Medicolegal Issues

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

No Action Taken in Suspected Appendiceal Abscess
In 2002, a New Jersey man presented to the defendant family practitioner, Dr. W., with complaints of a cold, a sore throat, and abdominal discomfort. Dr. W. referred the patient to a county hospital for abdominal CT. A radiologist there found evidence of a prior appendiceal abscess but no evidence of inflammatory changes.

The radiologist recommended a clinical consultation to determine whether the CT results, when correlated with other clinical findings, indicated appendicitis or some other condition. On being questioned by Dr. W., the patient denied having any right lower quadrant pain.

The man continued to be seen by Dr. W. for longer than two years for various medical needs. One day at work in February 2005, the man began to experience severe abdominal pain in the right lower quadrant. He went to Dr. W.’s office and was sent to an emergency department (ED), where he was admitted to the hospital to undergo surgery to treat appendicitis, including removal of his appendix.

The postsurgical pathology report included a finding of appendiceal carcinoma, which had advanced to the point of perforating the wall of the appendix. In response to results from further testing, a right hemicolectomy was performed with removal of lymph nodes that were found negative for cancer.

The patient underwent chemotherapy and experienced no recurrence of the cancer. He did experience complications as a result of the hemicolectomy, however, which required lysis of adhesions in September 2005. In 2006, the man underwent surgeries for treatment of five hernias.

The plaintiff claimed that Dr. W. should have referred him to a surgeon in 2002 at the time of his initial visit. The plaintiff claimed that the CT findings made surgery necessary to confirm their cause and to prevent persistent appendicitis. The plaintiff claimed that surgery at that time would have led to a diagnosis of cancer prior to perforation of the appendix wall.

The defendant countered that in 2002, the plaintiff had no clinical complaints to warrant referral to a surgeon.

According to a published account, a defense verdict was returned.

Stroke and Intracerebral Hematoma After Anticoagulant Therapy
Several days after giving birth, a 33-year-old woman presented to the ED of a Michigan hospital with a recent history of dyspnea, chest pain, headaches, and abdominal pain. She was seen and treated by an emergency physician and an obstetrician/gynecologist. An order was issued for chest CT in accordance with a pulmonary embolism protocol, and heparin was administered. Following CT, the patient allegedly claimed that her chest pain had resolved. The attending radiologist’s report revealed no pulmonary embolism. The woman was discharged less than four hours later, without undergoing any further testing.

The next day, the patient went to the ED at a different hospital with complaints of headache and right-sided weakness. CT performed there revealed a large left parietal lobe intracerebral hematoma. Over the next two days, a ventricular catheter was placed and a stereotactic craniotomy was performed in order to evacuate the hematoma. The patient underwent two additional surgeries and was transferred to a rehabilitation facility about one month later. She was discharged home with permanent neurologic damage, including short-term memory loss and an inability to lift or walk for any great distance.

The plaintiff claimed that both physicians failed to diagnose and treat her acute neurologic event in a timely fashion and failed to obtain consults with appropriate specialists. The plaintiff claimed that the physicians were negligent in administering an anticoagulant and that protamine therapy should have been started to reverse the anticoagulant effects. The plaintiff claimed that laboratory testing of clotting times and a ventilation-perfusion lung scan should have been conducted to confirm or rule out the presence of a pulmonary embolism.

The defendants contended that the administration of anticoagulants was appropriate in the face of suspected pulmonary embolism. The defendants also denied any evidence that the heparin given to the patient the day before her stroke was a factor in the subsequent neurologic event. The obstetrician/gynecologist was dismissed from the case prior to trial.

According to a published account, a defense verdict was returned.

Severed Artery Missed After Stabbing
A Virginia man, age 29, was stabbed in a drunken brawl at the home of a friend. The weapon, an 18-inch “dragon dagger” (a curved blade with serration on one side), left a stab wound in the man’s left lateral thigh.

He was taken to a hospital ED within minutes, but on his arrival, he was hypotensive and barely conscious. The emergency physician began IV fluids, ordered a blood transfusion, and sutured the wound. He doubted that a major vessel injury was involved, considering the location of the wound.

About two hours after the patient’s arrival, the emergency physician called the defendant on-call surgeon to apprise him of the patient’s condition and to ask him to admit the patient to the ICU, which the defendant agreed to do. The defendant did not see the patient for three hours, by which time he was coding.

The patient was immediately taken to the operating room, where the defendant found and repaired a severed left internal iliac artery. The surgery took four hours, after which the patient developed disseminated intravascular coagulation and multiorgan failure. He died the next day.

The plaintiff alleged negligence in the defendant’s failure to respond immediately to the emergency physician’s call.

The defendant claimed he had not been told that the ­decedent was in extremis and hemorrhagic shock, or that the emergency department staff needed his help. The defendant also maintained that the emergency physician did not call him a second time. According to the defendant, he had been at the hospital for about 90 minutes after the call from the emergency physician but was not paged by the ICU staff about the decedent’s deterioriating condition for another 90 minutes.

According to a published account, a defense verdict was returned. A defense verdict had been returned earlier on claims against the emergency physician.

Unusually Severe Pain After Colonoscopy
A 49-year-old Michigan woman with persistent complaints of abdominal pain and diarrhea underwent a colonoscopy at a hospital outpatient surgery department in November 2003 to rule out colitis. After the procedure, which was performed by a gastroenterologist, Dr. T., the patient was given standard instructions for follow-up care, including contacting Dr. T. in the event of any unusual developments. She was also advised to follow up with Dr. T. in three to four weeks.

Later that afternoon, a call was made to Dr. T.’s receptionist to report that the patient was experiencing severe pain. On being informed of this, Dr. T. prescribed a 24-hour supply (five tablets) of hydrocodone/acetaminophen. The woman, who had a history of frequent pain medication use, was instructed to go to the hospital ED if the pain persisted.

The next day, the hospital’s anesthesia service made a routine postoperative phone call to the patient, whose husband reported that she had been experiencing severe left lower quadrant pain since the previous evening. He was told to contact the doctor the next day if her condition did not improve. No call was made.

Six days later, when the woman’s husband was helping her dress, he noticed a bruise on her stomach. She was taken to the hospital, where CT revealed a splenic hematoma. An exploratory laparotomy performed the next day revealed adhesions between the colon splenic flexure and the spleen. A splenectomy was performed. During a second exploratory laparotomy about two weeks later, a left subphrenic hematoma was found and drained. The patient was discharged in February 2004.

In addition to the splenic problem, the woman had an esophageal stricture, which left her unable to eat. She was given J-tube nutrition, which was not sufficient. She experienced several episodes of dehydration and was losing weight as a result of malnutrition.

Her case was transferred to another physician group. An operative surgical repair was considered but could not be performed unless the patient weighed at least 115 lb. She died in December 2004 weighing 70 lb.

The plaintiff claimed that the decedent suffered a large subcapsular splenic hematoma after the colonoscopy, necessitating the splenectomy. The plaintiff contended that the multiple surgeries and esophageal stenosis led to dehydration and malnutrition, preventing the possibility of treatment and resulting in the woman’s death.

Dr. T. claimed there was no negligence and that neither the decedent nor her husband followed up with him regarding her pain. Dr. T. argued that the decedent had reported what are known complications of a colonoscopy.

According to a published account, a defense verdict was re­turned. 

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

No Action Taken in Suspected Appendiceal Abscess
In 2002, a New Jersey man presented to the defendant family practitioner, Dr. W., with complaints of a cold, a sore throat, and abdominal discomfort. Dr. W. referred the patient to a county hospital for abdominal CT. A radiologist there found evidence of a prior appendiceal abscess but no evidence of inflammatory changes.

The radiologist recommended a clinical consultation to determine whether the CT results, when correlated with other clinical findings, indicated appendicitis or some other condition. On being questioned by Dr. W., the patient denied having any right lower quadrant pain.

The man continued to be seen by Dr. W. for longer than two years for various medical needs. One day at work in February 2005, the man began to experience severe abdominal pain in the right lower quadrant. He went to Dr. W.’s office and was sent to an emergency department (ED), where he was admitted to the hospital to undergo surgery to treat appendicitis, including removal of his appendix.

The postsurgical pathology report included a finding of appendiceal carcinoma, which had advanced to the point of perforating the wall of the appendix. In response to results from further testing, a right hemicolectomy was performed with removal of lymph nodes that were found negative for cancer.

The patient underwent chemotherapy and experienced no recurrence of the cancer. He did experience complications as a result of the hemicolectomy, however, which required lysis of adhesions in September 2005. In 2006, the man underwent surgeries for treatment of five hernias.

The plaintiff claimed that Dr. W. should have referred him to a surgeon in 2002 at the time of his initial visit. The plaintiff claimed that the CT findings made surgery necessary to confirm their cause and to prevent persistent appendicitis. The plaintiff claimed that surgery at that time would have led to a diagnosis of cancer prior to perforation of the appendix wall.

The defendant countered that in 2002, the plaintiff had no clinical complaints to warrant referral to a surgeon.

According to a published account, a defense verdict was returned.

Stroke and Intracerebral Hematoma After Anticoagulant Therapy
Several days after giving birth, a 33-year-old woman presented to the ED of a Michigan hospital with a recent history of dyspnea, chest pain, headaches, and abdominal pain. She was seen and treated by an emergency physician and an obstetrician/gynecologist. An order was issued for chest CT in accordance with a pulmonary embolism protocol, and heparin was administered. Following CT, the patient allegedly claimed that her chest pain had resolved. The attending radiologist’s report revealed no pulmonary embolism. The woman was discharged less than four hours later, without undergoing any further testing.

The next day, the patient went to the ED at a different hospital with complaints of headache and right-sided weakness. CT performed there revealed a large left parietal lobe intracerebral hematoma. Over the next two days, a ventricular catheter was placed and a stereotactic craniotomy was performed in order to evacuate the hematoma. The patient underwent two additional surgeries and was transferred to a rehabilitation facility about one month later. She was discharged home with permanent neurologic damage, including short-term memory loss and an inability to lift or walk for any great distance.

The plaintiff claimed that both physicians failed to diagnose and treat her acute neurologic event in a timely fashion and failed to obtain consults with appropriate specialists. The plaintiff claimed that the physicians were negligent in administering an anticoagulant and that protamine therapy should have been started to reverse the anticoagulant effects. The plaintiff claimed that laboratory testing of clotting times and a ventilation-perfusion lung scan should have been conducted to confirm or rule out the presence of a pulmonary embolism.

The defendants contended that the administration of anticoagulants was appropriate in the face of suspected pulmonary embolism. The defendants also denied any evidence that the heparin given to the patient the day before her stroke was a factor in the subsequent neurologic event. The obstetrician/gynecologist was dismissed from the case prior to trial.

According to a published account, a defense verdict was returned.

Severed Artery Missed After Stabbing
A Virginia man, age 29, was stabbed in a drunken brawl at the home of a friend. The weapon, an 18-inch “dragon dagger” (a curved blade with serration on one side), left a stab wound in the man’s left lateral thigh.

He was taken to a hospital ED within minutes, but on his arrival, he was hypotensive and barely conscious. The emergency physician began IV fluids, ordered a blood transfusion, and sutured the wound. He doubted that a major vessel injury was involved, considering the location of the wound.

About two hours after the patient’s arrival, the emergency physician called the defendant on-call surgeon to apprise him of the patient’s condition and to ask him to admit the patient to the ICU, which the defendant agreed to do. The defendant did not see the patient for three hours, by which time he was coding.

The patient was immediately taken to the operating room, where the defendant found and repaired a severed left internal iliac artery. The surgery took four hours, after which the patient developed disseminated intravascular coagulation and multiorgan failure. He died the next day.

The plaintiff alleged negligence in the defendant’s failure to respond immediately to the emergency physician’s call.

The defendant claimed he had not been told that the ­decedent was in extremis and hemorrhagic shock, or that the emergency department staff needed his help. The defendant also maintained that the emergency physician did not call him a second time. According to the defendant, he had been at the hospital for about 90 minutes after the call from the emergency physician but was not paged by the ICU staff about the decedent’s deterioriating condition for another 90 minutes.

According to a published account, a defense verdict was returned. A defense verdict had been returned earlier on claims against the emergency physician.

Unusually Severe Pain After Colonoscopy
A 49-year-old Michigan woman with persistent complaints of abdominal pain and diarrhea underwent a colonoscopy at a hospital outpatient surgery department in November 2003 to rule out colitis. After the procedure, which was performed by a gastroenterologist, Dr. T., the patient was given standard instructions for follow-up care, including contacting Dr. T. in the event of any unusual developments. She was also advised to follow up with Dr. T. in three to four weeks.

Later that afternoon, a call was made to Dr. T.’s receptionist to report that the patient was experiencing severe pain. On being informed of this, Dr. T. prescribed a 24-hour supply (five tablets) of hydrocodone/acetaminophen. The woman, who had a history of frequent pain medication use, was instructed to go to the hospital ED if the pain persisted.

The next day, the hospital’s anesthesia service made a routine postoperative phone call to the patient, whose husband reported that she had been experiencing severe left lower quadrant pain since the previous evening. He was told to contact the doctor the next day if her condition did not improve. No call was made.

Six days later, when the woman’s husband was helping her dress, he noticed a bruise on her stomach. She was taken to the hospital, where CT revealed a splenic hematoma. An exploratory laparotomy performed the next day revealed adhesions between the colon splenic flexure and the spleen. A splenectomy was performed. During a second exploratory laparotomy about two weeks later, a left subphrenic hematoma was found and drained. The patient was discharged in February 2004.

In addition to the splenic problem, the woman had an esophageal stricture, which left her unable to eat. She was given J-tube nutrition, which was not sufficient. She experienced several episodes of dehydration and was losing weight as a result of malnutrition.

Her case was transferred to another physician group. An operative surgical repair was considered but could not be performed unless the patient weighed at least 115 lb. She died in December 2004 weighing 70 lb.

The plaintiff claimed that the decedent suffered a large subcapsular splenic hematoma after the colonoscopy, necessitating the splenectomy. The plaintiff contended that the multiple surgeries and esophageal stenosis led to dehydration and malnutrition, preventing the possibility of treatment and resulting in the woman’s death.

Dr. T. claimed there was no negligence and that neither the decedent nor her husband followed up with him regarding her pain. Dr. T. argued that the decedent had reported what are known complications of a colonoscopy.

According to a published account, a defense verdict was re­turned. 

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

No Action Taken in Suspected Appendiceal Abscess
In 2002, a New Jersey man presented to the defendant family practitioner, Dr. W., with complaints of a cold, a sore throat, and abdominal discomfort. Dr. W. referred the patient to a county hospital for abdominal CT. A radiologist there found evidence of a prior appendiceal abscess but no evidence of inflammatory changes.

The radiologist recommended a clinical consultation to determine whether the CT results, when correlated with other clinical findings, indicated appendicitis or some other condition. On being questioned by Dr. W., the patient denied having any right lower quadrant pain.

The man continued to be seen by Dr. W. for longer than two years for various medical needs. One day at work in February 2005, the man began to experience severe abdominal pain in the right lower quadrant. He went to Dr. W.’s office and was sent to an emergency department (ED), where he was admitted to the hospital to undergo surgery to treat appendicitis, including removal of his appendix.

The postsurgical pathology report included a finding of appendiceal carcinoma, which had advanced to the point of perforating the wall of the appendix. In response to results from further testing, a right hemicolectomy was performed with removal of lymph nodes that were found negative for cancer.

