Sunday, December 16, 2018

Case Summary:

The patient had uneventful prenatal care through the doctor, with an EDD of 12/21/95 by last menstrual period, and an EDD of 12/18/95 by an ultrasound on August '95. In December '96, she had an office visit, though the records are unclear. Her BP was taken and her doctor said it was elevated, and that she had swollen feet, though labs from the day before appeared normal, and the records seem to show normal BP, or at least BP consistent with readings during the pre-natal period. The doctor then determines that an induction is appropriate and sends her to the medical center for delivery. The patient gets there that night, and they start the induction process with gel, Pitocin and breaking of her water. As the labor proceeds, they start pushing. After a few hours of pushing, her vertex was at 0+1, so vacuum assisted vagina delivery was attempted and successful, but not without a shoulder dystocia. Once the shoulder dystocia was recognized, the doctor performed the McRoberts maneuver, followed by suprapubic pressure, followed by a repeated McRoberts maneuver, and then again with suprapubic pressure, at which point, she was able to successfully deliver the baby, but not without causing long term, permanent injury to the brachial plexus.

 

Questions/ Allegations:

The questions of concern are: (1) Whether the initial decision to induce labor was within the standard of care, or simply an appropriate choice made with the consent of the patient? (2) Whether the choices made during the induction itself were within the standard of care, or should a switch to C-section delivery been chosen?

 

Expert Findings

An AMFS Obstetrics- Gynecology expert reviewed this matter and provided the following opinion: The reason for induction seems kind of ambiguous here. The doctor claims that the patient had high blood pressure in the office, there was trace to 1+ protein in the urine, and there was edema in the lower extremities. However, when the patient reached the hospital her blood pressure was within normal limits. Her blood pressure remained within normal limits through most of her labor. She may have had transient elevations in blood pressure and this can happen due to the pain of labor. However most of her blood pressures were normal. She had some mild protein in the urine and some edema. This can happen in a normal pregnancy. I do not think this patient had pregnancy induced hypertension (the correct term at this time is gestational hypertension) at the time of delivery. Typically, if a patient has a high blood pressure reading it should be repeated a few times to confirm that it is in fact a high blood pressure and not just a transient elevation which it was in this case. So I do not really have an adequate reason for induction here as the readings were not clear. The patient was 2-3/50 and the head was high. A cervidil was placed to start the induction. This is indeed an induction and not an augmentation. If she was already contracting, then augmenting the labor would have been justified. However, the big problem here was the dystocia. Inducing this patient early did not cause the dystocia. Even if the patient could go into labor on her own the baby would have been a little bit bigger in utero and the dystocia would have still occurred. So there is not much of a reason to induce this patient early, but inducing her early did not cause the dystocia.

The negligence here was the use of the vacuum. This patient had a normal course of labor. This patient had an anterior lip which disappeared. So this patient was fully dilated at 1:40PM. The vacuum was placed at 1hr and 5 min after complete dilation. The reason for vacuum was maternal exhaustion. You may want to ask your client if she was truly exhausted or was this just written in the chart as a reason to use the vacuum. The fetal heart tracing had early decelerations which are not a pathological phenomenon, but a physiological phenomenon. The heart rate did go down to the 100's. So the defendant may say that the vacuum was used for a non-reassuring fetal heart tracing. However the main reason for negligence was the fact that this vacuum was placed when the head was at 0 to +1 station and this is clearly documented in the chart. Vacuums should not be placed unless the patient is at least 2+ station or more. In other words, it can be placed if the head is at 2+ to 3+ station. If there was an immediate need to deliver this patient and the head was at 0 to +1 station, then a cesarean section should have been done. I am not sure what the estimated weight of this baby was on prenatal sonogram but this was a fairly big baby and the weight was 4111g or 9lbs 1oz at the time of delivery. Again I will also say that it is not a deviation from the standard of care to deliver a baby that is this size. The cut off for a cesarean section in a nondiabetic pregnancy is 5000g. By putting on a vacuum at 0 to 1+ station you are forcing a head to come down when it is not coming down on its own. If the head is not coming down and the baby is a large sized baby then it is not a good idea to put on a vacuum. This was the patients first baby and she was not given an epidural. These patients are typically given two hours in the second stage of labor. This patient was given less than two hours for her second stage. Her second stage started when she was fully dilated at 1:40PM. She was delivered at 3:12PM. So another indication for vacuum placement is prolonged second stage of labor and this was not even a prolonged second stage. More than two it would be considered a prolonged second stage. Even then if the head is 0 to +1 station a vacuum delivery is contraindicated and a cesarean section is warranted. So in conclusion there were two things that were done wrong here. The induction was done without any reason. The second thing was a vacuum was placed at 0 to +1 station. Vacuum placement should not be done until the patient is at least 2+ station. If there was an immediate need to deliver her at 0 to +1 station then a cesarean section should have been done. The induction did not contribute to the dystocia. The fact that a vacuum assisted delivery was done (when it was contraindicated) and a cesarean section was not done (when it was indicated) is what resulted in the dystocia.