Case Study
Complications Follow Questionable Induction of Labor
Description
An induced labor complicated by a ruptured uterus and fetal compromise, resulted in newborn birth asphyxia and infant death.
Key Lessons
- Employ teamwork skills of cross monitoring (i.e., reviewing fellow team members’ decisions and actions) and seeking second opinions to help preserve situational awareness.
- Continue to review risks/benefits as the patient’s clinical status or circumstances change; document such discussions in the medical record.
- Make use of clinical guidelines to support decision making.
Clinical Sequence
A healthy 30-year-old, with no known allergies, entered Labor and Delivery for induction at 40 weeks. This was her fourth pregnancy, including two previous live births. The patient had a McDonald’s cerclage at 14 weeks gestation which was removed by her obstetrician at 36 weeks. Her cervix was notable for the laceration and scarring at the 4 o’clock position. Her obstetrician scheduled an induction of labor (the indication for this was not documented). Examination in Labor and Delivery revealed that her cervix was 1cm dilated. Pitocin was ordered to induce labor, and the obstetrician attempted rupture of amniotic membrane on three separate occasions over six hours without success. The fetal heart rate (FHR) tracing was reactive throughout the day. Pitocin was stopped in the late afternoon because the patient’s cervix did not dilate. She was sent home with plans to return in a few days.
Six days later, the patient returned for a second induction.
9:00 a.m.
Her cervix was 1-2cm and long, and the FHR had mild-moderate variability. with a baseline of 140-150 beats per minute (bpm). Prostin gel was placed to ripen the cervix and Pitocin started “per protocol.”
12:30 p.m.
Her cervix was 2-3cm dilated and the FHR tracing had moderate variability with occasional variable decelerations.
1:30 p.m.
She received an epidural for pain relief, and her cervix was about 4cm dilated. Her amniotic fluid sac ruptured spontaneously and a “small amount, blood-tinged” fluid was noted.
3:00 p.m.
Her cervix was 5cm dilated, the FHR was 140bpm with minimal variability and variable decelerations around the time of contractions.
7:00 p.m.
Her cervix was 8cm dilated and the fetal head at 1+/2+ station. The FHR was 160-170bpm with minimal variability and variable decelerations, some with slow return to baseline. The patient complained of left-sided pain and her epidural was reinforced.
7:30 p.m.
Her cervix was an “anterior lip.” The FHR was 170bpm with persistent variable decelerations.
9:00 p.m.
The FHR baseline was 170bpm with deep decelerations. An intrauterine pressure catheter was used to record contractions. The patient complained of severe pain and a fetal scalp electrode was applied.
9:35 p.m.
No cervical change. The FHR was 170bpm with deep decelerations. The obstetrician decided to deliver by cesarean section.
A female infant was found free-floating in the abdomen, requiring resuscitation. The mother’s uterus and bladder had ruptured. The infant was severely asphyxiated with extensive neurologic injury, and died at three weeks.
Allegation
The parents sued the obstetrician, alleging negligent care during labor and delivery.Disposition
The case was settled in the high range (>$500,000).
Analysis
- The indication for inducing labor prior to the patient’s due date, especially with an unripe cervix, was unclear and undocumented
A pregnant woman should be counseled regarding potential risks to her and her fetus, agents and methods of labor stimulation, and the possible need for a repeat induction or a cesarean section instead of a vaginal delivery (See Guideline15: Assessment and Monitoring in Labor and Delivery). The rationale for the procedure or treatment, risks involved, expected benefits, and alternatives to treatment including the likely results of no treatment should be documented in the patient’s medical records.
- The obstetrician failed to recognize that the fetal heart tracing deteriorated during the course of labor, reflecting worsening fetal status and fetal acidosis.
Per the American College of Obstetrics and Gynecology, FHR tracings that begin with moderate variability, progressing to minimal or no variability with persistent deepening decelerations are indicative of deteriorating fetal status and require evaluation for possible causes.
- Several factors likely contributed to the uterine rupture during labor, including the lacerated and scarred cervix that prevented normal dilation in response to labor contractions, and the integrity of cervical tissue at the laceration site.
A scheduled induction should have given the care team maximum opportunity to review the chart and be alert for such risks, circumstances that could be highlighted in a Labor and Delivery team briefing. A huddle or checklist review of concerns prior to induction of labor and repeated intrapartum as the need arises can help raise the appropriate red flags and increase situational awareness.
- The patient contested that she was not informed about the risks and benefits of induction of labor.
Informed consent for induction of labor, as for any medical or surgical procedure, involves a series of discussions. These should include the rationale for the procedure or treatment, risks involved, including severity of potential harm and the likelihood of occurrence, and the expected benefits and alternatives to treatment or no treatment. Documentation highlighting those elements of the discussion should be entered on the consent form or in the patient’s medical record.
- The patient alleged that the standard of care was breached when the obstetrician failed to recognize deteriorating fetal status and failed to perform a cesarean section in a timely fashion. The obstetrician could not explain why he didn’t respond to the deteriorating FHR pattern, and the nurse involved in this delivery did not convey her concerns about the FHR tracings.
Effective communication and teamwork skills might have facilitated the nurse’s ability to speak up and discuss her concerns, and enhanced the obstetrician’s awareness of the gravity of the situation.
- The patient argued that substandard care during the course of labor and delivery led to her daughter’s demise.
Experts who reviewed the case for the defense concluded that earlier detection of deteriorating fetal status, and earlier intervention, would likely have averted the infant death.
- This case had many of the elements that complicated its defense and reduced the likelihood it would be tried in front of a jury:
- unclear justification for practice outside the standard of care (induction prior to due date):
- lack of documentation of informed consent,
- delay in diagnosis and treatment of deteriorating fetal status, and
- failure to perform a cesarean section in a timely fashion.
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