The patient underwent chemotherapy and experienced no recurrence of the cancer. He did experience complications as a result of the hemicolectomy, however, which required lysis of adhesions in September 2005. In 2006, the man underwent surgeries for treatment of five hernias.

The plaintiff claimed that Dr. W. should have referred him to a surgeon in 2002 at the time of his initial visit. The plaintiff claimed that the CT findings made surgery necessary to confirm their cause and to prevent persistent appendicitis. The plaintiff claimed that surgery at that time would have led to a diagnosis of cancer prior to perforation of the appendix wall.

The defendant countered that in 2002, the plaintiff had no clinical complaints to warrant referral to a surgeon.

According to a published account, a defense verdict was returned.

Stroke and Intracerebral Hematoma After Anticoagulant Therapy
Several days after giving birth, a 33-year-old woman presented to the ED of a Michigan hospital with a recent history of dyspnea, chest pain, headaches, and abdominal pain. She was seen and treated by an emergency physician and an obstetrician/gynecologist. An order was issued for chest CT in accordance with a pulmonary embolism protocol, and heparin was administered. Following CT, the patient allegedly claimed that her chest pain had resolved. The attending radiologist’s report revealed no pulmonary embolism. The woman was discharged less than four hours later, without undergoing any further testing.

The next day, the patient went to the ED at a different hospital with complaints of headache and right-sided weakness. CT performed there revealed a large left parietal lobe intracerebral hematoma. Over the next two days, a ventricular catheter was placed and a stereotactic craniotomy was performed in order to evacuate the hematoma. The patient underwent two additional surgeries and was transferred to a rehabilitation facility about one month later. She was discharged home with permanent neurologic damage, including short-term memory loss and an inability to lift or walk for any great distance.

The plaintiff claimed that both physicians failed to diagnose and treat her acute neurologic event in a timely fashion and failed to obtain consults with appropriate specialists. The plaintiff claimed that the physicians were negligent in administering an anticoagulant and that protamine therapy should have been started to reverse the anticoagulant effects. The plaintiff claimed that laboratory testing of clotting times and a ventilation-perfusion lung scan should have been conducted to confirm or rule out the presence of a pulmonary embolism.

The defendants contended that the administration of anticoagulants was appropriate in the face of suspected pulmonary embolism. The defendants also denied any evidence that the heparin given to the patient the day before her stroke was a factor in the subsequent neurologic event. The obstetrician/gynecologist was dismissed from the case prior to trial.

According to a published account, a defense verdict was returned.

Severed Artery Missed After Stabbing
A Virginia man, age 29, was stabbed in a drunken brawl at the home of a friend. The weapon, an 18-inch “dragon dagger” (a curved blade with serration on one side), left a stab wound in the man’s left lateral thigh.

He was taken to a hospital ED within minutes, but on his arrival, he was hypotensive and barely conscious. The emergency physician began IV fluids, ordered a blood transfusion, and sutured the wound. He doubted that a major vessel injury was involved, considering the location of the wound.

About two hours after the patient’s arrival, the emergency physician called the defendant on-call surgeon to apprise him of the patient’s condition and to ask him to admit the patient to the ICU, which the defendant agreed to do. The defendant did not see the patient for three hours, by which time he was coding.

The patient was immediately taken to the operating room, where the defendant found and repaired a severed left internal iliac artery. The surgery took four hours, after which the patient developed disseminated intravascular coagulation and multiorgan failure. He died the next day.

The plaintiff alleged negligence in the defendant’s failure to respond immediately to the emergency physician’s call.

The defendant claimed he had not been told that the ­decedent was in extremis and hemorrhagic shock, or that the emergency department staff needed his help. The defendant also maintained that the emergency physician did not call him a second time. According to the defendant, he had been at the hospital for about 90 minutes after the call from the emergency physician but was not paged by the ICU staff about the decedent’s deterioriating condition for another 90 minutes.

According to a published account, a defense verdict was returned. A defense verdict had been returned earlier on claims against the emergency physician.

Unusually Severe Pain After Colonoscopy
A 49-year-old Michigan woman with persistent complaints of abdominal pain and diarrhea underwent a colonoscopy at a hospital outpatient surgery department in November 2003 to rule out colitis. After the procedure, which was performed by a gastroenterologist, Dr. T., the patient was given standard instructions for follow-up care, including contacting Dr. T. in the event of any unusual developments. She was also advised to follow up with Dr. T. in three to four weeks.

Later that afternoon, a call was made to Dr. T.’s receptionist to report that the patient was experiencing severe pain. On being informed of this, Dr. T. prescribed a 24-hour supply (five tablets) of hydrocodone/acetaminophen. The woman, who had a history of frequent pain medication use, was instructed to go to the hospital ED if the pain persisted.

The next day, the hospital’s anesthesia service made a routine postoperative phone call to the patient, whose husband reported that she had been experiencing severe left lower quadrant pain since the previous evening. He was told to contact the doctor the next day if her condition did not improve. No call was made.

Six days later, when the woman’s husband was helping her dress, he noticed a bruise on her stomach. She was taken to the hospital, where CT revealed a splenic hematoma. An exploratory laparotomy performed the next day revealed adhesions between the colon splenic flexure and the spleen. A splenectomy was performed. During a second exploratory laparotomy about two weeks later, a left subphrenic hematoma was found and drained. The patient was discharged in February 2004.

In addition to the splenic problem, the woman had an esophageal stricture, which left her unable to eat. She was given J-tube nutrition, which was not sufficient. She experienced several episodes of dehydration and was losing weight as a result of malnutrition.

Her case was transferred to another physician group. An operative surgical repair was considered but could not be performed unless the patient weighed at least 115 lb. She died in December 2004 weighing 70 lb.

The plaintiff claimed that the decedent suffered a large subcapsular splenic hematoma after the colonoscopy, necessitating the splenectomy. The plaintiff contended that the multiple surgeries and esophageal stenosis led to dehydration and malnutrition, preventing the possibility of treatment and resulting in the woman’s death.

Dr. T. claimed there was no negligence and that neither the decedent nor her husband followed up with him regarding her pain. Dr. T. argued that the decedent had reported what are known complications of a colonoscopy.

According to a published account, a defense verdict was re­turned. 

Woman refuses hysterectomy,
dies of invasive cancer

A 37-YEAR-OLD WOMAN VISITED HER GYNECOLOGIST for an annual physical exam. A Pap smear revealed human papillomavirus (HPV) infection and abnormal cells. The pathology report after cone biopsy indicated adenoid cystic carcinoma. The physician told the patient that she needed a hysterectomy, which she refused.

The patient visited her primary care physician 9 months later because of abdominal bloating. He palpated a pelvic mass and sent her for a CT scan, which showed a mass within the pelvis as well as liver metastases. Surgery was not an option because of the metastases. Chemotherapy was started but the woman died in less than a month.

ESTATE’S CLAIM Although the gynecologist told the patient she needed a hysterectomy, he did not 1) correctly report the results of the biopsy or 2) explain the reasons why he was recommending hysterectomy.

PHYSICIAN’S DEFENSE The patient was properly treated when advised to have a hysterectomy. She refused treatment

VERDICT A $1.4 million Virginia settlement was reached.

NEONATAL DEATH FROM GROUP B STREP

AN INMATE AT A STATE PRISON gave birth to a healthy baby at 39 weeks’ gestation. The baby died the next day from a perinatal group B Streptococcal (GBS) infection.

ESTATE’S CLAIM The two ObGyns who treated the mother were negligent: the mother’s GBS status was unknown; she was never informed that she needed GBS testing; testing was not administered.

PHYSICIANS’ DEFENSE The primary ObGyn (Dr. A) denied negligence. The other (Dr. B) claimed that he had no duty to administer GBS testing because he was not the primary ObGyn. Prophylactic antibiotics in the absence of certain risk factors—none were present—were inappropriate.

VERDICT A $150,000 California settlement was reached with Dr. A. A defense verdict was returned for Dr. B.

>> READ New group B strep guidelines clarify management of key groups.

DIFFICULT DELIVERY, INJURED BABY

FETAL HEART RATE TRACING was not reassuring, and the fetus did not descend during prolonged labor and delivery. After more than 15 minutes of bradycardia, the hospital staff contacted the ObGyn, who then ordered cesarean delivery. At the initiation of surgery, the anesthetic was insufficient and the mother was unable to tolerate the abdominal incision.

The child has cerebral palsy and suffers motor delays and moderate cognitive deficits.

PATIENTS’ CLAIM The ObGyn failed to recognize cephalopelvic dispro-portion. The hospital staff misread fetal monitoring strips, delaying response to fetal distress because the umbilical cord was compressed between the baby’s cheekbone and maternal pelvis. A cesarean delivery should have been performed earlier, immediately after the baby showed signs of distress. The staff administered the wrong type of anesthetic to the mother before surgery.

DEFENDANTS’ DEFENSE Proper care was provided. An occult prolapsed cord was unpredictable, unpreventable, and unforeseeable.

VERDICT A $6.5 million Illinois settlement was reached, including $300,000 for the mother.

FISTULA CAUSES INCONTINENCE, PROMPTS MULTIPLE SURGERIES

SEVERAL WEEKS AFTER a vaginal hysterectomy, a woman presented with urinary incontinence; vesicovaginal fistula was diagnosed. She underwent 9 surgeries to repair the bladder injury and fistula.

PATIENT’S CLAIM The injury occurred because the gynecologist used improper technique when retracting the bladder. He should have inspected the bladder for injury before finishing the operation.

PHYSICIAN’S DEFENSE Bladder injury is a known risk of laparoscopic transvaginal hysterectomy.

VERDICT A $796,617 Michigan verdict was returned.

URETER KINKS DURING DIFFICULT HYSTERECTOMY

A 36-YEAR-OLD WOMAN PRESENTED to her gynecologist complaining of heavy menses and abdominal and pelvic pain, especially in the lower left quadrant. Total abdominal hysterectomy was scheduled. During surgery, the gynecologist found that the bladder was densely adhered to the uterus. Brisk bleeding followed attempts to separate the bladder from the uterus. The physician placed a single suture to stop the bleeding, and the procedure was completed.

Three days later, she had pain in the right kidney area; testing determined her right ureter was kinked. She was sent to another hospital for placement of a stent and nephrostomy tube, which were removed 4 months later.

PATIENT’S CLAIM The gynecologist was negligent in failing to provide the patient with alternatives to hysterectomy, and in injuring the ureter during hysterectomy.

PHYSICIAN’S DEFENSE Four treatment options were provided to the patient. The injury is a known complication of the surgery. The patient has completely recovered.

VERDICT A Pennsylvania defense verdict was returned.

WOMAN DELIVERS AT HOME AFTER FETUS DIES

AT 16 WEEKS’ GESTATION, a woman went to the hospital complaining of vaginal discharge. Ultrasonography revealed that the fetus had died. The woman’s cervix was not dilated; when the hospital staff attempted to discharge her, she resisted. Hospital officials threatened to call the police if she did not leave. She left, and later delivered the dead fetus at home. She then called her ObGyn, who promptly admitted her for emergency dilation and curettage to remove the remaining placental tissue.

PATIENT’S CLAIM She alleged a violation of the Emergency Medical Treatment and Active Labor Act (EMTALA), arguing that instead of stabilizing her, she was sent home under the threat of police intervention.

DEFENDANT’S DEFENSE The hospital claimed it had done all it could for the patient; she was not ready to deliver the fetus. She was given instructions to see her ObGyn or return if her condition changed. She never returned.

VERDICT A Maine verdict of $50,000 compensatory damages was returned against the hospital. The jury added $150,000 for punitive damages.

A SECOND ECTOPIC PREGNANCY?

FOUR YEARS AFTER SUFFERING a ruptured tubal ectopic pregnancy that necessitated salpingectomy, a 30-year-old woman became pregnant again. At her first prenatal visit to a hospital clinic, she saw a certified nurse midwife. The patient reported the prior ectopic pregnancy and complained of spotting with left-sided pain, nausea, and vomiting. Six days later, she went to the emergency department and was given a diagnosis of a ruptured fallopian tube from an ectopic pregnancy. Surgery was performed to remove the fallopian tube, thus making her unable to naturally conceive a child.

PATIENT’S CLAIM The midwife should have responded immediately to the patient’s symptoms, ordered a sonogram, and sent her to the hospital. Any of several available options would have saved the fallopian tube if the ectopic pregnancy had been diagnosed before rupture. The patient has spiritual and moral objections to in vitro fertilization.

MIDWIFE’S DEFENSE The midwife ordered a Stat sonogram at the first prenatal visit, but the prescription form was never removed from the chart, and the sonogram never scheduled. It was the hospital’s responsibility to get the form to the plaintiff and have the procedure scheduled. The midwife was therefore not at fault.

VERDICT A $2.5 million Maryland verdict was returned; it was reduced under the state cap to $650,000.

OBGYN UNDERESTIMATES BIRTH WEIGHT—BY APPROXIMATELY 50%

A PREGNANT WOMAN WITH BACK PAIN went to the emergency department. She was discharged but returned the next day with the same complaint, and, shortly, went into labor. The ObGyn, who estimated fetal weight at 7 or 8 lbs, delivered the baby using a vacuum extractor. Shoulder dystocia was encountered, and four maneuvers were used to deliver the baby, who weighed more than 11 lbs at birth. The baby suffered global brachial plexus injury.

PATIENT’S CLAIM The ObGyn was negligent: in underestimating fetal weight; in failing to offer cesarean delivery after 2 hours of second-stage labor; and in applying excessive force to deliver the baby.

PHYSICIAN’S DEFENSE Fetal weight is almost impossible to accurately estimate. A cesarean delivery was unnecessary. Only gentle traction was used to deliver the child.

VERDICT An Illinois defense verdict was returned.

Woman refuses hysterectomy,
dies of invasive cancer

A 37-YEAR-OLD WOMAN VISITED HER GYNECOLOGIST for an annual physical exam. A Pap smear revealed human papillomavirus (HPV) infection and abnormal cells. The pathology report after cone biopsy indicated adenoid cystic carcinoma. The physician told the patient that she needed a hysterectomy, which she refused.

The patient visited her primary care physician 9 months later because of abdominal bloating. He palpated a pelvic mass and sent her for a CT scan, which showed a mass within the pelvis as well as liver metastases. Surgery was not an option because of the metastases. Chemotherapy was started but the woman died in less than a month.

ESTATE’S CLAIM Although the gynecologist told the patient she needed a hysterectomy, he did not 1) correctly report the results of the biopsy or 2) explain the reasons why he was recommending hysterectomy.

PHYSICIAN’S DEFENSE The patient was properly treated when advised to have a hysterectomy. She refused treatment

VERDICT A $1.4 million Virginia settlement was reached.

NEONATAL DEATH FROM GROUP B STREP

AN INMATE AT A STATE PRISON gave birth to a healthy baby at 39 weeks’ gestation. The baby died the next day from a perinatal group B Streptococcal (GBS) infection.

ESTATE’S CLAIM The two ObGyns who treated the mother were negligent: the mother’s GBS status was unknown; she was never informed that she needed GBS testing; testing was not administered.

PHYSICIANS’ DEFENSE The primary ObGyn (Dr. A) denied negligence. The other (Dr. B) claimed that he had no duty to administer GBS testing because he was not the primary ObGyn. Prophylactic antibiotics in the absence of certain risk factors—none were present—were inappropriate.

