Frequently the obstetrician is requested to
review records for medical-legal issues. Although each case is unique,
there are a number of common indicators that require expert evaluation.
This paper will describe the most frequent types of obstetrical cases
that are reviewed and important elements necessary to determine the
appropriateness of care.
Shoulder dystocia is an obstetrical complication
feared by obstetricians because it is often unpredictable, requires
immediate appropriate intervention and can result in injury to the
newborn infant. The problem is caused by the fetus's shoulders being
too large for the birth canal and thus becoming entrapped behind the
pubic bone after delivery of the head. Large infants such as those of
diabetic mothers are certainly at risk for shoulder dystocia, but normal
weight infants may also suffer this complication. A review of the
progress of labor is usually normal but prolonged second stage of labor
followed by forceps delivery can also be seen.
The steps which should be taken and reflected in
the medical records (both nursing and physician progress notes contain
this information) are in sequence:
a) Prompt identification of this problem.
b) McRobert's Manuever. The mother's legs are removed from the
stirrups and her knees are flexed back on her abdomen to expand the
c) Suprapubic pressure or pressure over the mother's pubic area is
applied (not fundal pressure which means pressing on the top of the
mother's uterus which only worsens the problem).
d) Steady traction on the head without torquiring the head relative
to the neck.
e) Rotating the fetus's upper shoulder downward and the lower
shoulder upward, called a Wood's manuever, thus "corkscrewing" the
f) As a final effort intentionally breaking the fetus's clavicle to
reduce the diameter of the shoulders.
A shoulder dystocia can result in a range of
injuries from broken arm or clavicle, strain of the nerves traveling
through the neck (brachioplexus) resulting in arm or shoulder paralysis
or if more severe, cerebral hypoxia. When a shoulder dystocia occurs
often times the question of why a caesarean section had not been
performed is raised. This procedures is not used except in cases where
a very large infant, perhaps more than 4,200 gm is anticipated by
examination, sonogram or diabetic condition. An abnormally small birth
passage such as that seen with a congenital deformity or prior trauma
may also increase the risk of shoulder dystocia. Failure to perform a
diabetic screening test or GLT, failure to perform or document the
appropriate treatment steps or significant inconsistencies in the
nurse's and physician's notes can lead to successful plaintiff cases.
Surgery is not risk-free even in the best of hands
and is riskier in the hands of a less skilled or poorly trained surgeon.
Injury does not necessarily mean malpractice so it is important to
review all records pertient to the surgery. These include:
a) Preoperative office records which should clearly document why
surgery was undertaken and express that surgical risks and alternatives
were discussed with the patient (informed consent). If surgery was not
indicated then complicaitons may not be justifiable. Surgical
indications, however, are often in the "gray" zone.
b) An admission history and physical which summarizes why surgery
is being done and describes the patient's past medical history should
be dictated prior to the patient arriving in the hospital. A notation
on the bottom of the history and physical form indicates when it was
c) Operative note should be dictated within 24 hours of surgery
when fresh on the surgeon's mind. Did the steps taken and the
materials used as described in the operative note conform to expected
d) Does the anesthesia record concur with the surgeon's statement
of drugs used, operative time, blood loss, etc.?
e) Postoperative care is an important issue. Were notes written
by a physician showing attentive care and assimilation of nursing
data, vital signs, laboratory information and the formulation of a
Failure to provide these records to the reviewing
expert can result in false assumptions regarding whether or not
substandard practice occurred.
Common injuries from open abdominal or pelvic
surgery include anesthetic complications, wound infection, and injury to
bladder, ureter, bowel, blood vessels and/or nerves. Newer emerging
technology involving the use of laser or camera-guided surgery with
small incisions (laparoscopy) has a significant learning curve and
injuries are inverse to a surgeon's training and experience. It is not
often possible to determine from the medical records who is a well
trained laparoscopic surgeon with a rare bad outcome versus one who is
inadequately trained and exceeding his or her ability. Discovery
depositions are usually needed to clarify these issues.
Cerebral palsy or developmental delay of the
newborn are common causes for suit because of the significant degree of
injury. It is important to review the prenatal records, entire labor
and delivery records including fetal monitoring strips, nurse's notes
and physician's notes to reconstruct whether an injury occurred in utero
during development, during labor or delivery. Apgar scores and cord
blood gas reflect the oxygenation state at the time around delivery and
should be reviewed. The timeliness of response by a pediatrician should
be noted in the nursery records. Red flags include a 5 minute apgar
score below 7, a low cord pH, meconium or seizures in the newborn
period. The American College of Ob Gyn has good technical bulletins
which describe criteria to make the diagnosis of birth asphyxia.
While many injuries occur during labor and
delivery, many also occur in early intrauterine life and are
unavoidable. Careful scrutiny is needed before embarking on a
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