicate ongoing patient evaluation. Serial studies usually require baseline measures for comparison. Even with real-time status measures, such as EFM, a normal baseline can offer one more clue to what’s happening in the moment. A reassuring EFM pattern includes: a stable baseline with a normal HR, presence of accelerations, absence of decelerations, and moderate variability. A non-reassuring baseline gives the physician a potentially critical piece of information about the effects of a new drug and whether to attribute symptoms to something more threatening. Without specific instructions about when to call the physician, continued worrisome signs can unnecessarily increase the risk to the patient.
- The obstetrician initially told her to stay home during her first call.
Telephone assessments in a case that is perceived as “low-risk” present a risk of under-evaluation of what the patient is experiencing. Probing questions that a high-risk pregnancy requires may be important for any pregnancy. Also, instructions must be well understood and well communicated. Prenatal visits should include counseling regarding awareness of danger signs, as well as how to report/communicate those signs to the obstetrician (OB Guidelines/Guideline 4). A well explained process better aligns a patient’s understanding and expectations. Good documentation of all phone conversations that have taken place will result in better flow of information and ultimately better care of the patient.
- The patient believed that the nurse and the obstetrician failed to appropriately monitor her labor.
A clinician may be closely observing results outside the patient room. If the physician is not visibly present in the room, a patient can easily perceive a lack of proper monitoring. This misperception can be prevented with an early explanation to the patient about key monitoring procedures and time flow of information between the bedside nurse and the obstetrician.
Risk Management Perspective
- During the RN’s call to the obstetrician after her initial assessment of the patient, she did not communicate the abnormal EFM findings or the meconium-stained peri pad.
Care teams need to develop an understanding of what needs to be communicated during patient status reports over the telephone. In order to consider more urgent possibilities in the differential diagnosis, all providers must understand the value of their observations. Physicians and nurses can use mental or written checklists to make sure everyone knows about the presence of significant symptoms. Junior team members should receive routine encouragement to volunteer potentially important details for the overall clinical picture, and to resist being rushed by the person receiving the information.
Legal Defense Perspective
- A mock trial and focus group considered the facts before this case went to arbitration, where the judge found for the plaintiff. They faulted the nurse for failing to report abnormal EFM findings to the obstetrician. They also believed the physician deviated from the standard of care by failing to recognize and treat fetal distress in a timely manner.
Mock trials and focus groups test how a real jury might respond to the evidence. If they conclude that the defendants deviated from the standard of care, the defense team must decide if enough evidence exists to defend the case at trial. An alternative, decided by both sides, would be to put the case before arbitration instead. For the defense, the professional arbitrator holds the potential benefit of a more objective clinical analysis of the evidence than a lay jury might bring. The plaintiff may favor this less expensive, speedier process in certain cases as well.