Managing Your Practice

A lot of things have changed in my office in the 24 years I've been practicing medicine, but nothing quite so much as the way I look for information.

Finding the latest articles on a rarely encountered disease used to entail a search through multiple textbooks, shelf after shelf of old journals, perhaps the hospital library, or even the med school library across town. It was tedious and time consuming, and all too often a hit-or-miss affair.

No longer. Nowadays I can find all the medical data I need—or indeed, any category of information at all—in a few minutes on the Internet.

The problem, of course, is that there is so much information located online, finding exactly what you need takes experience, practice, and often a bit of luck—unless you have mastered some shortcuts. I do a lot of searches, both medical and nonmedical, and here are some of the tricks I've picked up for finding all sorts of information both quickly and efficiently:

Don't limit yourself to one search engine. While Google is obviously the engine du jour (and has been for quite a few jours now), there are lots of other options, each with its own variations and advantages. If you're not finding it on Google, AltaVista, AlltheWeb, Teoma, Yahoo, Lycos, or HotBot, or one of dozens of others, might have what you want—and might even be better suited to your style. I'll be referring mostly to Google because it's so popular, but most of the techniques that follow will work on most search engines. (As always, I have no financial interest in any of the companies or Web sites I discuss in this column.)

Put quotes around words you want searched as a phrase. This is an old trick, but an important one. If you want to know if melasma has been linked to isotretinoin therapy, search “isotretinoin and melasma” so that Google won't waste your time finding a million Web pages containing the word “isotretinoin” and another million containing the word “melasma.”

You can also exclude words, by putting a hyphen (think of it as a minus sign) before any word you want screened out. For example, if you're researching tigers, you'll have to wade through scores of baseball sites unless you design the search as tigers-Detroit. Conversely, if you are looking for information about the baseball team and want to exclude anything relating to big cats, the search should be tigers + Detroit, meaning the word “Detroit” must be present.

You can widen your search by putting the tilde symbol before a word to get pages containing that word and anything similar. For example, ~tigers will pull up tigers, lions, leopards, and many other kinds of cats.

Another way to widen a search is with an asterisk at the beginning or end of a word. Searching acro* yields any word beginning with those four letters—“acrochordon,” “acronym,” “acrocyanosis,” and so on. Searching *genic yields “cryogenic,” “photogenic,” “dysgenic,” etc. (AltaVista seems to do this best.) You can also use an asterisk as a wildcard when you can't remember every single word in a phrase or name that you're seeking. For example *lupus erythematosus will yield “systemic,” “discoid,” “drug-induced,” etc.

Phrase your question in the form of an answer. Many people have been taught the opposite—to ask questions as questions—but you're not looking for Web sites that ask your question, you're looking for the answer! So “capital of California is” works much better than “What is the capital of California?”

For medical searches, consider limiting domains. If you're researching metastatic disease, you probably don't want thousands of extracts from cancer patient chat rooms, or commercial sites aimed at the general public, lawyers, etc. To pull only those pages posted on academic sites, use the “site:” syntax tool to limit your search to the .edu domain—in this case, metastasis site:edu. Avoid a space after the colon, or the engine will consider “site:” as a separate search word.

You can search news articles using the same techniques. Say you need to know what your patients are reading about a particular drug—isotretinoin, for example. Click “news” on the Google home page and search the same way you would search Web sites. If you want to see all new articles on a particular subject as they appear, go to Google Alerts and type “isotretinoin” and all its brand names into the search box; Google will e-mail you each time a story on that subject shows up online.

Search for clinical photographs in the same way. Say you're tapped to give a talk on short notice. On the Google site, go to “Images” and search the subject of your presentation. Narrow your search to PowerPoint files by using the “filetype” syntax tool (for example, psoriasis filetype:ppt), and you'll often find entire presentations, ready to download!

If you click a link and get the dreaded “Error 404, Document Not Found” message, do not despair. The message confirms that the site exists, and the Web page you want may still be there. Delete the last part of the address until you come to the next “/”. Hit enter and see what you get. If it's another error message, repeat the process. Eventually you'll end up on the home or index page, which may very well have a search box, or a link to the page you're looking for.

Finally, keep in mind that in many cases, the Web sites at the top of your search result are there because the owners of those sites have paid for prominent placement. Some search services are clearer than others about what has been paid for and what has not. Take the time to read the “help” section, which usually spells out the service's policies, and frequently offers valuable tips for making the most efficient use of that particular engine. And check back regularly; the best services frequently add new features to keep up with cutthroat competition.

A lot of things have changed in my office in the 24 years I've been practicing medicine, but nothing quite so much as the way I look for information.

Finding the latest articles on a rarely encountered disease used to entail a search through multiple textbooks, shelf after shelf of old journals, perhaps the hospital library, or even the med school library across town. It was tedious and time consuming, and all too often a hit-or-miss affair.

No longer. Nowadays I can find all the medical data I need—or indeed, any category of information at all—in a few minutes on the Internet.