VERDICT A $150,000 California settlement was reached with Dr. A. A defense verdict was returned for Dr. B.

>> READ New group B strep guidelines clarify management of key groups.

DIFFICULT DELIVERY, INJURED BABY

FETAL HEART RATE TRACING was not reassuring, and the fetus did not descend during prolonged labor and delivery. After more than 15 minutes of bradycardia, the hospital staff contacted the ObGyn, who then ordered cesarean delivery. At the initiation of surgery, the anesthetic was insufficient and the mother was unable to tolerate the abdominal incision.

The child has cerebral palsy and suffers motor delays and moderate cognitive deficits.

PATIENTS’ CLAIM The ObGyn failed to recognize cephalopelvic dispro-portion. The hospital staff misread fetal monitoring strips, delaying response to fetal distress because the umbilical cord was compressed between the baby’s cheekbone and maternal pelvis. A cesarean delivery should have been performed earlier, immediately after the baby showed signs of distress. The staff administered the wrong type of anesthetic to the mother before surgery.

DEFENDANTS’ DEFENSE Proper care was provided. An occult prolapsed cord was unpredictable, unpreventable, and unforeseeable.

VERDICT A $6.5 million Illinois settlement was reached, including $300,000 for the mother.

FISTULA CAUSES INCONTINENCE, PROMPTS MULTIPLE SURGERIES

SEVERAL WEEKS AFTER a vaginal hysterectomy, a woman presented with urinary incontinence; vesicovaginal fistula was diagnosed. She underwent 9 surgeries to repair the bladder injury and fistula.

PATIENT’S CLAIM The injury occurred because the gynecologist used improper technique when retracting the bladder. He should have inspected the bladder for injury before finishing the operation.

PHYSICIAN’S DEFENSE Bladder injury is a known risk of laparoscopic transvaginal hysterectomy.

VERDICT A $796,617 Michigan verdict was returned.

URETER KINKS DURING DIFFICULT HYSTERECTOMY

A 36-YEAR-OLD WOMAN PRESENTED to her gynecologist complaining of heavy menses and abdominal and pelvic pain, especially in the lower left quadrant. Total abdominal hysterectomy was scheduled. During surgery, the gynecologist found that the bladder was densely adhered to the uterus. Brisk bleeding followed attempts to separate the bladder from the uterus. The physician placed a single suture to stop the bleeding, and the procedure was completed.

Three days later, she had pain in the right kidney area; testing determined her right ureter was kinked. She was sent to another hospital for placement of a stent and nephrostomy tube, which were removed 4 months later.

PATIENT’S CLAIM The gynecologist was negligent in failing to provide the patient with alternatives to hysterectomy, and in injuring the ureter during hysterectomy.

PHYSICIAN’S DEFENSE Four treatment options were provided to the patient. The injury is a known complication of the surgery. The patient has completely recovered.

VERDICT A Pennsylvania defense verdict was returned.

WOMAN DELIVERS AT HOME AFTER FETUS DIES

AT 16 WEEKS’ GESTATION, a woman went to the hospital complaining of vaginal discharge. Ultrasonography revealed that the fetus had died. The woman’s cervix was not dilated; when the hospital staff attempted to discharge her, she resisted. Hospital officials threatened to call the police if she did not leave. She left, and later delivered the dead fetus at home. She then called her ObGyn, who promptly admitted her for emergency dilation and curettage to remove the remaining placental tissue.

PATIENT’S CLAIM She alleged a violation of the Emergency Medical Treatment and Active Labor Act (EMTALA), arguing that instead of stabilizing her, she was sent home under the threat of police intervention.

DEFENDANT’S DEFENSE The hospital claimed it had done all it could for the patient; she was not ready to deliver the fetus. She was given instructions to see her ObGyn or return if her condition changed. She never returned.

VERDICT A Maine verdict of $50,000 compensatory damages was returned against the hospital. The jury added $150,000 for punitive damages.

A SECOND ECTOPIC PREGNANCY?

FOUR YEARS AFTER SUFFERING a ruptured tubal ectopic pregnancy that necessitated salpingectomy, a 30-year-old woman became pregnant again. At her first prenatal visit to a hospital clinic, she saw a certified nurse midwife. The patient reported the prior ectopic pregnancy and complained of spotting with left-sided pain, nausea, and vomiting. Six days later, she went to the emergency department and was given a diagnosis of a ruptured fallopian tube from an ectopic pregnancy. Surgery was performed to remove the fallopian tube, thus making her unable to naturally conceive a child.

PATIENT’S CLAIM The midwife should have responded immediately to the patient’s symptoms, ordered a sonogram, and sent her to the hospital. Any of several available options would have saved the fallopian tube if the ectopic pregnancy had been diagnosed before rupture. The patient has spiritual and moral objections to in vitro fertilization.

MIDWIFE’S DEFENSE The midwife ordered a Stat sonogram at the first prenatal visit, but the prescription form was never removed from the chart, and the sonogram never scheduled. It was the hospital’s responsibility to get the form to the plaintiff and have the procedure scheduled. The midwife was therefore not at fault.

VERDICT A $2.5 million Maryland verdict was returned; it was reduced under the state cap to $650,000.

OBGYN UNDERESTIMATES BIRTH WEIGHT—BY APPROXIMATELY 50%

A PREGNANT WOMAN WITH BACK PAIN went to the emergency department. She was discharged but returned the next day with the same complaint, and, shortly, went into labor. The ObGyn, who estimated fetal weight at 7 or 8 lbs, delivered the baby using a vacuum extractor. Shoulder dystocia was encountered, and four maneuvers were used to deliver the baby, who weighed more than 11 lbs at birth. The baby suffered global brachial plexus injury.

PATIENT’S CLAIM The ObGyn was negligent: in underestimating fetal weight; in failing to offer cesarean delivery after 2 hours of second-stage labor; and in applying excessive force to deliver the baby.

PHYSICIAN’S DEFENSE Fetal weight is almost impossible to accurately estimate. A cesarean delivery was unnecessary. Only gentle traction was used to deliver the child.

VERDICT An Illinois defense verdict was returned.

Woman refuses hysterectomy,
dies of invasive cancer

A 37-YEAR-OLD WOMAN VISITED HER GYNECOLOGIST for an annual physical exam. A Pap smear revealed human papillomavirus (HPV) infection and abnormal cells. The pathology report after cone biopsy indicated adenoid cystic carcinoma. The physician told the patient that she needed a hysterectomy, which she refused.

The patient visited her primary care physician 9 months later because of abdominal bloating. He palpated a pelvic mass and sent her for a CT scan, which showed a mass within the pelvis as well as liver metastases. Surgery was not an option because of the metastases. Chemotherapy was started but the woman died in less than a month.

ESTATE’S CLAIM Although the gynecologist told the patient she needed a hysterectomy, he did not 1) correctly report the results of the biopsy or 2) explain the reasons why he was recommending hysterectomy.

PHYSICIAN’S DEFENSE The patient was properly treated when advised to have a hysterectomy. She refused treatment

VERDICT A $1.4 million Virginia settlement was reached.

NEONATAL DEATH FROM GROUP B STREP

AN INMATE AT A STATE PRISON gave birth to a healthy baby at 39 weeks’ gestation. The baby died the next day from a perinatal group B Streptococcal (GBS) infection.

ESTATE’S CLAIM The two ObGyns who treated the mother were negligent: the mother’s GBS status was unknown; she was never informed that she needed GBS testing; testing was not administered.

PHYSICIANS’ DEFENSE The primary ObGyn (Dr. A) denied negligence. The other (Dr. B) claimed that he had no duty to administer GBS testing because he was not the primary ObGyn. Prophylactic antibiotics in the absence of certain risk factors—none were present—were inappropriate.

VERDICT A $150,000 California settlement was reached with Dr. A. A defense verdict was returned for Dr. B.

>> READ New group B strep guidelines clarify management of key groups.

DIFFICULT DELIVERY, INJURED BABY

FETAL HEART RATE TRACING was not reassuring, and the fetus did not descend during prolonged labor and delivery. After more than 15 minutes of bradycardia, the hospital staff contacted the ObGyn, who then ordered cesarean delivery. At the initiation of surgery, the anesthetic was insufficient and the mother was unable to tolerate the abdominal incision.

The child has cerebral palsy and suffers motor delays and moderate cognitive deficits.

PATIENTS’ CLAIM The ObGyn failed to recognize cephalopelvic dispro-portion. The hospital staff misread fetal monitoring strips, delaying response to fetal distress because the umbilical cord was compressed between the baby’s cheekbone and maternal pelvis. A cesarean delivery should have been performed earlier, immediately after the baby showed signs of distress. The staff administered the wrong type of anesthetic to the mother before surgery.

DEFENDANTS’ DEFENSE Proper care was provided. An occult prolapsed cord was unpredictable, unpreventable, and unforeseeable.

VERDICT A $6.5 million Illinois settlement was reached, including $300,000 for the mother.

FISTULA CAUSES INCONTINENCE, PROMPTS MULTIPLE SURGERIES

SEVERAL WEEKS AFTER a vaginal hysterectomy, a woman presented with urinary incontinence; vesicovaginal fistula was diagnosed. She underwent 9 surgeries to repair the bladder injury and fistula.

PATIENT’S CLAIM The injury occurred because the gynecologist used improper technique when retracting the bladder. He should have inspected the bladder for injury before finishing the operation.

PHYSICIAN’S DEFENSE Bladder injury is a known risk of laparoscopic transvaginal hysterectomy.

VERDICT A $796,617 Michigan verdict was returned.

URETER KINKS DURING DIFFICULT HYSTERECTOMY

A 36-YEAR-OLD WOMAN PRESENTED to her gynecologist complaining of heavy menses and abdominal and pelvic pain, especially in the lower left quadrant. Total abdominal hysterectomy was scheduled. During surgery, the gynecologist found that the bladder was densely adhered to the uterus. Brisk bleeding followed attempts to separate the bladder from the uterus. The physician placed a single suture to stop the bleeding, and the procedure was completed.

Three days later, she had pain in the right kidney area; testing determined her right ureter was kinked. She was sent to another hospital for placement of a stent and nephrostomy tube, which were removed 4 months later.

PATIENT’S CLAIM The gynecologist was negligent in failing to provide the patient with alternatives to hysterectomy, and in injuring the ureter during hysterectomy.

PHYSICIAN’S DEFENSE Four treatment options were provided to the patient. The injury is a known complication of the surgery. The patient has completely recovered.

VERDICT A Pennsylvania defense verdict was returned.

WOMAN DELIVERS AT HOME AFTER FETUS DIES

AT 16 WEEKS’ GESTATION, a woman went to the hospital complaining of vaginal discharge. Ultrasonography revealed that the fetus had died. The woman’s cervix was not dilated; when the hospital staff attempted to discharge her, she resisted. Hospital officials threatened to call the police if she did not leave. She left, and later delivered the dead fetus at home. She then called her ObGyn, who promptly admitted her for emergency dilation and curettage to remove the remaining placental tissue.

PATIENT’S CLAIM She alleged a violation of the Emergency Medical Treatment and Active Labor Act (EMTALA), arguing that instead of stabilizing her, she was sent home under the threat of police intervention.

DEFENDANT’S DEFENSE The hospital claimed it had done all it could for the patient; she was not ready to deliver the fetus. She was given instructions to see her ObGyn or return if her condition changed. She never returned.

VERDICT A Maine verdict of $50,000 compensatory damages was returned against the hospital. The jury added $150,000 for punitive damages.

A SECOND ECTOPIC PREGNANCY?

FOUR YEARS AFTER SUFFERING a ruptured tubal ectopic pregnancy that necessitated salpingectomy, a 30-year-old woman became pregnant again. At her first prenatal visit to a hospital clinic, she saw a certified nurse midwife. The patient reported the prior ectopic pregnancy and complained of spotting with left-sided pain, nausea, and vomiting. Six days later, she went to the emergency department and was given a diagnosis of a ruptured fallopian tube from an ectopic pregnancy. Surgery was performed to remove the fallopian tube, thus making her unable to naturally conceive a child.

PATIENT’S CLAIM The midwife should have responded immediately to the patient’s symptoms, ordered a sonogram, and sent her to the hospital. Any of several available options would have saved the fallopian tube if the ectopic pregnancy had been diagnosed before rupture. The patient has spiritual and moral objections to in vitro fertilization.

MIDWIFE’S DEFENSE The midwife ordered a Stat sonogram at the first prenatal visit, but the prescription form was never removed from the chart, and the sonogram never scheduled. It was the hospital’s responsibility to get the form to the plaintiff and have the procedure scheduled. The midwife was therefore not at fault.

VERDICT A $2.5 million Maryland verdict was returned; it was reduced under the state cap to $650,000.

OBGYN UNDERESTIMATES BIRTH WEIGHT—BY APPROXIMATELY 50%

A PREGNANT WOMAN WITH BACK PAIN went to the emergency department. She was discharged but returned the next day with the same complaint, and, shortly, went into labor. The ObGyn, who estimated fetal weight at 7 or 8 lbs, delivered the baby using a vacuum extractor. Shoulder dystocia was encountered, and four maneuvers were used to deliver the baby, who weighed more than 11 lbs at birth. The baby suffered global brachial plexus injury.

PATIENT’S CLAIM The ObGyn was negligent: in underestimating fetal weight; in failing to offer cesarean delivery after 2 hours of second-stage labor; and in applying excessive force to deliver the baby.

PHYSICIAN’S DEFENSE Fetal weight is almost impossible to accurately estimate. A cesarean delivery was unnecessary. Only gentle traction was used to deliver the child.

VERDICT An Illinois defense verdict was returned.

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

Overlapping Errors in Inguinal Hernia Repair
At age 59, an Indiana man went to his family doctor complaining of pain in his right groin. He was referred to a surgical group and diagnosed with an inguinal hernia. Surgery was performed in April by Dr. R., a general surgeon.

The day after his discharge, the man began to experience fever and vomiting. He contacted Dr. R.’s office to report these developments, but later claimed that his call was never returned. By the next day, his fever had subsided, but he felt weak and nauseated, and his scrotum had become swollen.

When the patient did speak with Dr. R. later that afternoon, the doctor told him that his symptoms were not unusual. However, the man’s condition continued to worsen; the next day, he had difficulty getting out of bed, and on the fourth day after surgery, he called Dr. R. to report that his scrotum had swollen to the size of a grapefruit. Dr. R. sent him to the emergency department.

At the hospital, Dr. R. performed emergency surgery, during which dead and infected tissue was removed, in addition to a piece of gauze that had apparently been left behind during the initial surgery. It was also discovered that a surgical staple had pierced the patient’s colon, causing a fistula that had become infected.

After the emergency surgery, the patient required ICU care, including ventilation and life support. He also underwent two additional surgeries to remove dead and infected tissue, followed by a third surgery because repair of the colon injury had broken down. After this procedure, the man’s lung collapsed and he experienced cardiac arrest. He spent four weeks on a ventilator.

The patient continued to require rehabilitative care and underwent still one more surgery in August to remove a second piece of gauze from his right groin. He ultimately recovered.

The plaintiff charged the surgeon with negligence for leaving the gauze behind during the initial surgery and for placing a surgical staple in the cecum. The defendant denied any negligence.

According to a published account, a defense verdict was returned.

