Unit Ill-prepared for Labor and Delivery Complications

Description

Key Lessons

• Early signs of fetal distress should trigger the decision process re: early intervention
• Review of, and adherence to, policy/protocol is essential to patient safety
• The scope of practice requirements for covering physicians should be clear to all providers on the Labor & Delivery Unit

Clinical Sequence

1:00 p.m. A 30-year-old gravida 2, para 1 patient with a history of premature labor and cesarean delivery presented to the hospital in labor at 39.2 weeks (full term) for delivery. Her pre-natal course during this pregnancy had been unremarkable; the patient was counseled and consented for a trial of labor after cesarean. The patient was connected to an external fetal monitor and her labor progressed satisfactorily.

11:00 p.m. Recurrent late decelerations were noted in the fetal tracing, and then returned to baseline for a short period.

1:30 a.m. The patient had significant vomiting and a new series of decelerations were noted. Under such circumstances, hospital policy called for cessation of Pitocin, initiation of oxygen, resuscitation with intravenous fluids, and requesting the obstetrician’s presence at the bedside. In this case, the obstetrician (OB) was in the operating room (OR) with another case; a second OR team was unavailable, the covering (family practice) physician did not have OR privileges, and the nurse caring for this patient did not begin the protocol.

2:30 a.m. After completion of the prior case, the OB presented and immediately intervened. Delivery of the infant via vacuum assist was complicated by shoulder dystocia. The infant was born with poor Apgars and was cyanotic with low muscle tone. Resuscitation efforts were initiated. The mother suffered a partial uterine rupture that had to be surgically repaired.

4:30 a.m. The neonatal intensive care unit team from another hospital arrived to transfer the infant to their hospital.

The infant had a severe neurological injury and, at the family’s request, supportive care was withdrawn. The infant expired.

Allegation

The parents filed a medical professional liability case alleging that the obstetrics team failed to recognize, identify, and respond to the uterine rupture, resulting in their baby’s death.

Disposition

This case was settled in excess of $1M.

Analysis

1. Failure to appreciate and recognize signs and symptoms

There was evidence of fetal distress and concerning issues around 11:00 p.m. with the first series of decelerations. At this time, there was an opportunity for the OB to intervene. That might have led to a better outcome.

Best Practice/Recommendations

• Multidisciplinary huddles (at least daily) during which clinical issues are discussed. Ongoing continuing education (i.e., simulations) for obstetrical personnel to review fetal heart rate monitoring, emergency measures for treatment of shoulder dystocia, and forceps or vacuum application. Develop a program to evaluate and document staff competence (See CRICO OB Guideline #15: Assessment and Monitoring in Labor and Delivery).
• Develop a system to ensure that when there is an actively laboring patient on the labor floor, a physician credentialed to perform emergency delivery is readily available (See CRICO OB Guideline #13: Availability of Clinician and Case Load in Labor and Delivery).

2. Failure to follow policy/protocol

During the second series of decelerations (1:30 a.m.), the nurse did not urgently alert the OB and failed to implement the standard practice to stop the Pitocin, use oxygen, resuscitate with intravenous fluids, and request OB presence at the bedside.

Best Practice/Recommendation

Review policy/protocol for high-risk obstetrical situations. Develop a maternal early warning system (MEWS) to facilitate timely recognition, evaluation, and treatment for obstetrical patients developing critical conditions (See CRICO OB Guideline #30: Maternal Early Warning System).

3. Failure to respond

The covering physician did not have OR privileges but could have used the vacuum, thus decreasing the delay in responding to the fetal distress.

Best Practice/Recommendation

A systems approach to scheduling that plans for appropriate coverage of an unavailable surgeon or an unavailable OR. The clinician who is providing backup must be a qualified clinician of the same scope and skill as the attending. (See CRICO OB Guideline #3: Clinician Coverage and Transfer of Patient Care).

Resources

MEWS Algorithm