The problem, of course, is that there is so much information located online, finding exactly what you need takes experience, practice, and often a bit of luck—unless you have mastered some shortcuts. I do a lot of searches, both medical and nonmedical, and here are some of the tricks I've picked up for finding all sorts of information both quickly and efficiently:

Don't limit yourself to one search engine. While Google is obviously the engine du jour (and has been for quite a few jours now), there are lots of other options, each with its own variations and advantages. If you're not finding it on Google, AltaVista, AlltheWeb, Teoma, Yahoo, Lycos, or HotBot, or one of dozens of others, might have what you want—and might even be better suited to your style. I'll be referring mostly to Google because it's so popular, but most of the techniques that follow will work on most search engines. (As always, I have no financial interest in any of the companies or Web sites I discuss in this column.)

Put quotes around words you want searched as a phrase. This is an old trick, but an important one. If you want to know if melasma has been linked to isotretinoin therapy, search “isotretinoin and melasma” so that Google won't waste your time finding a million Web pages containing the word “isotretinoin” and another million containing the word “melasma.”

You can also exclude words, by putting a hyphen (think of it as a minus sign) before any word you want screened out. For example, if you're researching tigers, you'll have to wade through scores of baseball sites unless you design the search as tigers-Detroit. Conversely, if you are looking for information about the baseball team and want to exclude anything relating to big cats, the search should be tigers + Detroit, meaning the word “Detroit” must be present.

You can widen your search by putting the tilde symbol before a word to get pages containing that word and anything similar. For example, ~tigers will pull up tigers, lions, leopards, and many other kinds of cats.

Another way to widen a search is with an asterisk at the beginning or end of a word. Searching acro* yields any word beginning with those four letters—“acrochordon,” “acronym,” “acrocyanosis,” and so on. Searching *genic yields “cryogenic,” “photogenic,” “dysgenic,” etc. (AltaVista seems to do this best.) You can also use an asterisk as a wildcard when you can't remember every single word in a phrase or name that you're seeking. For example *lupus erythematosus will yield “systemic,” “discoid,” “drug-induced,” etc.

Phrase your question in the form of an answer. Many people have been taught the opposite—to ask questions as questions—but you're not looking for Web sites that ask your question, you're looking for the answer! So “capital of California is” works much better than “What is the capital of California?”

For medical searches, consider limiting domains. If you're researching metastatic disease, you probably don't want thousands of extracts from cancer patient chat rooms, or commercial sites aimed at the general public, lawyers, etc. To pull only those pages posted on academic sites, use the “site:” syntax tool to limit your search to the .edu domain—in this case, metastasis site:edu. Avoid a space after the colon, or the engine will consider “site:” as a separate search word.

You can search news articles using the same techniques. Say you need to know what your patients are reading about a particular drug—isotretinoin, for example. Click “news” on the Google home page and search the same way you would search Web sites. If you want to see all new articles on a particular subject as they appear, go to Google Alerts and type “isotretinoin” and all its brand names into the search box; Google will e-mail you each time a story on that subject shows up online.

Search for clinical photographs in the same way. Say you're tapped to give a talk on short notice. On the Google site, go to “Images” and search the subject of your presentation. Narrow your search to PowerPoint files by using the “filetype” syntax tool (for example, psoriasis filetype:ppt), and you'll often find entire presentations, ready to download!

If you click a link and get the dreaded “Error 404, Document Not Found” message, do not despair. The message confirms that the site exists, and the Web page you want may still be there. Delete the last part of the address until you come to the next “/”. Hit enter and see what you get. If it's another error message, repeat the process. Eventually you'll end up on the home or index page, which may very well have a search box, or a link to the page you're looking for.

Finally, keep in mind that in many cases, the Web sites at the top of your search result are there because the owners of those sites have paid for prominent placement. Some search services are clearer than others about what has been paid for and what has not. Take the time to read the “help” section, which usually spells out the service's policies, and frequently offers valuable tips for making the most efficient use of that particular engine. And check back regularly; the best services frequently add new features to keep up with cutthroat competition.

A lot of things have changed in my office in the 24 years I've been practicing medicine, but nothing quite so much as the way I look for information.

Finding the latest articles on a rarely encountered disease used to entail a search through multiple textbooks, shelf after shelf of old journals, perhaps the hospital library, or even the med school library across town. It was tedious and time consuming, and all too often a hit-or-miss affair.

No longer. Nowadays I can find all the medical data I need—or indeed, any category of information at all—in a few minutes on the Internet.

The problem, of course, is that there is so much information located online, finding exactly what you need takes experience, practice, and often a bit of luck—unless you have mastered some shortcuts. I do a lot of searches, both medical and nonmedical, and here are some of the tricks I've picked up for finding all sorts of information both quickly and efficiently:

Don't limit yourself to one search engine. While Google is obviously the engine du jour (and has been for quite a few jours now), there are lots of other options, each with its own variations and advantages. If you're not finding it on Google, AltaVista, AlltheWeb, Teoma, Yahoo, Lycos, or HotBot, or one of dozens of others, might have what you want—and might even be better suited to your style. I'll be referring mostly to Google because it's so popular, but most of the techniques that follow will work on most search engines. (As always, I have no financial interest in any of the companies or Web sites I discuss in this column.)

Put quotes around words you want searched as a phrase. This is an old trick, but an important one. If you want to know if melasma has been linked to isotretinoin therapy, search “isotretinoin and melasma” so that Google won't waste your time finding a million Web pages containing the word “isotretinoin” and another million containing the word “melasma.”

