Unfamiliarity Breeds Contempt

Description

A week after induction of labor and VBAC delivery of a 34-week breech stillborn, a patient with a history of DES exposure was found to have a uterine rupture.

Key Lessons

• An established physician-patient relationship may dissuade a contentious response to an adverse event.
• Appropriately documented practice within the accepted standard of care, generally, renders an adverse outcome defensible in court.

Clinical Sequence

A 33-year-old mother of one with a history of diethylstilbestrol (DES) exposure was found to have a fetal demise at approximately 34 weeks gestation, presumably related to a cord accident. After a discussion involving the patient, her husband, and the obstetrician who had delivered her first baby by cesarean section, a decision was made to attempt induction and vaginal delivery. Pitocin induction was begun by a physician in the obstetrics group practice treating the patient, and then assumed by a covering physician outside that practice.

As the induction proceeded, the patient developed increasing pain and bleeding. The covering obstetrician noted in the record the possibility of a placental abruption. In the differential diagnosis, uterine rupture was among the more remote possibilities, given the stability of the patient's vital signs and continued progression of labor.

Coagulation studies were monitored during labor and did not indicate excessive bleeding problems. A low grade fever resulted in the administration of antibiotics prior to delivery. The stillborn fetus was delivered by a member of the obstetrics group practice. The patient was discharged the next day, and returned three days later complaining of chills, fever, and pain. She received additional antibiotics and declined to have an ultrasound done.

Seven days after her discharge (nine days after the delivery), the patient’s fever recurred and she was re-admitted to the hospital for triple intravenous antibiotics. Ultrasound showed a mass within the uterine cavity and disruption of the uterine wall in an area not near the previous cesarean section scar. The patient would require major reconstructive surgery if another pregnancy was contemplated.

Allegation

The patient brought suit against the covering obstetrician who managed the time period spanning induction and labor. She alleged labor was improperly managed, resulting in a ruptured uterus, which then went undetected until an ultrasound a week after discharge.

Disposition

Following trial, the jury returned a verdict in favor of the defendant.

Analysis

1. Given the fetal demise, the patient was, understandably, anxious to deliver. Unfortunately, the defendant who was providing weekend coverage for the patient's obstetrical group had not previously treated the patient.
   The convergence of extreme emotional and physical stress makes it difficult for a patient and an unfamiliar physician to build a relationship quickly. In the face of a complication that the patient may see as life-altering, the lack of an ongoing relationship may promote consideration of legal recourse. Helping obstetrical patients understand the coverage arrangements and having them meet the providers in advance, or at least giving them information about them, can help alleviate some of this stress.
2. Medical literature does not support increased incidence of uterine rupture due to DES exposure, therefore, the obstetrician did not have a high index of suspicion for it in this case.
   Physicians are held to the standard of care practiced by their peers at the time the care was rendered. Literature and practice guidelines that support the decision-making process for care alleged to be negligent can deter litigation or significantly bolster the defense of such claims.
3. The jury adopted the defense expert's view that the only management indicated was an induction and vaginal delivery. They rejected the plaintiff's theory that a cesarean section delivery was not fully considered.
   A known fetal demise makes the mother's well-being and safety the only concern in selection of the delivery method. Documentation of discussions with the patient and the primary obstetrician regarding various options were helpful in defense of the case. The fact that, in hindsight, one avenue would have been better to pursue than another is not indicative of malpractice.