Risk for Streptococcal Infection Overlooked
In February 2006, a woman who was eight months pregnant experienced abdominal pain and cramping with a mucus-like discharge. Her treating physician ordered a test for group B streptococcal infection.

The next day, the mother presented to a Texas hospital in labor. She gave birth to a girl with the assistance of Dr. O. The infant was cared for by Dr. P. during her three-day hospital stay.

The day after discharge, the infant stopped breathing and was rushed to the hospital, where she was pronounced dead one hour after her arrival. An autopsy determined the cause of death to be streptococcal pneumonia.

The plaintiffs claimed that prophylactic antibiotics should have been administered, and that additional laboratory studies should have been ordered.

The plaintiffs also claimed that within 24 hours of birth, the child lost five ounces and ran a fever for which she was not treated, and that she had an elevated bilirubin level, indicating jaundice. The plaintiffs maintained that the hospital staff should have gone up the chain of command to prevent the infant’s discharge, which had been ordered by Dr. P.

The defendants argued that the mother’s labor proceeded too quickly for antibiotics to be administered, and that a blood culture taken at birth yielded no evidence of infection. The defendants also claimed that the infant’s temperature was normal at the next check and that her bilirubin level was within normal range.

According to a published account, a defense verdict was returned.

Failure to Diagnose Dislocated Knee
A 38-year-old woman sustained a knee injury while staying at a hotel in Arizona. The plaintiff was taken to a regional medical center by ambulance, where an emergency physician diagnosed a tibial plateau fracture but failed to diagnose a dislocated knee and did not perform angiography of the leg.

The patient later required a one-month hospitalization for an occluded popliteal artery, which required a vein graft and fasciotomies of all four compartments.

The plaintiff claimed that if an angiogram had been performed, damage to the popliteal artery and peroneal nerve, which resulted in permanent foot drop, would have been identified and treated.

The plaintiff also claimed that her x-rays were not given to her when she was discharged. If they had been, she argued, her treating physician in California would have diagnosed the dislocation.

The plaintiff also claimed that the emergency physician failed to stress the knee, which would have shown ligament damage consistent with a knee dislocation. Further, the plaintiff claimed that an orthopedic consult should have been ordered.

The plaintiff also claimed the splinting was applied too tightly, and that she developed an infection and subsequent sequelae related to poor blood flow. The plaintiff later underwent tendon transfer surgery in an attempt to stabilize the foot so that she could walk.

The defendants argued that the plaintiff had sustained a tibial plateau fracture, not a dislocation, and that the physical exam was inconsistent with a knee dislocation. The defendants also claimed that the x-ray showed only a tibial plateau fracture and corresponding damage.

Further, the defendants maintained that the splint was applied properly. The defendants claimed that the peroneal nerve damage occurred at the time of the fracture but was not apparent in the ED, and that the resulting nerve deficit developed gradually.

The defendants also argued that even if an angiogram had been performed, it would not have shown a tear.

A defense verdict was returned. According to a published account, the hospital settled for a confidential amount during ­trial.   

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

Overlapping Errors in Inguinal Hernia Repair
At age 59, an Indiana man went to his family doctor complaining of pain in his right groin. He was referred to a surgical group and diagnosed with an inguinal hernia. Surgery was performed in April by Dr. R., a general surgeon.

The day after his discharge, the man began to experience fever and vomiting. He contacted Dr. R.’s office to report these developments, but later claimed that his call was never returned. By the next day, his fever had subsided, but he felt weak and nauseated, and his scrotum had become swollen.

When the patient did speak with Dr. R. later that afternoon, the doctor told him that his symptoms were not unusual. However, the man’s condition continued to worsen; the next day, he had difficulty getting out of bed, and on the fourth day after surgery, he called Dr. R. to report that his scrotum had swollen to the size of a grapefruit. Dr. R. sent him to the emergency department.

At the hospital, Dr. R. performed emergency surgery, during which dead and infected tissue was removed, in addition to a piece of gauze that had apparently been left behind during the initial surgery. It was also discovered that a surgical staple had pierced the patient’s colon, causing a fistula that had become infected.

After the emergency surgery, the patient required ICU care, including ventilation and life support. He also underwent two additional surgeries to remove dead and infected tissue, followed by a third surgery because repair of the colon injury had broken down. After this procedure, the man’s lung collapsed and he experienced cardiac arrest. He spent four weeks on a ventilator.

The patient continued to require rehabilitative care and underwent still one more surgery in August to remove a second piece of gauze from his right groin. He ultimately recovered.

The plaintiff charged the surgeon with negligence for leaving the gauze behind during the initial surgery and for placing a surgical staple in the cecum. The defendant denied any negligence.

According to a published account, a defense verdict was returned.

Risk for Streptococcal Infection Overlooked
In February 2006, a woman who was eight months pregnant experienced abdominal pain and cramping with a mucus-like discharge. Her treating physician ordered a test for group B streptococcal infection.

The next day, the mother presented to a Texas hospital in labor. She gave birth to a girl with the assistance of Dr. O. The infant was cared for by Dr. P. during her three-day hospital stay.

The day after discharge, the infant stopped breathing and was rushed to the hospital, where she was pronounced dead one hour after her arrival. An autopsy determined the cause of death to be streptococcal pneumonia.

The plaintiffs claimed that prophylactic antibiotics should have been administered, and that additional laboratory studies should have been ordered.

The plaintiffs also claimed that within 24 hours of birth, the child lost five ounces and ran a fever for which she was not treated, and that she had an elevated bilirubin level, indicating jaundice. The plaintiffs maintained that the hospital staff should have gone up the chain of command to prevent the infant’s discharge, which had been ordered by Dr. P.

The defendants argued that the mother’s labor proceeded too quickly for antibiotics to be administered, and that a blood culture taken at birth yielded no evidence of infection. The defendants also claimed that the infant’s temperature was normal at the next check and that her bilirubin level was within normal range.

According to a published account, a defense verdict was returned.

Failure to Diagnose Dislocated Knee
A 38-year-old woman sustained a knee injury while staying at a hotel in Arizona. The plaintiff was taken to a regional medical center by ambulance, where an emergency physician diagnosed a tibial plateau fracture but failed to diagnose a dislocated knee and did not perform angiography of the leg.

The patient later required a one-month hospitalization for an occluded popliteal artery, which required a vein graft and fasciotomies of all four compartments.

The plaintiff claimed that if an angiogram had been performed, damage to the popliteal artery and peroneal nerve, which resulted in permanent foot drop, would have been identified and treated.

The plaintiff also claimed that her x-rays were not given to her when she was discharged. If they had been, she argued, her treating physician in California would have diagnosed the dislocation.

The plaintiff also claimed that the emergency physician failed to stress the knee, which would have shown ligament damage consistent with a knee dislocation. Further, the plaintiff claimed that an orthopedic consult should have been ordered.

The plaintiff also claimed the splinting was applied too tightly, and that she developed an infection and subsequent sequelae related to poor blood flow. The plaintiff later underwent tendon transfer surgery in an attempt to stabilize the foot so that she could walk.

The defendants argued that the plaintiff had sustained a tibial plateau fracture, not a dislocation, and that the physical exam was inconsistent with a knee dislocation. The defendants also claimed that the x-ray showed only a tibial plateau fracture and corresponding damage.

Further, the defendants maintained that the splint was applied properly. The defendants claimed that the peroneal nerve damage occurred at the time of the fracture but was not apparent in the ED, and that the resulting nerve deficit developed gradually.

The defendants also argued that even if an angiogram had been performed, it would not have shown a tear.

A defense verdict was returned. According to a published account, the hospital settled for a confidential amount during ­trial.   

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

Overlapping Errors in Inguinal Hernia Repair
At age 59, an Indiana man went to his family doctor complaining of pain in his right groin. He was referred to a surgical group and diagnosed with an inguinal hernia. Surgery was performed in April by Dr. R., a general surgeon.

The day after his discharge, the man began to experience fever and vomiting. He contacted Dr. R.’s office to report these developments, but later claimed that his call was never returned. By the next day, his fever had subsided, but he felt weak and nauseated, and his scrotum had become swollen.

When the patient did speak with Dr. R. later that afternoon, the doctor told him that his symptoms were not unusual. However, the man’s condition continued to worsen; the next day, he had difficulty getting out of bed, and on the fourth day after surgery, he called Dr. R. to report that his scrotum had swollen to the size of a grapefruit. Dr. R. sent him to the emergency department.

At the hospital, Dr. R. performed emergency surgery, during which dead and infected tissue was removed, in addition to a piece of gauze that had apparently been left behind during the initial surgery. It was also discovered that a surgical staple had pierced the patient’s colon, causing a fistula that had become infected.

After the emergency surgery, the patient required ICU care, including ventilation and life support. He also underwent two additional surgeries to remove dead and infected tissue, followed by a third surgery because repair of the colon injury had broken down. After this procedure, the man’s lung collapsed and he experienced cardiac arrest. He spent four weeks on a ventilator.

The patient continued to require rehabilitative care and underwent still one more surgery in August to remove a second piece of gauze from his right groin. He ultimately recovered.

The plaintiff charged the surgeon with negligence for leaving the gauze behind during the initial surgery and for placing a surgical staple in the cecum. The defendant denied any negligence.

According to a published account, a defense verdict was returned.

Risk for Streptococcal Infection Overlooked
In February 2006, a woman who was eight months pregnant experienced abdominal pain and cramping with a mucus-like discharge. Her treating physician ordered a test for group B streptococcal infection.

The next day, the mother presented to a Texas hospital in labor. She gave birth to a girl with the assistance of Dr. O. The infant was cared for by Dr. P. during her three-day hospital stay.

The day after discharge, the infant stopped breathing and was rushed to the hospital, where she was pronounced dead one hour after her arrival. An autopsy determined the cause of death to be streptococcal pneumonia.

The plaintiffs claimed that prophylactic antibiotics should have been administered, and that additional laboratory studies should have been ordered.

The plaintiffs also claimed that within 24 hours of birth, the child lost five ounces and ran a fever for which she was not treated, and that she had an elevated bilirubin level, indicating jaundice. The plaintiffs maintained that the hospital staff should have gone up the chain of command to prevent the infant’s discharge, which had been ordered by Dr. P.

The defendants argued that the mother’s labor proceeded too quickly for antibiotics to be administered, and that a blood culture taken at birth yielded no evidence of infection. The defendants also claimed that the infant’s temperature was normal at the next check and that her bilirubin level was within normal range.

According to a published account, a defense verdict was returned.

Failure to Diagnose Dislocated Knee
A 38-year-old woman sustained a knee injury while staying at a hotel in Arizona. The plaintiff was taken to a regional medical center by ambulance, where an emergency physician diagnosed a tibial plateau fracture but failed to diagnose a dislocated knee and did not perform angiography of the leg.

The patient later required a one-month hospitalization for an occluded popliteal artery, which required a vein graft and fasciotomies of all four compartments.

The plaintiff claimed that if an angiogram had been performed, damage to the popliteal artery and peroneal nerve, which resulted in permanent foot drop, would have been identified and treated.

The plaintiff also claimed that her x-rays were not given to her when she was discharged. If they had been, she argued, her treating physician in California would have diagnosed the dislocation.

The plaintiff also claimed that the emergency physician failed to stress the knee, which would have shown ligament damage consistent with a knee dislocation. Further, the plaintiff claimed that an orthopedic consult should have been ordered.

The plaintiff also claimed the splinting was applied too tightly, and that she developed an infection and subsequent sequelae related to poor blood flow. The plaintiff later underwent tendon transfer surgery in an attempt to stabilize the foot so that she could walk.

The defendants argued that the plaintiff had sustained a tibial plateau fracture, not a dislocation, and that the physical exam was inconsistent with a knee dislocation. The defendants also claimed that the x-ray showed only a tibial plateau fracture and corresponding damage.

Further, the defendants maintained that the splint was applied properly. The defendants claimed that the peroneal nerve damage occurred at the time of the fracture but was not apparent in the ED, and that the resulting nerve deficit developed gradually.

The defendants also argued that even if an angiogram had been performed, it would not have shown a tear.

A defense verdict was returned. According to a published account, the hospital settled for a confidential amount during ­trial.   

Hemorrhage, death follow placenta percreta

A 30-YEAR-OLD WOMAN WAS ADMITTED TO THE HOSPITAL for cesarean delivery of a stillborn child at 6 months’ gestation. The patient was known to have placenta previa.

After delivery and attempted removal of the placenta, she began to hemorrhage profusely. It was determined that the placenta had grown through the uterine wall and into the bladder.

Despite attempts to control bleeding surgically, she continued to hemorrhage, suffered cardiopulmonary arrest, and could not be resuscitated.

ESTATE’S CLAIM The obstetrician who performed the delivery was negligent in failing to diagnose placenta percreta. Both the OB and the nurse-anesthetist should have been able to assess and control the bleeding.

The hospital failed to deliver blood products to the operating room in a timely manner, thereby contributing to the patient’s death.

DEFENDANTS’ DEFENSE The patient’s condition was managed appropriately. Everything was done to resuscitate her in a timely and proper fashion.

VERDICT The estate settled with the OB and nurse-anesthetist for an undisclosed amount. A $2,124,200 Texas verdict was returned against the hospital.

Brachial paralysis in 11 lb, 5 oz newborn

A WOMAN HAD RISK FACTORS for a macrosomic fetus, including obesity before pregnancy, excessive weight gain during pregnancy, and small stature. Before delivery, the OB estimated the fetal weight to be as much as 10 lb.

Shoulder dystocia was encountered during delivery. The baby weighed 11 lb, 5 oz at birth. A diagnosis of brachial plexus injury was made.

PATIENTS’ CLAIM The child’s right arm is paralyzed. He has undergone three surgeries and continues to require physical therapy.

The mother was never told of the risks of vaginal delivery, including shoulder dystocia and brachial plexus injury. She should have been offered cesarean delivery.

The OB applied inappropriate traction to the baby’s head and neck during delivery.

PHYSICIAN’S DEFENSE There is no requirement to tell the mother all the risks of childbirth because they are too numerous and too frightening. Shoulder dystocia was appropriately treated.

VERDICT A $3.27 million Illinois verdict was returned.

Twins die after premature birth

A WOMAN PREGNANT WITH TWINS had a history of incompetent cervix. Her OB performed cervical cerclage in May.

At 26 weeks’ gestation, the mother experienced preterm contractions. She went to the hospital, where she was examined and discharged.

Three days later, the cerclage tore, and she gave birth vaginally. The twins suffered from respiratory distress syndrome, hyaline membrane disease, and intraventricular hemorrhage. One twin died in October; the other, the following May.

PATIENT’S CLAIM She should have been admitted when contractions began, to be monitored and given antenatal steroids and medication to control contractions. After cervical cerclage tore, the OB should have performed transabdominal cerclage.

PHYSICIAN’S DEFENSE The OB denied negligence.

VERDICT A $160,000 Michigan settlement was reached.

Bowel injury during tubal ligation

AFTER A VAGINAL DELIVERY of a healthy child, a 28-year-old woman’s OB performed laparoscopic bilateral tubal ligation.

Several days later, she suffered bowel obstruction. Exploratory laparotomy revealed that a suture had injured the bowel; a portion was resected. The woman made a complete recovery.

PATIENT’S CLAIM The OB was negligent for 1) passing suture into bowel and 2) not checking to ensure there were no injuries after tubal ligation.