You can also exclude words, by putting a hyphen (think of it as a minus sign) before any word you want screened out. For example, if you're researching tigers, you'll have to wade through scores of baseball sites unless you design the search as tigers-Detroit. Conversely, if you are looking for information about the baseball team and want to exclude anything relating to big cats, the search should be tigers + Detroit, meaning the word “Detroit” must be present.

You can widen your search by putting the tilde symbol before a word to get pages containing that word and anything similar. For example, ~tigers will pull up tigers, lions, leopards, and many other kinds of cats.

Another way to widen a search is with an asterisk at the beginning or end of a word. Searching acro* yields any word beginning with those four letters—“acrochordon,” “acronym,” “acrocyanosis,” and so on. Searching *genic yields “cryogenic,” “photogenic,” “dysgenic,” etc. (AltaVista seems to do this best.) You can also use an asterisk as a wildcard when you can't remember every single word in a phrase or name that you're seeking. For example *lupus erythematosus will yield “systemic,” “discoid,” “drug-induced,” etc.

Phrase your question in the form of an answer. Many people have been taught the opposite—to ask questions as questions—but you're not looking for Web sites that ask your question, you're looking for the answer! So “capital of California is” works much better than “What is the capital of California?”

For medical searches, consider limiting domains. If you're researching metastatic disease, you probably don't want thousands of extracts from cancer patient chat rooms, or commercial sites aimed at the general public, lawyers, etc. To pull only those pages posted on academic sites, use the “site:” syntax tool to limit your search to the .edu domain—in this case, metastasis site:edu. Avoid a space after the colon, or the engine will consider “site:” as a separate search word.

You can search news articles using the same techniques. Say you need to know what your patients are reading about a particular drug—isotretinoin, for example. Click “news” on the Google home page and search the same way you would search Web sites. If you want to see all new articles on a particular subject as they appear, go to Google Alerts and type “isotretinoin” and all its brand names into the search box; Google will e-mail you each time a story on that subject shows up online.

Search for clinical photographs in the same way. Say you're tapped to give a talk on short notice. On the Google site, go to “Images” and search the subject of your presentation. Narrow your search to PowerPoint files by using the “filetype” syntax tool (for example, psoriasis filetype:ppt), and you'll often find entire presentations, ready to download!

If you click a link and get the dreaded “Error 404, Document Not Found” message, do not despair. The message confirms that the site exists, and the Web page you want may still be there. Delete the last part of the address until you come to the next “/”. Hit enter and see what you get. If it's another error message, repeat the process. Eventually you'll end up on the home or index page, which may very well have a search box, or a link to the page you're looking for.

Finally, keep in mind that in many cases, the Web sites at the top of your search result are there because the owners of those sites have paid for prominent placement. Some search services are clearer than others about what has been paid for and what has not. Take the time to read the “help” section, which usually spells out the service's policies, and frequently offers valuable tips for making the most efficient use of that particular engine. And check back regularly; the best services frequently add new features to keep up with cutthroat competition.

Cook County (Ill) Circuit Court

Due to complaints of “kicking” and shooting back pain, a 44-year-old woman at 25 weeks’ gestation was ordered to the hospital by her obstetrician, for evaluation for preterm labor. A nurse conducted the exam from the physician’s telephone instructions.

Both palpation and examination via external monitoring revealed no signs of contractions, and the nurse observed that the woman’s cervix was closed. When the patient noted continued pain, the physician ordered 3 doses of terbutaline. The woman later reported her symptoms had resolved, and was released 3 hours later with instructions to call if she felt pain or kicking more than 4 times per hour.

The woman was previously scheduled for a prenatal visit 9 hours later. Upon presenting for that appointment, she reported 3 to 4 brief contractions in the intervening hours. Examination revealed cervical dilation of 2 to 3 cm with a bulging bag. She was transferred to the hospital, but did not experience any contractions during transport. Upon arrival at the hospital, her cervix was to 3 to 4 cm dilated. The child was delivered via cesarean section 2 hours later.

The child suffered cerebral palsy and spastic quadriplegia and required a tracheostomy tube. He is currently confined to a wheelchair.

The plaintiff sued the hospital, the medical group, and the obstetrician, claiming negligence for failing to properly treat preterm labor.

The defendants maintained that the woman was not experiencing preterm labor at her initial visit. Instead, they argued that an incompetent cervix aggravated by chorioamnionitis led to the preterm labor, and claimed that the outcome could not have been prevented.

• The hospital settled for $600,000 prior to trial. The jury returned a defense verdict for the obstetrician and the medical group.
  

Cook County (Ill) Circuit Court

Due to complaints of “kicking” and shooting back pain, a 44-year-old woman at 25 weeks’ gestation was ordered to the hospital by her obstetrician, for evaluation for preterm labor. A nurse conducted the exam from the physician’s telephone instructions.

Both palpation and examination via external monitoring revealed no signs of contractions, and the nurse observed that the woman’s cervix was closed. When the patient noted continued pain, the physician ordered 3 doses of terbutaline. The woman later reported her symptoms had resolved, and was released 3 hours later with instructions to call if she felt pain or kicking more than 4 times per hour.

The woman was previously scheduled for a prenatal visit 9 hours later. Upon presenting for that appointment, she reported 3 to 4 brief contractions in the intervening hours. Examination revealed cervical dilation of 2 to 3 cm with a bulging bag. She was transferred to the hospital, but did not experience any contractions during transport. Upon arrival at the hospital, her cervix was to 3 to 4 cm dilated. The child was delivered via cesarean section 2 hours later.

