Should Pregnancy Have Been Considered High Risk?

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A pregnant woman received prenatal care from nurse-midwives and family practice physicians at a federally funded community health center in Wisconsin. On the day of delivery, according to the patient, the nurse-midwives covering deliveries failed to come to the hospital to evaluate her.

A nurse-midwife arrived about 40 minutes before the woman’s delivery and had difficulty delivering the infant because of shoulder dystocia. A second nurse-midwife arrived and performed maneuvers to facilitate delivery. The infant sustained severe brain damage.

At a trial conducted on the issue of damages only, the plaintiff claimed her pregnancy was high risk due to her previous history of delivering two large infants, her advanced age, and symptoms of gestational diabetes. The plaintiff maintained that she should have been given a referral to an obstetrician/gynecologist and/or a perinatologist.

Continue for the outcome and David Lang's comments >>

OUTCOME
The judge awarded about $20 million to the plaintiff. According to a published report, a posttrial settlement of $18.2 million was reached.

COMMENT
We are not told any specifics regarding the patient’s age or prior deliveries or her specific prenatal screening to determine whether the fetus was large for gestational age—and if so, to what degree; or the birth weight, or maternal factors that may have been suggestive of cephalopelvic disproportion. We are also not told about the fetal presentation or given results of fetal heart monitoring.

Fetal macrosomia (an estimated fetal weight of ≥ 4,500 g) has been correlated with shoulder dystocia, as has gestational diabetes. If there was evidence of malpresentation combined with macrosomia and/or small pelvic outlet, it is likely that the standard of care would have required a cesarean delivery to avoid an unreasonable risk to the mother and fetus.

While shoulder dystocia can be unexpected and unavoidable, the clinician must have a plan to address it—and be well versed in the plan. This should include immediately recognizing the condition as an emergency, summoning help, and initiating appropriate maneuvers. Practice drills can help clinicians rehearse the plan before an emergency arises.

In this case, liability was not contested—which is tantamount to an admission of liability. The plaintiff likely had overwhelming evidence that the history of gestational diabetes and maternal screening made vaginal delivery unreasonably risky in this specific case. In short, ­obstetrical/midwifery practice carries an inherent high risk for litigation: Screen adequately for likely complications, consider the appropriate use of cesarean delivery for high-risk patients, know your positions and maneuvers, and maintain a plan for performing them. —DML

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A pregnant woman received prenatal care from nurse-midwives and family practice physicians at a federally funded community health center in Wisconsin. On the day of delivery, according to the patient, the nurse-midwives covering deliveries failed to come to the hospital to evaluate her.

A nurse-midwife arrived about 40 minutes before the woman’s delivery and had difficulty delivering the infant because of shoulder dystocia. A second nurse-midwife arrived and performed maneuvers to facilitate delivery. The infant sustained severe brain damage.

At a trial conducted on the issue of damages only, the plaintiff claimed her pregnancy was high risk due to her previous history of delivering two large infants, her advanced age, and symptoms of gestational diabetes. The plaintiff maintained that she should have been given a referral to an obstetrician/gynecologist and/or a perinatologist.

Continue for the outcome and David Lang's comments >>

OUTCOME
The judge awarded about $20 million to the plaintiff. According to a published report, a posttrial settlement of $18.2 million was reached.

COMMENT
We are not told any specifics regarding the patient’s age or prior deliveries or her specific prenatal screening to determine whether the fetus was large for gestational age—and if so, to what degree; or the birth weight, or maternal factors that may have been suggestive of cephalopelvic disproportion. We are also not told about the fetal presentation or given results of fetal heart monitoring.

Fetal macrosomia (an estimated fetal weight of ≥ 4,500 g) has been correlated with shoulder dystocia, as has gestational diabetes. If there was evidence of malpresentation combined with macrosomia and/or small pelvic outlet, it is likely that the standard of care would have required a cesarean delivery to avoid an unreasonable risk to the mother and fetus.

While shoulder dystocia can be unexpected and unavoidable, the clinician must have a plan to address it—and be well versed in the plan. This should include immediately recognizing the condition as an emergency, summoning help, and initiating appropriate maneuvers. Practice drills can help clinicians rehearse the plan before an emergency arises.

In this case, liability was not contested—which is tantamount to an admission of liability. The plaintiff likely had overwhelming evidence that the history of gestational diabetes and maternal screening made vaginal delivery unreasonably risky in this specific case. In short, ­obstetrical/midwifery practice carries an inherent high risk for litigation: Screen adequately for likely complications, consider the appropriate use of cesarean delivery for high-risk patients, know your positions and maneuvers, and maintain a plan for performing them. —DML

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A pregnant woman received prenatal care from nurse-midwives and family practice physicians at a federally funded community health center in Wisconsin. On the day of delivery, according to the patient, the nurse-midwives covering deliveries failed to come to the hospital to evaluate her.

A nurse-midwife arrived about 40 minutes before the woman’s delivery and had difficulty delivering the infant because of shoulder dystocia. A second nurse-midwife arrived and performed maneuvers to facilitate delivery. The infant sustained severe brain damage.

At a trial conducted on the issue of damages only, the plaintiff claimed her pregnancy was high risk due to her previous history of delivering two large infants, her advanced age, and symptoms of gestational diabetes. The plaintiff maintained that she should have been given a referral to an obstetrician/gynecologist and/or a perinatologist.

Continue for the outcome and David Lang's comments >>

OUTCOME
The judge awarded about $20 million to the plaintiff. According to a published report, a posttrial settlement of $18.2 million was reached.

COMMENT
We are not told any specifics regarding the patient’s age or prior deliveries or her specific prenatal screening to determine whether the fetus was large for gestational age—and if so, to what degree; or the birth weight, or maternal factors that may have been suggestive of cephalopelvic disproportion. We are also not told about the fetal presentation or given results of fetal heart monitoring.

Fetal macrosomia (an estimated fetal weight of ≥ 4,500 g) has been correlated with shoulder dystocia, as has gestational diabetes. If there was evidence of malpresentation combined with macrosomia and/or small pelvic outlet, it is likely that the standard of care would have required a cesarean delivery to avoid an unreasonable risk to the mother and fetus.

While shoulder dystocia can be unexpected and unavoidable, the clinician must have a plan to address it—and be well versed in the plan. This should include immediately recognizing the condition as an emergency, summoning help, and initiating appropriate maneuvers. Practice drills can help clinicians rehearse the plan before an emergency arises.

In this case, liability was not contested—which is tantamount to an admission of liability. The plaintiff likely had overwhelming evidence that the history of gestational diabetes and maternal screening made vaginal delivery unreasonably risky in this specific case. In short, ­obstetrical/midwifery practice carries an inherent high risk for litigation: Screen adequately for likely complications, consider the appropriate use of cesarean delivery for high-risk patients, know your positions and maneuvers, and maintain a plan for performing them. —DML