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Failure to perform cesarean delivery

Presentation

At 8:20 p.m. on July 8, a 24-year-old pregnant woman arrived at the hospital in active labor. Initial exam by the nurse showed the patient’s cervix was dilated to 5 cm, 100% effaced, and the baby was at the -1 station.

An ob-gyn was called, though this was not the ob-gyn who had provided the patient’s prenatal care. A CRNA placed the epidural. The patient’s membranes ruptured spontaneously. This was the patient’s second pregnancy. She was morbidly obese, and had gained 56 pounds during her pregnancy.

Physician action

The ob-gyn examined the patient at 9:48 p.m., 10:12 p.m., and 10:30 p.m. He returned to the delivery suite at 10:40 p.m. The last nurse’s note indicated the patient was at a +1 station and her cervix was dilated to 8 cm.

Once the patient’s cervix was fully dilated and she began pushing, the ob-gyn proceeded with a vacuum-assisted delivery. According to the delivery note, after the head delivered, it retracted back, alerting the ob-gyn to a shoulder dystocia. A 4th-degree midline episiotomy was performed after the McRoberts maneuver failed. The delivery team continued to employ McRoberts along with suprapubic pressure. Ultimately, the ob-gyn placed his hand into the pelvis and used a cork-screw motion to dislodge the right shoulder from a seemingly occiput transverse position. Delivery occurred at 11:15 p.m.

The baby boy weighed 10 pounds, 1 ounce and was resuscitated in the delivery room. His Apgar scores were 4, 7, and 8 at one, five, and ten minutes. There was no evidence of hypoxic injury. At birth, a possible right brachial plexus injury was noted based on decreased movement and tone in the right arm.

Over the next two years the child received intermittent treatment for his brachial palsy and underwent two surgeries to improve the use of his right arm.

Allegations

A lawsuit was filed against the delivering ob-gyn. The allegations included:

  • failure to properly assess fetal weight during initial exam;
  • failure to use ultrasound to assess fetal weight in a large patient;
  • improper use of vacuum extractor; and
  • failure to order and perform a cesarean delivery.

Legal implications

The plaintiff’s expert stated that the defendant failed to properly explain to the mother the increased risks of shoulder dystocia and brachial plexus injury in a macrosomic baby. The option of cesarean delivery was not offered to her. He also asserted that the ob-gyn did not obtain informed consent for use of the vacuum extractor, failed to document this in the chart, and failed to review the prenatal records and assess the fetal weight when assuming the care of an unfamiliar patient.

The defense expert argued that the defendant managed the baby’s delivery and reacted appropriately when he encountered shoulder dystocia. Shoulder dystocia is an unpredictable intrapartum complication. The patient’s obesity and 56-pound weight gain during pregnancy were risk factors for shoulder dystocia, but they did not indicate shoulder dystocia would occur.

At the time of delivery the defendant estimated the baby’s weight at 8 pounds. The patient’s treating ob-gyn estimated the baby’s weight two days before delivery using Leopold’s maneuvers and sonogram. His estimate was also 8 pounds.

Disposition

This case was taken to trial and the jury returned a verdict in favor of the defendant.

Risk management considerations

The plaintiff’s expert criticized the ob-gyn for not obtaining informed consent concerning the risks and benefits of a cesarean delivery. Any conversations the ob-gyn had with the patient about the possibilities of a cesarean delivery were not documented. The ob-gyn explained that he began caring for the patient while on call. Because she was in labor and progressing well, he felt no reason to discuss alternatives until it was necessary.

The duty to obtain informed consent before a treatment or procedure is the responsibility of the physician or treating provider. Discussing potential issues and options, and documenting those discussions, can assist in preventing allegations that the physician did not keep the patient informed.

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