The child suffered cerebral palsy and spastic quadriplegia and required a tracheostomy tube. He is currently confined to a wheelchair.

The plaintiff sued the hospital, the medical group, and the obstetrician, claiming negligence for failing to properly treat preterm labor.

The defendants maintained that the woman was not experiencing preterm labor at her initial visit. Instead, they argued that an incompetent cervix aggravated by chorioamnionitis led to the preterm labor, and claimed that the outcome could not have been prevented.

• The hospital settled for $600,000 prior to trial. The jury returned a defense verdict for the obstetrician and the medical group.
  

Cook County (Ill) Circuit Court

Due to complaints of “kicking” and shooting back pain, a 44-year-old woman at 25 weeks’ gestation was ordered to the hospital by her obstetrician, for evaluation for preterm labor. A nurse conducted the exam from the physician’s telephone instructions.

Both palpation and examination via external monitoring revealed no signs of contractions, and the nurse observed that the woman’s cervix was closed. When the patient noted continued pain, the physician ordered 3 doses of terbutaline. The woman later reported her symptoms had resolved, and was released 3 hours later with instructions to call if she felt pain or kicking more than 4 times per hour.

The woman was previously scheduled for a prenatal visit 9 hours later. Upon presenting for that appointment, she reported 3 to 4 brief contractions in the intervening hours. Examination revealed cervical dilation of 2 to 3 cm with a bulging bag. She was transferred to the hospital, but did not experience any contractions during transport. Upon arrival at the hospital, her cervix was to 3 to 4 cm dilated. The child was delivered via cesarean section 2 hours later.

The child suffered cerebral palsy and spastic quadriplegia and required a tracheostomy tube. He is currently confined to a wheelchair.

The plaintiff sued the hospital, the medical group, and the obstetrician, claiming negligence for failing to properly treat preterm labor.

The defendants maintained that the woman was not experiencing preterm labor at her initial visit. Instead, they argued that an incompetent cervix aggravated by chorioamnionitis led to the preterm labor, and claimed that the outcome could not have been prevented.

• The hospital settled for $600,000 prior to trial. The jury returned a defense verdict for the obstetrician and the medical group.
  

Undisclosed Massachusetts venue

Ultrasound examination of a woman at 16.4 weeks’ gestation revealed anterior marginal placenta previa. Three months later, follow-up study showed the condition had resolved, with the placenta in an anterior position.

At 33 weeks, the woman suffered a fall, but did not sustain abdominal trauma. At 35 weeks, she was involved in a motor vehicle accident, but maintained normal fetal movement. At 38 weeks she was treated for suspected urinary tract infection after reporting decreased fetal movement. At 40 weeks, following a normal reactive stress test and observation of a normal, active, vertex fetus, the physician scheduled an induction for 8 days later.

The next day, the plaintiff reported contractions every 5 minutes and decreased fetal movement. At the hospital, no cervical dilation was observed. The fetal heart rate was 140 with accelerations to 150 to 160 and average long-term variability.

She was discharged home, but returned in labor the following day, with a cervical dilation of 6 cm and bulging membranes. The fetal heart rate on arrival was in the 150s; 15 minutes later, decelerations to 90 were noted, with poor beat-to-beat variability. Vaginal examination 10 minutes later revealed meconium with spontaneous rupture of membranes.

An hour later, the fetal heart rate fell to 100, with decelerations to 50 to 60. The child was delivered by emergency cesarean section 17 minutes later. Apgar scores were 0, 0, and 3, and cord pH was 6.86. The child was transferred to another facility and suffered seizures within 12 hours of birth. It was determined that the child suffered perinatal hypoxic ischemic encephalopathy.

The plaintiff sued, arguing that cesarean should have been performed earlier.

The defendants denied negligence, noting normal tests the day prior to birth, and maintaining that the fetal heart rate during labor was not diagnostic of fetal distress.

• The case settled for $400,000 at mediation.
  

Undisclosed Massachusetts venue

Ultrasound examination of a woman at 16.4 weeks’ gestation revealed anterior marginal placenta previa. Three months later, follow-up study showed the condition had resolved, with the placenta in an anterior position.

At 33 weeks, the woman suffered a fall, but did not sustain abdominal trauma. At 35 weeks, she was involved in a motor vehicle accident, but maintained normal fetal movement. At 38 weeks she was treated for suspected urinary tract infection after reporting decreased fetal movement. At 40 weeks, following a normal reactive stress test and observation of a normal, active, vertex fetus, the physician scheduled an induction for 8 days later.

The next day, the plaintiff reported contractions every 5 minutes and decreased fetal movement. At the hospital, no cervical dilation was observed. The fetal heart rate was 140 with accelerations to 150 to 160 and average long-term variability.

She was discharged home, but returned in labor the following day, with a cervical dilation of 6 cm and bulging membranes. The fetal heart rate on arrival was in the 150s; 15 minutes later, decelerations to 90 were noted, with poor beat-to-beat variability. Vaginal examination 10 minutes later revealed meconium with spontaneous rupture of membranes.

An hour later, the fetal heart rate fell to 100, with decelerations to 50 to 60. The child was delivered by emergency cesarean section 17 minutes later. Apgar scores were 0, 0, and 3, and cord pH was 6.86. The child was transferred to another facility and suffered seizures within 12 hours of birth. It was determined that the child suffered perinatal hypoxic ischemic encephalopathy.