PHYSICIAN’S DEFENSE Inadvertent suturing of bowel is a recognized complication of laparoscopic tubal ligation.

VERDICT A Tennessee defense verdict was returned.

Hemorrhage, death follow placenta percreta

A 30-YEAR-OLD WOMAN WAS ADMITTED TO THE HOSPITAL for cesarean delivery of a stillborn child at 6 months’ gestation. The patient was known to have placenta previa.

After delivery and attempted removal of the placenta, she began to hemorrhage profusely. It was determined that the placenta had grown through the uterine wall and into the bladder.

Despite attempts to control bleeding surgically, she continued to hemorrhage, suffered cardiopulmonary arrest, and could not be resuscitated.

ESTATE’S CLAIM The obstetrician who performed the delivery was negligent in failing to diagnose placenta percreta. Both the OB and the nurse-anesthetist should have been able to assess and control the bleeding.

The hospital failed to deliver blood products to the operating room in a timely manner, thereby contributing to the patient’s death.

DEFENDANTS’ DEFENSE The patient’s condition was managed appropriately. Everything was done to resuscitate her in a timely and proper fashion.

VERDICT The estate settled with the OB and nurse-anesthetist for an undisclosed amount. A $2,124,200 Texas verdict was returned against the hospital.

Brachial paralysis in 11 lb, 5 oz newborn

A WOMAN HAD RISK FACTORS for a macrosomic fetus, including obesity before pregnancy, excessive weight gain during pregnancy, and small stature. Before delivery, the OB estimated the fetal weight to be as much as 10 lb.

Shoulder dystocia was encountered during delivery. The baby weighed 11 lb, 5 oz at birth. A diagnosis of brachial plexus injury was made.

PATIENTS’ CLAIM The child’s right arm is paralyzed. He has undergone three surgeries and continues to require physical therapy.

The mother was never told of the risks of vaginal delivery, including shoulder dystocia and brachial plexus injury. She should have been offered cesarean delivery.

The OB applied inappropriate traction to the baby’s head and neck during delivery.

PHYSICIAN’S DEFENSE There is no requirement to tell the mother all the risks of childbirth because they are too numerous and too frightening. Shoulder dystocia was appropriately treated.

VERDICT A $3.27 million Illinois verdict was returned.

Twins die after premature birth

A WOMAN PREGNANT WITH TWINS had a history of incompetent cervix. Her OB performed cervical cerclage in May.

At 26 weeks’ gestation, the mother experienced preterm contractions. She went to the hospital, where she was examined and discharged.

Three days later, the cerclage tore, and she gave birth vaginally. The twins suffered from respiratory distress syndrome, hyaline membrane disease, and intraventricular hemorrhage. One twin died in October; the other, the following May.

PATIENT’S CLAIM She should have been admitted when contractions began, to be monitored and given antenatal steroids and medication to control contractions. After cervical cerclage tore, the OB should have performed transabdominal cerclage.

PHYSICIAN’S DEFENSE The OB denied negligence.

VERDICT A $160,000 Michigan settlement was reached.

Bowel injury during tubal ligation

AFTER A VAGINAL DELIVERY of a healthy child, a 28-year-old woman’s OB performed laparoscopic bilateral tubal ligation.

Several days later, she suffered bowel obstruction. Exploratory laparotomy revealed that a suture had injured the bowel; a portion was resected. The woman made a complete recovery.

PATIENT’S CLAIM The OB was negligent for 1) passing suture into bowel and 2) not checking to ensure there were no injuries after tubal ligation.

PHYSICIAN’S DEFENSE Inadvertent suturing of bowel is a recognized complication of laparoscopic tubal ligation.

VERDICT A Tennessee defense verdict was returned.

Hemorrhage, death follow placenta percreta

A 30-YEAR-OLD WOMAN WAS ADMITTED TO THE HOSPITAL for cesarean delivery of a stillborn child at 6 months’ gestation. The patient was known to have placenta previa.

After delivery and attempted removal of the placenta, she began to hemorrhage profusely. It was determined that the placenta had grown through the uterine wall and into the bladder.

Despite attempts to control bleeding surgically, she continued to hemorrhage, suffered cardiopulmonary arrest, and could not be resuscitated.

ESTATE’S CLAIM The obstetrician who performed the delivery was negligent in failing to diagnose placenta percreta. Both the OB and the nurse-anesthetist should have been able to assess and control the bleeding.

The hospital failed to deliver blood products to the operating room in a timely manner, thereby contributing to the patient’s death.

DEFENDANTS’ DEFENSE The patient’s condition was managed appropriately. Everything was done to resuscitate her in a timely and proper fashion.

VERDICT The estate settled with the OB and nurse-anesthetist for an undisclosed amount. A $2,124,200 Texas verdict was returned against the hospital.

Brachial paralysis in 11 lb, 5 oz newborn

A WOMAN HAD RISK FACTORS for a macrosomic fetus, including obesity before pregnancy, excessive weight gain during pregnancy, and small stature. Before delivery, the OB estimated the fetal weight to be as much as 10 lb.

Shoulder dystocia was encountered during delivery. The baby weighed 11 lb, 5 oz at birth. A diagnosis of brachial plexus injury was made.

PATIENTS’ CLAIM The child’s right arm is paralyzed. He has undergone three surgeries and continues to require physical therapy.

The mother was never told of the risks of vaginal delivery, including shoulder dystocia and brachial plexus injury. She should have been offered cesarean delivery.

The OB applied inappropriate traction to the baby’s head and neck during delivery.

PHYSICIAN’S DEFENSE There is no requirement to tell the mother all the risks of childbirth because they are too numerous and too frightening. Shoulder dystocia was appropriately treated.

VERDICT A $3.27 million Illinois verdict was returned.

Twins die after premature birth

A WOMAN PREGNANT WITH TWINS had a history of incompetent cervix. Her OB performed cervical cerclage in May.

At 26 weeks’ gestation, the mother experienced preterm contractions. She went to the hospital, where she was examined and discharged.

Three days later, the cerclage tore, and she gave birth vaginally. The twins suffered from respiratory distress syndrome, hyaline membrane disease, and intraventricular hemorrhage. One twin died in October; the other, the following May.

PATIENT’S CLAIM She should have been admitted when contractions began, to be monitored and given antenatal steroids and medication to control contractions. After cervical cerclage tore, the OB should have performed transabdominal cerclage.

PHYSICIAN’S DEFENSE The OB denied negligence.

VERDICT A $160,000 Michigan settlement was reached.

Bowel injury during tubal ligation

AFTER A VAGINAL DELIVERY of a healthy child, a 28-year-old woman’s OB performed laparoscopic bilateral tubal ligation.

Several days later, she suffered bowel obstruction. Exploratory laparotomy revealed that a suture had injured the bowel; a portion was resected. The woman made a complete recovery.

PATIENT’S CLAIM The OB was negligent for 1) passing suture into bowel and 2) not checking to ensure there were no injuries after tubal ligation.

PHYSICIAN’S DEFENSE Inadvertent suturing of bowel is a recognized complication of laparoscopic tubal ligation.

VERDICT A Tennessee defense verdict was returned.

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

Volvulus Missed in Gastric Bypass Patient
A 37-year-old woman presented to an emergency department (ED) in Kentucky with nausea and vomiting. The defendant emergency physician noted a soft abdomen. The woman’s vital signs were mostly normal; fluids were administered, and she was discharged with instructions that included an admonition to return if her symptoms worsened. 

The emergency physician had previously seen the patient several times in the ED for various complaints. In the previous three years, she had experienced weakness and other symptoms after successful gastric bypass, as a result of which her weight had dropped from 300 to 93 lb.

The woman returned to the ED that evening. It was claimed that the emergency physician was indifferent and dismissive, and that in one exchange, asked her, “What am I supposed to do for you?” The patient replied, “I’m not a doctor, I don’t know.”

The patient’s symptoms were unchanged, but her vital signs were stable. The emergency physician suggested blood work, which the woman refused. She was released that night with a prescription for pain medication and spent most of the following day in bed. She died during the night.

An autopsy revealed a volvulus of the jejunum, which had caused a fatal septic event. The plaintiff claimed that CT should have been performed, as it would have led to detection of the volvulus. The emergency physician claimed that CT was not required, based on the decedent’s presentation. The defendant hospital denied any negligence, arguing that the emergency physician was not an employee.

According to a published account, $2,192,000 was awarded against both defendants.

Too Little Testing, Too Little Follow-Up
In May 2004, a 49-year-old man went to defendant Dr. D.’s office in Pennsylvania for a physical examination. At this visit, the patient complained of muscle aches, joint pain, fatigue, impotence, and other symptoms. No laboratory tests were ordered.

In October 2005, the patient returned to Dr. D. with the same symptoms and a weight loss of 40 lb. Blood work was ordered at that time, which it was later claimed revealed hematologic abnormalities. Recorded findings included elevated levels of triglycerides (500 mg/dL) and total cholesterol (205 mg/dL), a low HDL cholesterol level (30 mg/dL), elevated blood glucose (308 mg/dL), and a low platelet count (63,000/L). The man’s alkaline phosphatase level was also elevated (172 U/L). No follow-up took place.

Later that month, the patient returned to Dr. D. complaining of persistent symptoms. At that time, Dr. D. suggested that results of an ECG the man had undergone were abnormal. However, Dr. D. still did not follow up on abnormalities in the patient’s blood work.

Early in January 2006, the patient contacted Dr. D. and reported that he was experiencing constant nausea, headaches, and decreased urination. Dr. D. instructed him to go to the ED. There, a chest x-ray revealed pulmonary vascular congestion, bilateral pulmonary effusions, and splenomegaly. Heart studies showed heart dysfunction, and blood test results indicated abnormal liver function.

Four days later, the man was transferred to another hospital for placement of an intra-aortic balloon pump. He died the following day as a result of undiagnosed and untreated hemochromatosis, which had led to multisystem organ failure.

The plaintiff claimed that Dr. D. failed to order blood work to rule out or confirm hemochromatosis or other medical conditions at the decedent’s first visit. The plaintiff claimed that Dr. D. was negligent in failing to follow up on the decedent’s complaints and later on his abnormal test results.

The defendant maintained that the decedent’s liver test results were normal and that his other health issues had given the defendant no reason to refer the man to a hematologist.

A defense verdict was reportedly returned.

Man With Aortic Occlusion Requests Transfer
A 59-year-old Illinois man awoke one morning experiencing back pain and the inability to move his legs. Paramedics responded and transported him to a hospital, where he was examined by Dr. E., an emergency physician. Dr. E. found normal vital signs, diminished lung sounds, no detectable pulses in the man’s legs, and mottled feet.

In consideration of the patient’s diabetic neuropathy, abdominal CT was performed without contrast dye; it did not reveal an abdominal aortic aneurysm, but it did show a large pleural effusion on both sides. Dr. E. believed there was a mass in the left lower lobe and suspected that aortic disease was present.

A vascular surgeon, Dr. V., was consulted regarding concerns of a possible occluded or dissecting aorta. Dr. V. found Doppler pulses in the groin and felt a faint femoral pulse on the left side. Dr. V. believed that there was an occluded aorta, but due to effusion in the chest, as well as the patient’s history of smoking, hemoptysis, weight loss, and acute-onset paralysis, Dr. V. also suspected a malignancy with spinal cord involvement.

A consulting neurosurgeon recommended an MRI of the spinal cord, and Dr. E. and Dr. V. agreed. A stat MRI could not be performed at this facility during overnight hours, so the patient was transferred to another hospital for the MRI and magnetic resonance angiography (MRA). Before the transfer, Dr. V. performed a thoracentesis in which 3,000 cc of fluid was drained.

The patient was gone from the hospital for a little longer than four hours. The MRI did not reveal any spinal cord compression, but the MRA showed complete occlusion of the abdominal aorta below the renal arteries. Dr. V. was informed of the results during a phone conversation with the radiologist.

When the patient was returned to the hospital, attempts were made to contact Dr. V., but Dr. V. never received those calls. Dr. V. returned to the ED after the patient had been there for about 40 minutes and told him that he needed immediate surgery. The patient, a veteran, requested that he be transferred to the VA hospital where his records were maintained. Heparin was administered and he was transferred to the VA hospital, accompanied by a nurse.

Upon the man’s arrival at the VA hospital, a surgical resident assessed his prognosis as poor, with or without surgical exploration. The patient’s wife called the ED a few hours later and requested that no intervention be performed until her arrival at the VA hospital.

When the family arrived there about three hours later, the vascular surgery chief resident advised them that the man’s prognosis was certain death with no intervention, and an 80% to 90% probability of death with thrombectomy/revascularization. The family agreed to surgery, which was begun more than 12 hours after the MRA was performed. The surgery, which included bilateral groin exploration, aortic thrombectomy, and bilateral fasciotomy, was completed after five hours with no complications.

The patient’s condition began to deteriorate two days later. CT revealed left parietal and right temporal hemispheric stroke. After further deterioration, the family requested DNR status, and the man died.

The plaintiff alleged negligence in the failure to timely diagnose and treat the aortic occlusion and in negligently allowing transfer to a VA hospital despite the decedent’s emergent and unstable condition. The defendants claimed that the decedent’s vital signs were stable throughout his care before transfer to the VA and that he was always alert and oriented.

According to a published report, a defense verdict was returned.

Did Missed Orbital Fracture Lead to Nerve Impingement?
During a softball game, a 35-year-old New Jersey man was struck in the eye by a line drive. He went to a medical center ED where he was seen by an emergency physician. The physician did not order CT and, according to the patient, failed to diagnose a fractured orbit.

The man later developed an impinged infraorbital nerve as a result of untreated bone fragments, which allegedly resulted in permanent complications of the underlying injury. He claimed that CT was required, given the nature of the injury, because it would have revealed the fracture, allowing for timely treatment. The defendant maintained that CT was not necessary.

The jury found the physician negligent and also found that the physician’s negligence was the proximate cause of the plaintiff’s condition. The plaintiff received a $240,000 judgment.

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

Volvulus Missed in Gastric Bypass Patient
A 37-year-old woman presented to an emergency department (ED) in Kentucky with nausea and vomiting. The defendant emergency physician noted a soft abdomen. The woman’s vital signs were mostly normal; fluids were administered, and she was discharged with instructions that included an admonition to return if her symptoms worsened. 

The emergency physician had previously seen the patient several times in the ED for various complaints. In the previous three years, she had experienced weakness and other symptoms after successful gastric bypass, as a result of which her weight had dropped from 300 to 93 lb.

The woman returned to the ED that evening. It was claimed that the emergency physician was indifferent and dismissive, and that in one exchange, asked her, “What am I supposed to do for you?” The patient replied, “I’m not a doctor, I don’t know.”

The patient’s symptoms were unchanged, but her vital signs were stable. The emergency physician suggested blood work, which the woman refused. She was released that night with a prescription for pain medication and spent most of the following day in bed. She died during the night.

An autopsy revealed a volvulus of the jejunum, which had caused a fatal septic event. The plaintiff claimed that CT should have been performed, as it would have led to detection of the volvulus. The emergency physician claimed that CT was not required, based on the decedent’s presentation. The defendant hospital denied any negligence, arguing that the emergency physician was not an employee.

According to a published account, $2,192,000 was awarded against both defendants.

