A 33-year-old woman G 7 P5 with a history of chronic hypertension, asthma and gestational diabetes presented in labor at term and underwent an emergency cesarean delivery, resulting in an infant with hypoxic-ischemic encephalopathy who died four days after delivery.
- Early recognition and evaluation of persistently non-reassuring fetal heart rate patterns can facilitate early intervention and timely resolution of fetal acidemia.
- Effective communication between clinical providers, including early recognition and resolution of clinical discord, can help optimize birth outcomes.
- Briefing, cross monitoring, and lowering the threshold in seeking another opinion facilitate situation awareness, increasing the likelihood for timely recognition and treatment of deteriorating fetal status.
A 33-year-old woman, G7 P5 with a high BMI of 40.5, a history of asthma, gestational diabetes and chronic hypertension controlled with 50 mg of atenolol, was admitted in active labor at term. The midwife examined her and found her fetus in transverse lie and her cervix dilated to 5cm and 100 percent effaced. The fetal heart rate tracing was reassuring, with a baseline of 130 bpm, moderate variability, some accelerations and no decelerations. The obstetrician on-call performed an ultrasound and confirmed fetal transverse lie, with back down. The obstetrician discussed the option of proceeding with a cesarean delivery versus attempting an external cephalic version followed by a vaginal delivery. The patient agreed to external version, but if not successful to proceed with a cesarean delivery and post partum tubal ligation.
Surgical consent was obtained. An epidural was placed after several attempts, and post-epidural ultrasound showed the fetus was now vertex but not engaged in the pelvis. The fetal heart was bradycardic and controlled artificial rupture of the membranes was performed in the operating room, yielding clear fluid. Fetal bradycardia of 70 bpm was confirmed, lasting about 5 minutes before spontaneous recovery to a rate of 110-120. The cervix was 5-6 centimeters dilated and 80 percent effaced. A fetal scalp electrode was applied after several unsuccessful attempts, and variable decelerations were seen. The fetal heart rate accelerated in response to scalp stimulation but variable decelerations persisted.
The patient was moved from the operating room back to the labor room and within the hour her cervix was 6-7 cm and fetal vertex at -3 station. A cesarean section was called because of fetal bradycardia of 70 bpm, but then cancelled as the fetal heart rate recovered. A fetal scalp ph was attempted, but failed. The patient repeatedly asked the OB if everything was ok and the OB repeatedly said, "he's ok, he'll be fine."
Over the next two hours, minimal variability and recurrent variable decelerations were noted, with the baseline rising to 180 bpm. A cesarean section was called again for fetal bradycardia of 70 bpm but again cancelled as the fetal heart rate recovered. Deep variable decelerations persisted, with a baseline of 180 bpm and absent variability.
The obstetrician involved in this case had less than 5 years post-residency experience and demonstrated indecision and frequent change in the plan of care for managing the patient's labor and delivery. The nurse was initially reluctant to express her concerns to the obstetrician or her charge nurse. After several hours of a non-reassuring fetal heart rate tracing, the nurse notified the charge nurse and the charge nurse spoke to the obstetrician but the clinical discord was not resolved, and no further action was taken.
The patient became fully dilated, and a fetal scalp ph of 6.9 was obtained. She was taken to the operating room and had a spontaneous vaginal delivery of a liveborn male infant with a tight, double nuchal cord. The pediatric team arrived to resuscitate a limp, cyanotic baby. APGARS were 1 at 1min., 3 at 5min. and 5 at 10min., and the initial cord ph was 6.8. The infant was transferred to the intensive care unit and developed disseminated intravascular coagulation, acute renal failure and seizures. Hypoxic-ischemic encephalopathy was diagnosed; life support was withdrawn; and the infant died on day four of life.
The patient sued the covering obstetrician and two labor and delivery nurses, alleging delay in diagnosis and treatment of fetal distress.