The plaintiff sued, arguing that cesarean should have been performed earlier.

The defendants denied negligence, noting normal tests the day prior to birth, and maintaining that the fetal heart rate during labor was not diagnostic of fetal distress.

• The case settled for $400,000 at mediation.
  

Undisclosed Massachusetts venue

Ultrasound examination of a woman at 16.4 weeks’ gestation revealed anterior marginal placenta previa. Three months later, follow-up study showed the condition had resolved, with the placenta in an anterior position.

At 33 weeks, the woman suffered a fall, but did not sustain abdominal trauma. At 35 weeks, she was involved in a motor vehicle accident, but maintained normal fetal movement. At 38 weeks she was treated for suspected urinary tract infection after reporting decreased fetal movement. At 40 weeks, following a normal reactive stress test and observation of a normal, active, vertex fetus, the physician scheduled an induction for 8 days later.

The next day, the plaintiff reported contractions every 5 minutes and decreased fetal movement. At the hospital, no cervical dilation was observed. The fetal heart rate was 140 with accelerations to 150 to 160 and average long-term variability.

She was discharged home, but returned in labor the following day, with a cervical dilation of 6 cm and bulging membranes. The fetal heart rate on arrival was in the 150s; 15 minutes later, decelerations to 90 were noted, with poor beat-to-beat variability. Vaginal examination 10 minutes later revealed meconium with spontaneous rupture of membranes.

An hour later, the fetal heart rate fell to 100, with decelerations to 50 to 60. The child was delivered by emergency cesarean section 17 minutes later. Apgar scores were 0, 0, and 3, and cord pH was 6.86. The child was transferred to another facility and suffered seizures within 12 hours of birth. It was determined that the child suffered perinatal hypoxic ischemic encephalopathy.

The plaintiff sued, arguing that cesarean should have been performed earlier.

The defendants denied negligence, noting normal tests the day prior to birth, and maintaining that the fetal heart rate during labor was not diagnostic of fetal distress.

• The case settled for $400,000 at mediation.
  

Undisclosed California venue

Soon after a woman at full term presented to a hospital, fetal compromise was noted on heart-rate tracings, but no intervention was taken. At birth the child suffered severe acute asphyxia, leading to brain damage, kidney failure, and hypertension.

In suing, the plaintiff claimed that the Ob/Gyn was negligent for not responding to the fetal distress in a timely manner.

The defense argued that the child’s injury occurred before the mother presented to the hospital, and maintained that delivery staff acted expeditiously once further deterioration was noted on fetal monitoring.

• The parties settled for $1.3 million.
  

Undisclosed California venue

Soon after a woman at full term presented to a hospital, fetal compromise was noted on heart-rate tracings, but no intervention was taken. At birth the child suffered severe acute asphyxia, leading to brain damage, kidney failure, and hypertension.

In suing, the plaintiff claimed that the Ob/Gyn was negligent for not responding to the fetal distress in a timely manner.

The defense argued that the child’s injury occurred before the mother presented to the hospital, and maintained that delivery staff acted expeditiously once further deterioration was noted on fetal monitoring.

• The parties settled for $1.3 million.
  

Undisclosed California venue

Soon after a woman at full term presented to a hospital, fetal compromise was noted on heart-rate tracings, but no intervention was taken. At birth the child suffered severe acute asphyxia, leading to brain damage, kidney failure, and hypertension.

In suing, the plaintiff claimed that the Ob/Gyn was negligent for not responding to the fetal distress in a timely manner.

The defense argued that the child’s injury occurred before the mother presented to the hospital, and maintained that delivery staff acted expeditiously once further deterioration was noted on fetal monitoring.

• The parties settled for $1.3 million.
  

New York County (NY) Supreme Court

When delivery had not occurred after 3 hours of stage 2 labor, a 30-year-old woman under the care of a certified nurse midwife was transferred from a childbirth facility to a hospital. The obstetrician opted to proceed with vaginal delivery, and ordered an epidural and oxytocin.

After 6 hours of second-stage labor, the physician instructed a second-year resident to apply fundal pressure. Half an hour later, following a midline episiotomy, the midwife delivered an 8-lb, 14-oz child. A 4th-degree perineal tear was identified and repaired by the resident physician.

Several weeks after the delivery, the woman noted symptoms of fecal incontinence. Despite conservative management and 3 surgical interventions, the woman’s condition persists.

In suing, the patient claimed that the obstetrician should have ordered a cesarean delivery immediately upon her presentation at the hospital. She claimed that vaginal delivery was inappropriate after a 6.5-hour second stage of labor, and alleged that oxytocin and fundal pressure were contraindicated. Finally, she claimed the episiotomy was improperly performed.

The defense denied negligence, noting that the woman’s injury is a known risk of a properly performed episiotomy and repair. Further, they noted that use of fundal pressure and oxytocin led to the delivery of a healthy infant.

• The jury returned a defense verdict.
  

New York County (NY) Supreme Court

When delivery had not occurred after 3 hours of stage 2 labor, a 30-year-old woman under the care of a certified nurse midwife was transferred from a childbirth facility to a hospital. The obstetrician opted to proceed with vaginal delivery, and ordered an epidural and oxytocin.