Too Little Testing, Too Little Follow-Up
In May 2004, a 49-year-old man went to defendant Dr. D.’s office in Pennsylvania for a physical examination. At this visit, the patient complained of muscle aches, joint pain, fatigue, impotence, and other symptoms. No laboratory tests were ordered.

In October 2005, the patient returned to Dr. D. with the same symptoms and a weight loss of 40 lb. Blood work was ordered at that time, which it was later claimed revealed hematologic abnormalities. Recorded findings included elevated levels of triglycerides (500 mg/dL) and total cholesterol (205 mg/dL), a low HDL cholesterol level (30 mg/dL), elevated blood glucose (308 mg/dL), and a low platelet count (63,000/L). The man’s alkaline phosphatase level was also elevated (172 U/L). No follow-up took place.

Later that month, the patient returned to Dr. D. complaining of persistent symptoms. At that time, Dr. D. suggested that results of an ECG the man had undergone were abnormal. However, Dr. D. still did not follow up on abnormalities in the patient’s blood work.

Early in January 2006, the patient contacted Dr. D. and reported that he was experiencing constant nausea, headaches, and decreased urination. Dr. D. instructed him to go to the ED. There, a chest x-ray revealed pulmonary vascular congestion, bilateral pulmonary effusions, and splenomegaly. Heart studies showed heart dysfunction, and blood test results indicated abnormal liver function.

Four days later, the man was transferred to another hospital for placement of an intra-aortic balloon pump. He died the following day as a result of undiagnosed and untreated hemochromatosis, which had led to multisystem organ failure.

The plaintiff claimed that Dr. D. failed to order blood work to rule out or confirm hemochromatosis or other medical conditions at the decedent’s first visit. The plaintiff claimed that Dr. D. was negligent in failing to follow up on the decedent’s complaints and later on his abnormal test results.

The defendant maintained that the decedent’s liver test results were normal and that his other health issues had given the defendant no reason to refer the man to a hematologist.

A defense verdict was reportedly returned.

Man With Aortic Occlusion Requests Transfer
A 59-year-old Illinois man awoke one morning experiencing back pain and the inability to move his legs. Paramedics responded and transported him to a hospital, where he was examined by Dr. E., an emergency physician. Dr. E. found normal vital signs, diminished lung sounds, no detectable pulses in the man’s legs, and mottled feet.

In consideration of the patient’s diabetic neuropathy, abdominal CT was performed without contrast dye; it did not reveal an abdominal aortic aneurysm, but it did show a large pleural effusion on both sides. Dr. E. believed there was a mass in the left lower lobe and suspected that aortic disease was present.

A vascular surgeon, Dr. V., was consulted regarding concerns of a possible occluded or dissecting aorta. Dr. V. found Doppler pulses in the groin and felt a faint femoral pulse on the left side. Dr. V. believed that there was an occluded aorta, but due to effusion in the chest, as well as the patient’s history of smoking, hemoptysis, weight loss, and acute-onset paralysis, Dr. V. also suspected a malignancy with spinal cord involvement.

A consulting neurosurgeon recommended an MRI of the spinal cord, and Dr. E. and Dr. V. agreed. A stat MRI could not be performed at this facility during overnight hours, so the patient was transferred to another hospital for the MRI and magnetic resonance angiography (MRA). Before the transfer, Dr. V. performed a thoracentesis in which 3,000 cc of fluid was drained.

The patient was gone from the hospital for a little longer than four hours. The MRI did not reveal any spinal cord compression, but the MRA showed complete occlusion of the abdominal aorta below the renal arteries. Dr. V. was informed of the results during a phone conversation with the radiologist.

When the patient was returned to the hospital, attempts were made to contact Dr. V., but Dr. V. never received those calls. Dr. V. returned to the ED after the patient had been there for about 40 minutes and told him that he needed immediate surgery. The patient, a veteran, requested that he be transferred to the VA hospital where his records were maintained. Heparin was administered and he was transferred to the VA hospital, accompanied by a nurse.

Upon the man’s arrival at the VA hospital, a surgical resident assessed his prognosis as poor, with or without surgical exploration. The patient’s wife called the ED a few hours later and requested that no intervention be performed until her arrival at the VA hospital.

When the family arrived there about three hours later, the vascular surgery chief resident advised them that the man’s prognosis was certain death with no intervention, and an 80% to 90% probability of death with thrombectomy/revascularization. The family agreed to surgery, which was begun more than 12 hours after the MRA was performed. The surgery, which included bilateral groin exploration, aortic thrombectomy, and bilateral fasciotomy, was completed after five hours with no complications.

The patient’s condition began to deteriorate two days later. CT revealed left parietal and right temporal hemispheric stroke. After further deterioration, the family requested DNR status, and the man died.

The plaintiff alleged negligence in the failure to timely diagnose and treat the aortic occlusion and in negligently allowing transfer to a VA hospital despite the decedent’s emergent and unstable condition. The defendants claimed that the decedent’s vital signs were stable throughout his care before transfer to the VA and that he was always alert and oriented.

According to a published report, a defense verdict was returned.

Did Missed Orbital Fracture Lead to Nerve Impingement?
During a softball game, a 35-year-old New Jersey man was struck in the eye by a line drive. He went to a medical center ED where he was seen by an emergency physician. The physician did not order CT and, according to the patient, failed to diagnose a fractured orbit.

The man later developed an impinged infraorbital nerve as a result of untreated bone fragments, which allegedly resulted in permanent complications of the underlying injury. He claimed that CT was required, given the nature of the injury, because it would have revealed the fracture, allowing for timely treatment. The defendant maintained that CT was not necessary.

The jury found the physician negligent and also found that the physician’s negligence was the proximate cause of the plaintiff’s condition. The plaintiff received a $240,000 judgment.

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

Volvulus Missed in Gastric Bypass Patient
A 37-year-old woman presented to an emergency department (ED) in Kentucky with nausea and vomiting. The defendant emergency physician noted a soft abdomen. The woman’s vital signs were mostly normal; fluids were administered, and she was discharged with instructions that included an admonition to return if her symptoms worsened. 

The emergency physician had previously seen the patient several times in the ED for various complaints. In the previous three years, she had experienced weakness and other symptoms after successful gastric bypass, as a result of which her weight had dropped from 300 to 93 lb.

The woman returned to the ED that evening. It was claimed that the emergency physician was indifferent and dismissive, and that in one exchange, asked her, “What am I supposed to do for you?” The patient replied, “I’m not a doctor, I don’t know.”

The patient’s symptoms were unchanged, but her vital signs were stable. The emergency physician suggested blood work, which the woman refused. She was released that night with a prescription for pain medication and spent most of the following day in bed. She died during the night.

An autopsy revealed a volvulus of the jejunum, which had caused a fatal septic event. The plaintiff claimed that CT should have been performed, as it would have led to detection of the volvulus. The emergency physician claimed that CT was not required, based on the decedent’s presentation. The defendant hospital denied any negligence, arguing that the emergency physician was not an employee.

According to a published account, $2,192,000 was awarded against both defendants.

Too Little Testing, Too Little Follow-Up
In May 2004, a 49-year-old man went to defendant Dr. D.’s office in Pennsylvania for a physical examination. At this visit, the patient complained of muscle aches, joint pain, fatigue, impotence, and other symptoms. No laboratory tests were ordered.

In October 2005, the patient returned to Dr. D. with the same symptoms and a weight loss of 40 lb. Blood work was ordered at that time, which it was later claimed revealed hematologic abnormalities. Recorded findings included elevated levels of triglycerides (500 mg/dL) and total cholesterol (205 mg/dL), a low HDL cholesterol level (30 mg/dL), elevated blood glucose (308 mg/dL), and a low platelet count (63,000/L). The man’s alkaline phosphatase level was also elevated (172 U/L). No follow-up took place.

Later that month, the patient returned to Dr. D. complaining of persistent symptoms. At that time, Dr. D. suggested that results of an ECG the man had undergone were abnormal. However, Dr. D. still did not follow up on abnormalities in the patient’s blood work.

Early in January 2006, the patient contacted Dr. D. and reported that he was experiencing constant nausea, headaches, and decreased urination. Dr. D. instructed him to go to the ED. There, a chest x-ray revealed pulmonary vascular congestion, bilateral pulmonary effusions, and splenomegaly. Heart studies showed heart dysfunction, and blood test results indicated abnormal liver function.

Four days later, the man was transferred to another hospital for placement of an intra-aortic balloon pump. He died the following day as a result of undiagnosed and untreated hemochromatosis, which had led to multisystem organ failure.

The plaintiff claimed that Dr. D. failed to order blood work to rule out or confirm hemochromatosis or other medical conditions at the decedent’s first visit. The plaintiff claimed that Dr. D. was negligent in failing to follow up on the decedent’s complaints and later on his abnormal test results.

The defendant maintained that the decedent’s liver test results were normal and that his other health issues had given the defendant no reason to refer the man to a hematologist.

A defense verdict was reportedly returned.

Man With Aortic Occlusion Requests Transfer
A 59-year-old Illinois man awoke one morning experiencing back pain and the inability to move his legs. Paramedics responded and transported him to a hospital, where he was examined by Dr. E., an emergency physician. Dr. E. found normal vital signs, diminished lung sounds, no detectable pulses in the man’s legs, and mottled feet.

In consideration of the patient’s diabetic neuropathy, abdominal CT was performed without contrast dye; it did not reveal an abdominal aortic aneurysm, but it did show a large pleural effusion on both sides. Dr. E. believed there was a mass in the left lower lobe and suspected that aortic disease was present.

A vascular surgeon, Dr. V., was consulted regarding concerns of a possible occluded or dissecting aorta. Dr. V. found Doppler pulses in the groin and felt a faint femoral pulse on the left side. Dr. V. believed that there was an occluded aorta, but due to effusion in the chest, as well as the patient’s history of smoking, hemoptysis, weight loss, and acute-onset paralysis, Dr. V. also suspected a malignancy with spinal cord involvement.

A consulting neurosurgeon recommended an MRI of the spinal cord, and Dr. E. and Dr. V. agreed. A stat MRI could not be performed at this facility during overnight hours, so the patient was transferred to another hospital for the MRI and magnetic resonance angiography (MRA). Before the transfer, Dr. V. performed a thoracentesis in which 3,000 cc of fluid was drained.

The patient was gone from the hospital for a little longer than four hours. The MRI did not reveal any spinal cord compression, but the MRA showed complete occlusion of the abdominal aorta below the renal arteries. Dr. V. was informed of the results during a phone conversation with the radiologist.

When the patient was returned to the hospital, attempts were made to contact Dr. V., but Dr. V. never received those calls. Dr. V. returned to the ED after the patient had been there for about 40 minutes and told him that he needed immediate surgery. The patient, a veteran, requested that he be transferred to the VA hospital where his records were maintained. Heparin was administered and he was transferred to the VA hospital, accompanied by a nurse.

Upon the man’s arrival at the VA hospital, a surgical resident assessed his prognosis as poor, with or without surgical exploration. The patient’s wife called the ED a few hours later and requested that no intervention be performed until her arrival at the VA hospital.

When the family arrived there about three hours later, the vascular surgery chief resident advised them that the man’s prognosis was certain death with no intervention, and an 80% to 90% probability of death with thrombectomy/revascularization. The family agreed to surgery, which was begun more than 12 hours after the MRA was performed. The surgery, which included bilateral groin exploration, aortic thrombectomy, and bilateral fasciotomy, was completed after five hours with no complications.

The patient’s condition began to deteriorate two days later. CT revealed left parietal and right temporal hemispheric stroke. After further deterioration, the family requested DNR status, and the man died.

The plaintiff alleged negligence in the failure to timely diagnose and treat the aortic occlusion and in negligently allowing transfer to a VA hospital despite the decedent’s emergent and unstable condition. The defendants claimed that the decedent’s vital signs were stable throughout his care before transfer to the VA and that he was always alert and oriented.

According to a published report, a defense verdict was returned.

Did Missed Orbital Fracture Lead to Nerve Impingement?
During a softball game, a 35-year-old New Jersey man was struck in the eye by a line drive. He went to a medical center ED where he was seen by an emergency physician. The physician did not order CT and, according to the patient, failed to diagnose a fractured orbit.

The man later developed an impinged infraorbital nerve as a result of untreated bone fragments, which allegedly resulted in permanent complications of the underlying injury. He claimed that CT was required, given the nature of the injury, because it would have revealed the fracture, allowing for timely treatment. The defendant maintained that CT was not necessary.

The jury found the physician negligent and also found that the physician’s negligence was the proximate cause of the plaintiff’s condition. The plaintiff received a $240,000 judgment.

Estate of breast cancer victim appeals

COMPLAINING OF FATIGUE, a 44-year-old woman went to a university medical center staffed by residents supervised by faculty. Resident Dr. A discovered a 1.5-cm mobile mass in her right breast. Although he never saw the patient, Dr. B, the supervising physician, suggested a mammogram with ultrasonography. Results were reported as benign, and the patient was advised to follow up in 6 months, or earlier if her condition changed.

A month later, the patient returned to the clinic. Resident Dr. C advised her to have a biopsy; the patient declined.

She returned 8 months later, after the clinic sent a reminder. The skin on her breast had the consistency of an orange, and the lump had grown. A diagnosis of metastatic breast cancer was made. Aggressive treatment was recommended, but the patient opted for herbal and other homeopathic remedies.

PATIENT’S CLAIM The physicians were negligent for not diagnosing breast cancer in a timely manner. A needle biopsy should have been performed when the lump was first detected.

PHYSICIANS’ DEFENSE The treatment plan was reasonable. The patient declined the biopsy, and failed to return when her condition changed.

VERDICT A Tennessee defense verdict was returned.

ESTATE’S APPEAL After the patient died 2 years later, an appeal trial resulted in finding Dr. B 99% at fault and the deceased 1% at fault. The jury awarded $2.7 million to the estate.

ObGyn exonerated in Erb’s palsy case

2 WEEKS BEFORE GIVING BIRTH, a woman underwent a sonogram. A radiologist evaluated the images and did not report an abnormality. The infant was delivered vaginally by an ObGyn. Later, the child was given a diagnosis of Erb’s palsy.

PATIENT’S CLAIM The radiologist failed to properly estimate the fetus’ weight. The ObGyn used excessive lateral traction during delivery.

PHYSICIANS’ DEFENSE Both physicians denied negligence.

VERDICT The radiologist settled for $150,000 before trial. A Texas jury returned a defense verdict for the ObGyn.

Profuse bleeding; patient dies

AFTER BLEEDING PROFUSELY during laparoscopic-assisted vaginal hysterectomy, a 46-year-old woman died.

ESTATE’S CLAIM The gynecologist failed to recognize bleeding complications and transfuse blood quickly enough. Type O-negative blood should have been ordered because it would have been available sooner than type-specific blood.

PHYSICIAN’S DEFENSE Bleeding is a known complication of the procedure. There was insufficient time to effectively transfuse the patient.

VERDICT An Arizona defense verdict was returned.

Estate of breast cancer victim appeals

COMPLAINING OF FATIGUE, a 44-year-old woman went to a university medical center staffed by residents supervised by faculty. Resident Dr. A discovered a 1.5-cm mobile mass in her right breast. Although he never saw the patient, Dr. B, the supervising physician, suggested a mammogram with ultrasonography. Results were reported as benign, and the patient was advised to follow up in 6 months, or earlier if her condition changed.

