Common Obstetrical Complications
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 pelvic opening.
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 fetus.
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 dictated.
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 standards?
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 care plan?
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 malpractice action.
* This article is presented and copyrighted by The 'Lectric Law Library
and Dr. Steven E. Lerner & Associates (www.drlerner.com)