After 6 hours of second-stage labor, the physician instructed a second-year resident to apply fundal pressure. Half an hour later, following a midline episiotomy, the midwife delivered an 8-lb, 14-oz child. A 4th-degree perineal tear was identified and repaired by the resident physician.

Several weeks after the delivery, the woman noted symptoms of fecal incontinence. Despite conservative management and 3 surgical interventions, the woman’s condition persists.

In suing, the patient claimed that the obstetrician should have ordered a cesarean delivery immediately upon her presentation at the hospital. She claimed that vaginal delivery was inappropriate after a 6.5-hour second stage of labor, and alleged that oxytocin and fundal pressure were contraindicated. Finally, she claimed the episiotomy was improperly performed.

The defense denied negligence, noting that the woman’s injury is a known risk of a properly performed episiotomy and repair. Further, they noted that use of fundal pressure and oxytocin led to the delivery of a healthy infant.

• The jury returned a defense verdict.
  

New York County (NY) Supreme Court

When delivery had not occurred after 3 hours of stage 2 labor, a 30-year-old woman under the care of a certified nurse midwife was transferred from a childbirth facility to a hospital. The obstetrician opted to proceed with vaginal delivery, and ordered an epidural and oxytocin.

After 6 hours of second-stage labor, the physician instructed a second-year resident to apply fundal pressure. Half an hour later, following a midline episiotomy, the midwife delivered an 8-lb, 14-oz child. A 4th-degree perineal tear was identified and repaired by the resident physician.

Several weeks after the delivery, the woman noted symptoms of fecal incontinence. Despite conservative management and 3 surgical interventions, the woman’s condition persists.

In suing, the patient claimed that the obstetrician should have ordered a cesarean delivery immediately upon her presentation at the hospital. She claimed that vaginal delivery was inappropriate after a 6.5-hour second stage of labor, and alleged that oxytocin and fundal pressure were contraindicated. Finally, she claimed the episiotomy was improperly performed.

The defense denied negligence, noting that the woman’s injury is a known risk of a properly performed episiotomy and repair. Further, they noted that use of fundal pressure and oxytocin led to the delivery of a healthy infant.

• The jury returned a defense verdict.
  

Undisclosed Ohio venue

Following the vaginal birth of the first child in a set of twins, the second child began to experience prolonged deep decelerations. His heart rate remained at 60 to 80 beats per minutes for 17 minutes before a cesarean delivery was ordered. The infant suffered acute hypoxic ischemic encephalopathy.

In suing, the plaintiff argued the defendants were negligent in not initiating cesarean delivery sooner.

• The parties settled for $800,000.
  

Undisclosed Ohio venue

Following the vaginal birth of the first child in a set of twins, the second child began to experience prolonged deep decelerations. His heart rate remained at 60 to 80 beats per minutes for 17 minutes before a cesarean delivery was ordered. The infant suffered acute hypoxic ischemic encephalopathy.

In suing, the plaintiff argued the defendants were negligent in not initiating cesarean delivery sooner.

• The parties settled for $800,000.
  

Undisclosed Ohio venue

Following the vaginal birth of the first child in a set of twins, the second child began to experience prolonged deep decelerations. His heart rate remained at 60 to 80 beats per minutes for 17 minutes before a cesarean delivery was ordered. The infant suffered acute hypoxic ischemic encephalopathy.

In suing, the plaintiff argued the defendants were negligent in not initiating cesarean delivery sooner.

• The parties settled for $800,000.
  

Hillsborough County (Fla) Circuit Court

A woman at 40 weeks’ gestation presented to an Ob/Gyn due to a suspected amniotic leak. After examining the patient, the physician determined no amniotic fluid was present and sent the woman home.

The following day the woman once again presented with a suspected amniotic leak. Upon examination, a second Ob/Gyn observed green mucus, prompting the doctor to admit her to the hospital, where fetal heart monitoring and oxytocin administration were initiated.

Twelve hours after oxytocin was started, the woman was just 4 cm dilated and febrile. When, 3 hours later, fetal monitoring indicated signs of distress, the first Ob/Gyn was called. He soon left, however, to attend to another scheduled delivery.

Six hours later, when the woman’s temperature climbed to 101.1° and fetal monitoring indicated a heart rate of 160 to 170 beats per minute, a cesarean delivery was ordered. However, another 90 minutes passed before the procedure was initiated. At that time, fetal monitoring showed an almost flat heart rate with no variability.

The child was born with brain damage and cerebral palsy due to chorioamnionitis.

The plaintiffs sued, claiming the 2 obstetricians were negligent for failing to diagnose a ruptured membrane, administer prophylactic antibiotics to prevent chorioamnionitis, properly follow the patient, and order a timely cesarean section.

The defendants denied negligence, arguing that the child’s injury stemmed from a protein C deficiency.

• The jury awarded the plaintiffs $4.6 million.
  

Hillsborough County (Fla) Circuit Court

A woman at 40 weeks’ gestation presented to an Ob/Gyn due to a suspected amniotic leak. After examining the patient, the physician determined no amniotic fluid was present and sent the woman home.

The following day the woman once again presented with a suspected amniotic leak. Upon examination, a second Ob/Gyn observed green mucus, prompting the doctor to admit her to the hospital, where fetal heart monitoring and oxytocin administration were initiated.