A month later, the patient returned to the clinic. Resident Dr. C advised her to have a biopsy; the patient declined.

She returned 8 months later, after the clinic sent a reminder. The skin on her breast had the consistency of an orange, and the lump had grown. A diagnosis of metastatic breast cancer was made. Aggressive treatment was recommended, but the patient opted for herbal and other homeopathic remedies.

PATIENT’S CLAIM The physicians were negligent for not diagnosing breast cancer in a timely manner. A needle biopsy should have been performed when the lump was first detected.

PHYSICIANS’ DEFENSE The treatment plan was reasonable. The patient declined the biopsy, and failed to return when her condition changed.

VERDICT A Tennessee defense verdict was returned.

ESTATE’S APPEAL After the patient died 2 years later, an appeal trial resulted in finding Dr. B 99% at fault and the deceased 1% at fault. The jury awarded $2.7 million to the estate.

ObGyn exonerated in Erb’s palsy case

2 WEEKS BEFORE GIVING BIRTH, a woman underwent a sonogram. A radiologist evaluated the images and did not report an abnormality. The infant was delivered vaginally by an ObGyn. Later, the child was given a diagnosis of Erb’s palsy.

PATIENT’S CLAIM The radiologist failed to properly estimate the fetus’ weight. The ObGyn used excessive lateral traction during delivery.

PHYSICIANS’ DEFENSE Both physicians denied negligence.

VERDICT The radiologist settled for $150,000 before trial. A Texas jury returned a defense verdict for the ObGyn.

Profuse bleeding; patient dies

AFTER BLEEDING PROFUSELY during laparoscopic-assisted vaginal hysterectomy, a 46-year-old woman died.

ESTATE’S CLAIM The gynecologist failed to recognize bleeding complications and transfuse blood quickly enough. Type O-negative blood should have been ordered because it would have been available sooner than type-specific blood.

PHYSICIAN’S DEFENSE Bleeding is a known complication of the procedure. There was insufficient time to effectively transfuse the patient.

VERDICT An Arizona defense verdict was returned.

Estate of breast cancer victim appeals

COMPLAINING OF FATIGUE, a 44-year-old woman went to a university medical center staffed by residents supervised by faculty. Resident Dr. A discovered a 1.5-cm mobile mass in her right breast. Although he never saw the patient, Dr. B, the supervising physician, suggested a mammogram with ultrasonography. Results were reported as benign, and the patient was advised to follow up in 6 months, or earlier if her condition changed.

A month later, the patient returned to the clinic. Resident Dr. C advised her to have a biopsy; the patient declined.

She returned 8 months later, after the clinic sent a reminder. The skin on her breast had the consistency of an orange, and the lump had grown. A diagnosis of metastatic breast cancer was made. Aggressive treatment was recommended, but the patient opted for herbal and other homeopathic remedies.

PATIENT’S CLAIM The physicians were negligent for not diagnosing breast cancer in a timely manner. A needle biopsy should have been performed when the lump was first detected.

PHYSICIANS’ DEFENSE The treatment plan was reasonable. The patient declined the biopsy, and failed to return when her condition changed.

VERDICT A Tennessee defense verdict was returned.

ESTATE’S APPEAL After the patient died 2 years later, an appeal trial resulted in finding Dr. B 99% at fault and the deceased 1% at fault. The jury awarded $2.7 million to the estate.

ObGyn exonerated in Erb’s palsy case

2 WEEKS BEFORE GIVING BIRTH, a woman underwent a sonogram. A radiologist evaluated the images and did not report an abnormality. The infant was delivered vaginally by an ObGyn. Later, the child was given a diagnosis of Erb’s palsy.

PATIENT’S CLAIM The radiologist failed to properly estimate the fetus’ weight. The ObGyn used excessive lateral traction during delivery.

PHYSICIANS’ DEFENSE Both physicians denied negligence.

VERDICT The radiologist settled for $150,000 before trial. A Texas jury returned a defense verdict for the ObGyn.

Profuse bleeding; patient dies

AFTER BLEEDING PROFUSELY during laparoscopic-assisted vaginal hysterectomy, a 46-year-old woman died.

ESTATE’S CLAIM The gynecologist failed to recognize bleeding complications and transfuse blood quickly enough. Type O-negative blood should have been ordered because it would have been available sooner than type-specific blood.

PHYSICIAN’S DEFENSE Bleeding is a known complication of the procedure. There was insufficient time to effectively transfuse the patient.

VERDICT An Arizona defense verdict was returned.

CASE 1: Pregestational diabetes, large baby, birth injury

A 31-year-old gravida 1 is admitted to labor and delivery. She is at 39-5/7 weeks’ gestation, dated by last menstrual period and early sonogram. The woman is a pregestational diabetic and uses insulin to control her blood glucose level.

Three weeks before admission, ultrasonography (US) revealed an estimated fetal weight of 3,650 g—at the 71st percentile for gestational age.

After an unremarkable course of labor, delivery is complicated by severe shoulder dystocia. The newborn has a birth weight of 4,985 g and sustains an Erb’s palsy-type injury. The mother develops a rectovaginal fistula after a fourth-degree tear.

In the first part of this article, we discussed how an allegation of malpractice can arise because of an unexpected event or outcome for a mother in your care, or her baby, apart from any specific clinical action you undertook. We offered an example: Counseling that you provide about options for prenatal care that falls short of full understanding by the patient.

In this article, we enter the realm of the hands-on practice of medicine and discuss causation: namely, the actions of a physician, in the course of managing labor and delivering a baby, that put that physician at risk of a charge of malpractice because the medical care 1) is inconsistent with current medical practice and thus 2) harmed mother or newborn.

Let’s return to the opening case above and discuss key considerations for the physician. Three more cases follow that, with analysis and recommendations.

Considerations in CASE 1

• A woman who has pregestational diabetes should receive ongoing counseling about the risks of fetal anomalies, macrosomia, and problems in the neonatal period. Be certain that she understands that these risks can be ameliorated, but not eliminated, with careful blood glucose control.
• The fetus of a diabetic gravida develops a relative decrease in the ratio of head circumference-to-abdominal circumference that predisposes it to shoulder dystocia. Cesarean delivery can decrease, but not eliminate, the risk of traumatic birth injury in a diabetic mother. (Of course, cesarean delivery will, on its own, substantially increase the risk of maternal morbidity—including at any subsequent cesarean delivery.)

What do they mean? terms and concepts intended to bolster your work and protect you

It’s not easy to define what constitutes “best care” in a given clinical circumstance. Generalizations are useful, but they may possess an inherent weakness: “Best practices,” “evidence-based care,” “standardization of care,” and “uniformity of care” usually apply more usefully to populations than individuals.

Such concepts derive from broader applications in economics, politics, and science. They are useful to define a reasonable spectrum of anticipated practices, and they certainly have an expanding role in the care of patients and in medical education (TABLE). Clinical guidelines serve as strategies that may be very helpful to the clinician. All of us understand and implement appropriate care in the great majority of clinical scenarios, but none of us are, or can be, expert in all situations. Referencing and using guidelines can fill a need for a functional starting point when expertise is lacking or falls short.

Best practices result from evidence-directed decision-making. This concept logically yields a desirable uniformity of practice. Although we all believe that our experience is our best teacher, we may best serve patients if we sample knowledge and wisdom from controlled clinical trials and from the experiences of others. What is accepted local practice must also be considered important when you devise a plan of care.^1,2

A selected glossary of clinical care guidelines

Consider the management of breech presentation that is recognized at the 36th week antepartum visit: Discussion with the patient should include 1) reference to concerns with congenital anomalies and genetic syndromes, 2) in-utero growth and development, and 3) the delivery process. The management algorithm may include external cephalic version, elective cesarean delivery before onset of labor, or cesarean delivery after onset of labor. Each approach has advocates—based on expert opinion clinical trials.

Management options may vary from institution to institution, however, because of limited availability of certain services—such as the expertise required for a trial of external cephalic version, the availability of on-site cesarean delivery capabilities, and patient and clinician preferences.

Uniformity of care, based on best practices, can therefore simplify the care process and decrease the risk that may be associated with individual experience-based management. Adhering to a uniform practice augments the clinician’s knowledge and allows for enhanced nursing and therapeutic efficiency.

The greatest benefit of using an evidence-based, widely accepted approach, however, is the potential to diminish poor practice and consequent malpractice exposure for both clinicians and the hospital.

Note: Although your adherence to clinical guidelines, best practices, and uniformity of care ought to be consistent with established standards of care, don’t automatically consider any deviation a lapse or failing because it’s understood and accepted that some local variability exists in practice.

Prelude to birth: triage and admission Triage. Most women in labor arrive at the hospital or birthing center to an area set aside for labor and delivery triage. There, 1) recording of the chief complaint and vital signs and 2) completion of a brief history and physical generate a call to the clinician.

The record produced in triage should be scrutinized carefully for accuracy. Clarify, in as timely a manner as possible, any errors in:

• timing (possibly because of different clocks set to different times)
• the precise capture of the chief complaint
• reporting difficulty or ease in reaching the responsible clinician.

Whether these records are electronic or paper, an addendum marked with the time is always acceptable. Never attempt to correct a record! Always utilize a late entry or addendum.

Admission. After the patient is admitted, she generally undergoes an admission protocol, specific to the hospital, regarding her situation. This includes:

• the history
• special requests
• any previously agreed-on plan of care
• any problems that have developed since her last prenatal visit.

This protocol is generally completed by a nurse, resident, nurse practitioner, or physician assistant.

Hospitals generally request input from the attending physician on the specifics of the admission, based on those hospital protocols. There may be some room to individualize the admission process to labor and delivery.

4 pillars of care during labor

In general, labor is defined as progressive dilation of the cervix. Several parameters serve as guidelines regarding adequate progress through the various stages of labor.

Fetal monitoring. Continuous evaluation of the fetus during labor is a routine part of intrapartum care. Recording and observing the FHR tracing is an accepted—and expected—practice. Documentation of the FHR in the medical record is specifically required, and should include both the physician’s and nursing notes.

Anesthesia care. The patient’s preference and the availability of options allows for several accepted practices regarding anesthesia and analgesia during L & D. Does she want epidural anesthesia during labor, for example? Intravenous narcotics? Her choice is an important facet of your provision of care.

However, such choice requires the patient to give consent and to understand the risk-benefit equation. Documentation by nursing of the patient’s consent and understanding should be complete, including discussion and administration. Anesthesia staff should be clear, complete, and legible in making a record.

Neonatal care. If logistics permit, a member of the pediatrics service should be routinely available to see the newborn at delivery. The patient should view the pediatrician and obstetrician as partners working as a team for the benefit of the mother and her family. This can enhance the patient’s understanding and confidence about the well being of her baby.

Documentation. Although deficient documentation does not, itself, lead to a finding of malpractice, appropriate documentation plays an important role in demonstrating that clinical practices have addressed issues about both allegation and causation of potential adverse outcomes.

We cannot overemphasize that nursing documentation should complement and be consistent with notes made by the physician. That said, nursing notes are not a substitute for the physician’s notes. Practices that integrate the written comments of nursing and physician into a single set of progress notes facilitate this complementary interaction.

3 more clinical scenarios

CASE 2: Admitted at term with contractions

The initial exam determines that this 21-year-old gravida 1 is 2/80/-1. Re-examination in 3 hours finds her at 3-4/80/0.

She requests pain relief and states that she wants epidural anesthesia.

Evaluation 2 hours later suggests secondary arrest of dilation. Oxytocin is begun.

Soon after, late decelerations are observed on the FHR monitor.

Use of exogenous oxytocin in L & D is a double-edged sword: The drug can enhance the safety and efficacy of labor and delivery for mother and fetus, but using it in an unregulated manner (in terms of its indication and administration) can subject both to increased risk.

In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:

• indications
• dosage (including the maximum)
• interval
• fetal response
• ultimately, the availability of a physician during administration to manage any problem that arises.

Considerations in CASE 2

• Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
• Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
• Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
• Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
• Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
• Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O₂, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
• Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
• When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
• Chart the process concurrently. Specify options for delivery before delivery.

CASE 3: Spontaneous delivery arrests after delivery of the head

The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.

After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.

Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.

Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.³

Considerations in CASE 3

• Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
• Consider delivering all women at term in the McRobert’s position, prophylactically.
• Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
• Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
• Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
• Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
• When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
• If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
• Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
• Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
• After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.

CASE 4: Meconium-stained fluid

A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.

The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.⁴

Considerations in CASE 4

• Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
• Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
• Administer supplemental O₂. Increase IV fluids to facilitate utero-placental perfusion.
• If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
• When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
• Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
• Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
• Carefully review corresponding nursing notes. Always write your own assessment of events and actions.

Summing up: three “keepers”

First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.

Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.

Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.

We want to hear from you! Tell us what you think.

CASE 1: Pregestational diabetes, large baby, birth injury

A 31-year-old gravida 1 is admitted to labor and delivery. She is at 39-5/7 weeks’ gestation, dated by last menstrual period and early sonogram. The woman is a pregestational diabetic and uses insulin to control her blood glucose level.

Three weeks before admission, ultrasonography (US) revealed an estimated fetal weight of 3,650 g—at the 71st percentile for gestational age.

After an unremarkable course of labor, delivery is complicated by severe shoulder dystocia. The newborn has a birth weight of 4,985 g and sustains an Erb’s palsy-type injury. The mother develops a rectovaginal fistula after a fourth-degree tear.

In the first part of this article, we discussed how an allegation of malpractice can arise because of an unexpected event or outcome for a mother in your care, or her baby, apart from any specific clinical action you undertook. We offered an example: Counseling that you provide about options for prenatal care that falls short of full understanding by the patient.

In this article, we enter the realm of the hands-on practice of medicine and discuss causation: namely, the actions of a physician, in the course of managing labor and delivering a baby, that put that physician at risk of a charge of malpractice because the medical care 1) is inconsistent with current medical practice and thus 2) harmed mother or newborn.

Let’s return to the opening case above and discuss key considerations for the physician. Three more cases follow that, with analysis and recommendations.

Considerations in CASE 1

• A woman who has pregestational diabetes should receive ongoing counseling about the risks of fetal anomalies, macrosomia, and problems in the neonatal period. Be certain that she understands that these risks can be ameliorated, but not eliminated, with careful blood glucose control.
• The fetus of a diabetic gravida develops a relative decrease in the ratio of head circumference-to-abdominal circumference that predisposes it to shoulder dystocia. Cesarean delivery can decrease, but not eliminate, the risk of traumatic birth injury in a diabetic mother. (Of course, cesarean delivery will, on its own, substantially increase the risk of maternal morbidity—including at any subsequent cesarean delivery.)

What do they mean? terms and concepts intended to bolster your work and protect you

It’s not easy to define what constitutes “best care” in a given clinical circumstance. Generalizations are useful, but they may possess an inherent weakness: “Best practices,” “evidence-based care,” “standardization of care,” and “uniformity of care” usually apply more usefully to populations than individuals.

Such concepts derive from broader applications in economics, politics, and science. They are useful to define a reasonable spectrum of anticipated practices, and they certainly have an expanding role in the care of patients and in medical education (TABLE). Clinical guidelines serve as strategies that may be very helpful to the clinician. All of us understand and implement appropriate care in the great majority of clinical scenarios, but none of us are, or can be, expert in all situations. Referencing and using guidelines can fill a need for a functional starting point when expertise is lacking or falls short.