Following an unsuccessful Tribunal finding, the case was settled in the high range (>$500,000-$999,999)
- The physician did not recognize the ominous fetal heart pattern and the need to intervene and deliver the fetus. Although he was initially reassured by the fetal response to scalp stimulation and had attempted a scalp ph when the pattern became non-reassuring, no further attempts were made to assess fetal status during more than two hours of persistent deep variable decelerations with minimal to absent variability.
The ACOG Practice Bulletin, number 62, December 2005, Intrapartum Fetal Heart Rate Monitoring, Table I defines various fetal heart rate patterns. The Bulletin identifies findings on EFM that reassure fetal status, including the "…presence of accelerations generally ensures the fetus is not acidemic and provides reassurance…." and "…in most cases, normal fetal heart rate variability provides reassurance..." Even though it is unrealistic to expect that a non-reassuring fetal heart rate tracing is predictive of cerebral palsy, "a persistently non-reassuring fetal heart rate requires evaluation of possible causes". Upon evaluation, a management plan should be determined and discussed with the patient and the obstetric team, and documented in the medical record.
- The nurse caring for the patient was concerned about the obstetrician's clinical management and spoke with the charge nurse, but the clinical discord was not resolved.
Timely discussion about differences in clinical opinion may affect perinatal outcomes. After initial discussion, if the involved parties cannot resolve the discord, then assistance should be sought through the appropriate supervisory physician and nursing hierarchy, rising to the Chief of Obstetrics, the Nurse-Midwifery Director and the Obstetrical Nursing Director as indicated.
Inadequate communication among providers regarding the plan of care for a patient is a common path for substandard care. Teams in which providers do not trust each other—and thus, do not communicate well—decrease each individual provider's ability to work effectively. In a well functioning team, individuals are better able to anticipate the needs of the others, including the patient. Although physicians need to respond to the circumstances as they present themselves, those faced with situations unfamiliar or worrisome need to consult with others who are more experienced or knowledgeable, or may provide a fresh perspective.
Obstetrical nurses have an independent responsibility for the patient and need to understand when and how to activate the chain of command. This responsibility should be supported by an environment that enables them to do so when:
- there is a significant change in the FHR baseline,
- the attending obstetrician fails to provide care in accordance with the accepted standard,
- the nurse disagrees with the attending obstetrician's interpretation of the fetal heart monitor, or
- the attending obstetrician prepares an inadequate treatment plan.
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 the clinical team's liability.
- The patient believed that the obstetrician was indecisive and not trustworthy because he changed his mind twice about doing a C-section and, in light of the outcome, his blanket reassurances seemed false.
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 physician is incompetent and cannot be trusted. It can also contribute to a patient's perception that the physician is covering up mistakes. Clinical management may change at a moment's notice depending on clinical circumstances but the patient should be apprised of the need for the change, and this should be documented in the medical record. Care should be taken to show patients that their concerns are being considered, and any efforts to reassure the patient should not patronize or appear to dismiss what the patient is saying.
Risk Management Perspective
- The patient observed the discordant relationship between members of her care team, and the apparent lack of trust the nurse had in the obstetrician's management.
In situations with clinical discord, the parties should first discuss their differences of opinion among themselves, and out of earshot of the patient. Differences in clinical observations and opinions should be documented in an objective, non-argumentative fashion in the medical record. If the discord is not resolved then the chain of command should be invoked, rising to the highest level as indicated, while maintaining the highest degree of professionalism among all members of the care team. Priority must be given to maintaining safe, quality patient care at all times.
Legal Defense Perspective
- Discord among the clinicians, along with some worrisome heart rate tracings, and an autopsy that found hypoxic-ischemic encephalopathy, provided strong support for the plaintiff's allegations.
Expert reviewers look for opportunities for the defendant to have intervened and caused a better outcome. Clinical discord about a physician's clinical judgment and care management can underscore the likelihood that the standard of care was not met, and influence a decision to settle the case.
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