Twelve hours after oxytocin was started, the woman was just 4 cm dilated and febrile. When, 3 hours later, fetal monitoring indicated signs of distress, the first Ob/Gyn was called. He soon left, however, to attend to another scheduled delivery.

Six hours later, when the woman’s temperature climbed to 101.1° and fetal monitoring indicated a heart rate of 160 to 170 beats per minute, a cesarean delivery was ordered. However, another 90 minutes passed before the procedure was initiated. At that time, fetal monitoring showed an almost flat heart rate with no variability.

The child was born with brain damage and cerebral palsy due to chorioamnionitis.

The plaintiffs sued, claiming the 2 obstetricians were negligent for failing to diagnose a ruptured membrane, administer prophylactic antibiotics to prevent chorioamnionitis, properly follow the patient, and order a timely cesarean section.

The defendants denied negligence, arguing that the child’s injury stemmed from a protein C deficiency.

• The jury awarded the plaintiffs $4.6 million.
  

Hillsborough County (Fla) Circuit Court

A woman at 40 weeks’ gestation presented to an Ob/Gyn due to a suspected amniotic leak. After examining the patient, the physician determined no amniotic fluid was present and sent the woman home.

The following day the woman once again presented with a suspected amniotic leak. Upon examination, a second Ob/Gyn observed green mucus, prompting the doctor to admit her to the hospital, where fetal heart monitoring and oxytocin administration were initiated.

Twelve hours after oxytocin was started, the woman was just 4 cm dilated and febrile. When, 3 hours later, fetal monitoring indicated signs of distress, the first Ob/Gyn was called. He soon left, however, to attend to another scheduled delivery.

Six hours later, when the woman’s temperature climbed to 101.1° and fetal monitoring indicated a heart rate of 160 to 170 beats per minute, a cesarean delivery was ordered. However, another 90 minutes passed before the procedure was initiated. At that time, fetal monitoring showed an almost flat heart rate with no variability.

The child was born with brain damage and cerebral palsy due to chorioamnionitis.

The plaintiffs sued, claiming the 2 obstetricians were negligent for failing to diagnose a ruptured membrane, administer prophylactic antibiotics to prevent chorioamnionitis, properly follow the patient, and order a timely cesarean section.

The defendants denied negligence, arguing that the child’s injury stemmed from a protein C deficiency.

• The jury awarded the plaintiffs $4.6 million.
  

Stamford Judicial District (Conn) Superior Court

Noting decreased fetal movement, a woman at 35 weeks’ gestation called her Ob/Gyn, who instructed her to report to the hospital. After performing an examination and nonreactive stress test, the physician discharged the woman, telling her to call if she did not feel 6 strong fetal movements upon returning home.

The woman called that evening, reporting just 2 light fetal movements. The doctor advised her to remain home.

The patient called the next morning to report pain near her pubic bone, at which time a different physician told her to call back if the pain worsened. When her pain intensified, she opted to report directly to the hospital, where she was admitted to labor and delivery.

An ultrasound examination 30 minutes later revealed intrauterine fetal death. Upon delivery, a nuchal cord was discovered.

In suing, the woman claimed that, on the day of her first call, her Ob/Gyn should have admitted her to the hospital due to a questionable nonstress test. At that time, she argued, a biophysical profile and other tests of fetal well-being should have been performed.

• The parties settled for $1.5 million.
  

Stamford Judicial District (Conn) Superior Court

Noting decreased fetal movement, a woman at 35 weeks’ gestation called her Ob/Gyn, who instructed her to report to the hospital. After performing an examination and nonreactive stress test, the physician discharged the woman, telling her to call if she did not feel 6 strong fetal movements upon returning home.

The woman called that evening, reporting just 2 light fetal movements. The doctor advised her to remain home.

The patient called the next morning to report pain near her pubic bone, at which time a different physician told her to call back if the pain worsened. When her pain intensified, she opted to report directly to the hospital, where she was admitted to labor and delivery.

An ultrasound examination 30 minutes later revealed intrauterine fetal death. Upon delivery, a nuchal cord was discovered.

In suing, the woman claimed that, on the day of her first call, her Ob/Gyn should have admitted her to the hospital due to a questionable nonstress test. At that time, she argued, a biophysical profile and other tests of fetal well-being should have been performed.

• The parties settled for $1.5 million.
  

Stamford Judicial District (Conn) Superior Court

Noting decreased fetal movement, a woman at 35 weeks’ gestation called her Ob/Gyn, who instructed her to report to the hospital. After performing an examination and nonreactive stress test, the physician discharged the woman, telling her to call if she did not feel 6 strong fetal movements upon returning home.

The woman called that evening, reporting just 2 light fetal movements. The doctor advised her to remain home.

The patient called the next morning to report pain near her pubic bone, at which time a different physician told her to call back if the pain worsened. When her pain intensified, she opted to report directly to the hospital, where she was admitted to labor and delivery.

An ultrasound examination 30 minutes later revealed intrauterine fetal death. Upon delivery, a nuchal cord was discovered.

In suing, the woman claimed that, on the day of her first call, her Ob/Gyn should have admitted her to the hospital due to a questionable nonstress test. At that time, she argued, a biophysical profile and other tests of fetal well-being should have been performed.

• The parties settled for $1.5 million.
  