Best practices result from evidence-directed decision-making. This concept logically yields a desirable uniformity of practice. Although we all believe that our experience is our best teacher, we may best serve patients if we sample knowledge and wisdom from controlled clinical trials and from the experiences of others. What is accepted local practice must also be considered important when you devise a plan of care.^1,2

A selected glossary of clinical care guidelines

Consider the management of breech presentation that is recognized at the 36th week antepartum visit: Discussion with the patient should include 1) reference to concerns with congenital anomalies and genetic syndromes, 2) in-utero growth and development, and 3) the delivery process. The management algorithm may include external cephalic version, elective cesarean delivery before onset of labor, or cesarean delivery after onset of labor. Each approach has advocates—based on expert opinion clinical trials.

Management options may vary from institution to institution, however, because of limited availability of certain services—such as the expertise required for a trial of external cephalic version, the availability of on-site cesarean delivery capabilities, and patient and clinician preferences.

Uniformity of care, based on best practices, can therefore simplify the care process and decrease the risk that may be associated with individual experience-based management. Adhering to a uniform practice augments the clinician’s knowledge and allows for enhanced nursing and therapeutic efficiency.

The greatest benefit of using an evidence-based, widely accepted approach, however, is the potential to diminish poor practice and consequent malpractice exposure for both clinicians and the hospital.

Note: Although your adherence to clinical guidelines, best practices, and uniformity of care ought to be consistent with established standards of care, don’t automatically consider any deviation a lapse or failing because it’s understood and accepted that some local variability exists in practice.

Prelude to birth: triage and admission Triage. Most women in labor arrive at the hospital or birthing center to an area set aside for labor and delivery triage. There, 1) recording of the chief complaint and vital signs and 2) completion of a brief history and physical generate a call to the clinician.

The record produced in triage should be scrutinized carefully for accuracy. Clarify, in as timely a manner as possible, any errors in:

• timing (possibly because of different clocks set to different times)
• the precise capture of the chief complaint
• reporting difficulty or ease in reaching the responsible clinician.

Whether these records are electronic or paper, an addendum marked with the time is always acceptable. Never attempt to correct a record! Always utilize a late entry or addendum.

Admission. After the patient is admitted, she generally undergoes an admission protocol, specific to the hospital, regarding her situation. This includes:

• the history
• special requests
• any previously agreed-on plan of care
• any problems that have developed since her last prenatal visit.

This protocol is generally completed by a nurse, resident, nurse practitioner, or physician assistant.

Hospitals generally request input from the attending physician on the specifics of the admission, based on those hospital protocols. There may be some room to individualize the admission process to labor and delivery.

4 pillars of care during labor

In general, labor is defined as progressive dilation of the cervix. Several parameters serve as guidelines regarding adequate progress through the various stages of labor.

Fetal monitoring. Continuous evaluation of the fetus during labor is a routine part of intrapartum care. Recording and observing the FHR tracing is an accepted—and expected—practice. Documentation of the FHR in the medical record is specifically required, and should include both the physician’s and nursing notes.

Anesthesia care. The patient’s preference and the availability of options allows for several accepted practices regarding anesthesia and analgesia during L & D. Does she want epidural anesthesia during labor, for example? Intravenous narcotics? Her choice is an important facet of your provision of care.

However, such choice requires the patient to give consent and to understand the risk-benefit equation. Documentation by nursing of the patient’s consent and understanding should be complete, including discussion and administration. Anesthesia staff should be clear, complete, and legible in making a record.

Neonatal care. If logistics permit, a member of the pediatrics service should be routinely available to see the newborn at delivery. The patient should view the pediatrician and obstetrician as partners working as a team for the benefit of the mother and her family. This can enhance the patient’s understanding and confidence about the well being of her baby.

Documentation. Although deficient documentation does not, itself, lead to a finding of malpractice, appropriate documentation plays an important role in demonstrating that clinical practices have addressed issues about both allegation and causation of potential adverse outcomes.

We cannot overemphasize that nursing documentation should complement and be consistent with notes made by the physician. That said, nursing notes are not a substitute for the physician’s notes. Practices that integrate the written comments of nursing and physician into a single set of progress notes facilitate this complementary interaction.

3 more clinical scenarios

CASE 2: Admitted at term with contractions

The initial exam determines that this 21-year-old gravida 1 is 2/80/-1. Re-examination in 3 hours finds her at 3-4/80/0.

She requests pain relief and states that she wants epidural anesthesia.

Evaluation 2 hours later suggests secondary arrest of dilation. Oxytocin is begun.

Soon after, late decelerations are observed on the FHR monitor.

Use of exogenous oxytocin in L & D is a double-edged sword: The drug can enhance the safety and efficacy of labor and delivery for mother and fetus, but using it in an unregulated manner (in terms of its indication and administration) can subject both to increased risk.

In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:

• indications
• dosage (including the maximum)
• interval
• fetal response
• ultimately, the availability of a physician during administration to manage any problem that arises.

Considerations in CASE 2

• Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
• Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
• Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
• Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
• Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
• Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O₂, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
• Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
• When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
• Chart the process concurrently. Specify options for delivery before delivery.

CASE 3: Spontaneous delivery arrests after delivery of the head

The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.

After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.

Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.

Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.³

Considerations in CASE 3

• Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
• Consider delivering all women at term in the McRobert’s position, prophylactically.
• Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
• Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
• Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
• Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
• When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
• If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
• Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
• Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
• After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.

CASE 4: Meconium-stained fluid

A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.

The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.⁴

Considerations in CASE 4

• Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
• Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
• Administer supplemental O₂. Increase IV fluids to facilitate utero-placental perfusion.
• If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
• When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
• Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
• Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
• Carefully review corresponding nursing notes. Always write your own assessment of events and actions.

Summing up: three “keepers”

First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.

Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.

Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.

We want to hear from you! Tell us what you think.

CASE 1: Pregestational diabetes, large baby, birth injury

A 31-year-old gravida 1 is admitted to labor and delivery. She is at 39-5/7 weeks’ gestation, dated by last menstrual period and early sonogram. The woman is a pregestational diabetic and uses insulin to control her blood glucose level.

Three weeks before admission, ultrasonography (US) revealed an estimated fetal weight of 3,650 g—at the 71st percentile for gestational age.

After an unremarkable course of labor, delivery is complicated by severe shoulder dystocia. The newborn has a birth weight of 4,985 g and sustains an Erb’s palsy-type injury. The mother develops a rectovaginal fistula after a fourth-degree tear.

In the first part of this article, we discussed how an allegation of malpractice can arise because of an unexpected event or outcome for a mother in your care, or her baby, apart from any specific clinical action you undertook. We offered an example: Counseling that you provide about options for prenatal care that falls short of full understanding by the patient.

In this article, we enter the realm of the hands-on practice of medicine and discuss causation: namely, the actions of a physician, in the course of managing labor and delivering a baby, that put that physician at risk of a charge of malpractice because the medical care 1) is inconsistent with current medical practice and thus 2) harmed mother or newborn.

Let’s return to the opening case above and discuss key considerations for the physician. Three more cases follow that, with analysis and recommendations.

Considerations in CASE 1

• A woman who has pregestational diabetes should receive ongoing counseling about the risks of fetal anomalies, macrosomia, and problems in the neonatal period. Be certain that she understands that these risks can be ameliorated, but not eliminated, with careful blood glucose control.
• The fetus of a diabetic gravida develops a relative decrease in the ratio of head circumference-to-abdominal circumference that predisposes it to shoulder dystocia. Cesarean delivery can decrease, but not eliminate, the risk of traumatic birth injury in a diabetic mother. (Of course, cesarean delivery will, on its own, substantially increase the risk of maternal morbidity—including at any subsequent cesarean delivery.)

What do they mean? terms and concepts intended to bolster your work and protect you

It’s not easy to define what constitutes “best care” in a given clinical circumstance. Generalizations are useful, but they may possess an inherent weakness: “Best practices,” “evidence-based care,” “standardization of care,” and “uniformity of care” usually apply more usefully to populations than individuals.

Such concepts derive from broader applications in economics, politics, and science. They are useful to define a reasonable spectrum of anticipated practices, and they certainly have an expanding role in the care of patients and in medical education (TABLE). Clinical guidelines serve as strategies that may be very helpful to the clinician. All of us understand and implement appropriate care in the great majority of clinical scenarios, but none of us are, or can be, expert in all situations. Referencing and using guidelines can fill a need for a functional starting point when expertise is lacking or falls short.

Best practices result from evidence-directed decision-making. This concept logically yields a desirable uniformity of practice. Although we all believe that our experience is our best teacher, we may best serve patients if we sample knowledge and wisdom from controlled clinical trials and from the experiences of others. What is accepted local practice must also be considered important when you devise a plan of care.^1,2

A selected glossary of clinical care guidelines

Consider the management of breech presentation that is recognized at the 36th week antepartum visit: Discussion with the patient should include 1) reference to concerns with congenital anomalies and genetic syndromes, 2) in-utero growth and development, and 3) the delivery process. The management algorithm may include external cephalic version, elective cesarean delivery before onset of labor, or cesarean delivery after onset of labor. Each approach has advocates—based on expert opinion clinical trials.

Management options may vary from institution to institution, however, because of limited availability of certain services—such as the expertise required for a trial of external cephalic version, the availability of on-site cesarean delivery capabilities, and patient and clinician preferences.

Uniformity of care, based on best practices, can therefore simplify the care process and decrease the risk that may be associated with individual experience-based management. Adhering to a uniform practice augments the clinician’s knowledge and allows for enhanced nursing and therapeutic efficiency.

The greatest benefit of using an evidence-based, widely accepted approach, however, is the potential to diminish poor practice and consequent malpractice exposure for both clinicians and the hospital.

Note: Although your adherence to clinical guidelines, best practices, and uniformity of care ought to be consistent with established standards of care, don’t automatically consider any deviation a lapse or failing because it’s understood and accepted that some local variability exists in practice.

Prelude to birth: triage and admission Triage. Most women in labor arrive at the hospital or birthing center to an area set aside for labor and delivery triage. There, 1) recording of the chief complaint and vital signs and 2) completion of a brief history and physical generate a call to the clinician.

The record produced in triage should be scrutinized carefully for accuracy. Clarify, in as timely a manner as possible, any errors in:

• timing (possibly because of different clocks set to different times)
• the precise capture of the chief complaint
• reporting difficulty or ease in reaching the responsible clinician.

Whether these records are electronic or paper, an addendum marked with the time is always acceptable. Never attempt to correct a record! Always utilize a late entry or addendum.

Admission. After the patient is admitted, she generally undergoes an admission protocol, specific to the hospital, regarding her situation. This includes:

• the history
• special requests
• any previously agreed-on plan of care
• any problems that have developed since her last prenatal visit.

This protocol is generally completed by a nurse, resident, nurse practitioner, or physician assistant.

Hospitals generally request input from the attending physician on the specifics of the admission, based on those hospital protocols. There may be some room to individualize the admission process to labor and delivery.

4 pillars of care during labor

In general, labor is defined as progressive dilation of the cervix. Several parameters serve as guidelines regarding adequate progress through the various stages of labor.

Fetal monitoring. Continuous evaluation of the fetus during labor is a routine part of intrapartum care. Recording and observing the FHR tracing is an accepted—and expected—practice. Documentation of the FHR in the medical record is specifically required, and should include both the physician’s and nursing notes.

Anesthesia care. The patient’s preference and the availability of options allows for several accepted practices regarding anesthesia and analgesia during L & D. Does she want epidural anesthesia during labor, for example? Intravenous narcotics? Her choice is an important facet of your provision of care.

However, such choice requires the patient to give consent and to understand the risk-benefit equation. Documentation by nursing of the patient’s consent and understanding should be complete, including discussion and administration. Anesthesia staff should be clear, complete, and legible in making a record.

Neonatal care. If logistics permit, a member of the pediatrics service should be routinely available to see the newborn at delivery. The patient should view the pediatrician and obstetrician as partners working as a team for the benefit of the mother and her family. This can enhance the patient’s understanding and confidence about the well being of her baby.

Documentation. Although deficient documentation does not, itself, lead to a finding of malpractice, appropriate documentation plays an important role in demonstrating that clinical practices have addressed issues about both allegation and causation of potential adverse outcomes.

We cannot overemphasize that nursing documentation should complement and be consistent with notes made by the physician. That said, nursing notes are not a substitute for the physician’s notes. Practices that integrate the written comments of nursing and physician into a single set of progress notes facilitate this complementary interaction.

3 more clinical scenarios

CASE 2: Admitted at term with contractions

The initial exam determines that this 21-year-old gravida 1 is 2/80/-1. Re-examination in 3 hours finds her at 3-4/80/0.

She requests pain relief and states that she wants epidural anesthesia.

Evaluation 2 hours later suggests secondary arrest of dilation. Oxytocin is begun.

Soon after, late decelerations are observed on the FHR monitor.

Use of exogenous oxytocin in L & D is a double-edged sword: The drug can enhance the safety and efficacy of labor and delivery for mother and fetus, but using it in an unregulated manner (in terms of its indication and administration) can subject both to increased risk.

In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:

• indications
• dosage (including the maximum)
• interval
• fetal response
• ultimately, the availability of a physician during administration to manage any problem that arises.

Considerations in CASE 2

• Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
• Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
• Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
• Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
• Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
• Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O₂, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
• Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
• When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
• Chart the process concurrently. Specify options for delivery before delivery.

CASE 3: Spontaneous delivery arrests after delivery of the head

The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.

After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.

Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.

Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.³

Considerations in CASE 3

• Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
• Consider delivering all women at term in the McRobert’s position, prophylactically.
• Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
• Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
• Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
• Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
• When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
• If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
• Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
• Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
• After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.

CASE 4: Meconium-stained fluid

A 35-year-old multigravida is 6 to 7 cm dilated. Her membranes have just spontaneously ruptured; you note copious meconium-stained fluid. The FHR demonstrates recurrent variable decelerations; baseline fetal heart rate remains normal.

The description and implications of various FHR patterns are important when documenting the fetal metabolic state during the birth process. Current guidelines have attempted to simplify, standardize, and clarify the interpretation of the FHR tracing.⁴

Considerations in CASE 4

• Explain the situation to the patient. Perform a pelvic examination. If possible, wait for nursing assistance to ensure accurate documentation.
• Reassure the patient; help her move to a lateral position. Observe the FHR monitor for a response.
• Administer supplemental O₂. Increase IV fluids to facilitate utero-placental perfusion.
• If useful or necessary, consider attaching a fetal scalp electrode to better delineate fetal status.
• When the FHR returns to baseline state (before spontaneous rupture of membranes), perform vibro-acoustic stimulation as a test to support fetal well-being.
• Engage the patient and her family in a discussion about the sequence of events. Depending on the acuity of the situation, allow her to voice her concerns and reiterate what has occurred, and what will occur.
• Outline a plan of management to the patient—verbally and in the record—with clear reference to events that have occurred. Then, stick to that plan!
• Carefully review corresponding nursing notes. Always write your own assessment of events and actions.

Summing up: three “keepers”

First, the cornerstones of your effort to reduce malpractice risk are 1) thoughtful and informed discussion with the patient and 2) clear, concise documentation.

Second, don’t expect to be able to eliminate unnecessary or inappropriate allegations of medical malpractice; the best you can do is limit them.

Third, and most important, remember: The knowledgeable clinician you strive to be will make appropriate judgments in a timely fashion and will take appropriate actions to provide good medical care.

We want to hear from you! Tell us what you think.