<court>San Francisco County (Calif) Superior Court</court>

After 2 years of unsuccessfully trying to conceive, a woman in her late forties gave birth to a healthy baby boy as a result of in vitro fertilization.

Following the child’s birth, the patient learned that she had inadvertently received an embryo intended for another couple: The wife in that couple, scheduled for implantation the same day as the plaintiff, was to be fertilized with an embryo consisting of her husband’s sperm and a donor egg. The plaintiff received this embryo.

The defendants did not deny negligence, but maintained that once the error was discovered, they acted in the plaintiff’s best interests.

• The plaintiff settled for $1 million with the physician and his practice. The case against the scientist who incubated the embryo and his employer was still pending.

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

<court>San Francisco County (Calif) Superior Court</court>

After 2 years of unsuccessfully trying to conceive, a woman in her late forties gave birth to a healthy baby boy as a result of in vitro fertilization.

Following the child’s birth, the patient learned that she had inadvertently received an embryo intended for another couple: The wife in that couple, scheduled for implantation the same day as the plaintiff, was to be fertilized with an embryo consisting of her husband’s sperm and a donor egg. The plaintiff received this embryo.

The defendants did not deny negligence, but maintained that once the error was discovered, they acted in the plaintiff’s best interests.

• The plaintiff settled for $1 million with the physician and his practice. The case against the scientist who incubated the embryo and his employer was still pending.

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

<court>San Francisco County (Calif) Superior Court</court>

After 2 years of unsuccessfully trying to conceive, a woman in her late forties gave birth to a healthy baby boy as a result of in vitro fertilization.

Following the child’s birth, the patient learned that she had inadvertently received an embryo intended for another couple: The wife in that couple, scheduled for implantation the same day as the plaintiff, was to be fertilized with an embryo consisting of her husband’s sperm and a donor egg. The plaintiff received this embryo.

The defendants did not deny negligence, but maintained that once the error was discovered, they acted in the plaintiff’s best interests.

• The plaintiff settled for $1 million with the physician and his practice. The case against the scientist who incubated the embryo and his employer was still pending.

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Davis County (Utah) District Court

A woman in her fourth pregnancy presented to a physician. Her first pregnancy, 18 years prior, was notable for 36-hour labor followed by delivery of a 9-lb infant; the next 2 pregnancies resulted in miscarriage.

The doctor deemed the patient a high-risk pregnancy and ordered sonograms every 2 weeks. When sonography in her sixth month indicated a fetal weight over 7 lb, the woman requested a cesarean delivery. A sonogram performed in her ninth month suggested a fetal weight over 10 lb, but the physician doubted the accuracy of these calculations and scheduled an induction to take place in 2 days.

Following a vaginal delivery complicated by shoulder dystocia and aided by episiotomy, the woman gave birth to a 9-lb, 13-oz child. The child suffered from Erb’s palsy, but the condition resolved. The mother, however, sustained a 3rd-degree laceration, postpartum hemorrhaging, and injury to the pelvic joints and vaginal area.

In suing, she claimed the physician did not properly evaluate the child’s birth weight, and was negligent in not granting her request for a cesarean.

• The doctor settled for $27,000 with the mother and $5,000 with the child.
  

Davis County (Utah) District Court

A woman in her fourth pregnancy presented to a physician. Her first pregnancy, 18 years prior, was notable for 36-hour labor followed by delivery of a 9-lb infant; the next 2 pregnancies resulted in miscarriage.

The doctor deemed the patient a high-risk pregnancy and ordered sonograms every 2 weeks. When sonography in her sixth month indicated a fetal weight over 7 lb, the woman requested a cesarean delivery. A sonogram performed in her ninth month suggested a fetal weight over 10 lb, but the physician doubted the accuracy of these calculations and scheduled an induction to take place in 2 days.

Following a vaginal delivery complicated by shoulder dystocia and aided by episiotomy, the woman gave birth to a 9-lb, 13-oz child. The child suffered from Erb’s palsy, but the condition resolved. The mother, however, sustained a 3rd-degree laceration, postpartum hemorrhaging, and injury to the pelvic joints and vaginal area.

In suing, she claimed the physician did not properly evaluate the child’s birth weight, and was negligent in not granting her request for a cesarean.

• The doctor settled for $27,000 with the mother and $5,000 with the child.
  

Davis County (Utah) District Court

A woman in her fourth pregnancy presented to a physician. Her first pregnancy, 18 years prior, was notable for 36-hour labor followed by delivery of a 9-lb infant; the next 2 pregnancies resulted in miscarriage.

The doctor deemed the patient a high-risk pregnancy and ordered sonograms every 2 weeks. When sonography in her sixth month indicated a fetal weight over 7 lb, the woman requested a cesarean delivery. A sonogram performed in her ninth month suggested a fetal weight over 10 lb, but the physician doubted the accuracy of these calculations and scheduled an induction to take place in 2 days.

Following a vaginal delivery complicated by shoulder dystocia and aided by episiotomy, the woman gave birth to a 9-lb, 13-oz child. The child suffered from Erb’s palsy, but the condition resolved. The mother, however, sustained a 3rd-degree laceration, postpartum hemorrhaging, and injury to the pelvic joints and vaginal area.

In suing, she claimed the physician did not properly evaluate the child’s birth weight, and was negligent in not granting her request for a cesarean.

• The doctor settled for $27,000 with the mother and $5,000 with the child.