Failure to properly manage shoulder dystocia

September 24, 2020

by Wayne Wenske, Senior Marketing Coordinator, and Jennifer Templin, Risk Management Representative

Presentation
On December 20, a 35-year-old woman went to an obstetrics/gynecology practice as a new patient for confirmation of pregnancy and prenatal care. She had a history of three prior pregnancies, with two ending in miscarriage and one resulting in the birth of a boy by vaginal delivery. At this visit, her blood pressure was 123/75 mmHg and she weighed 297 pounds. She would be 36 years old at the time of delivery.

 

Physician action
Ob-Gyn A saw the patient and diagnosed advanced maternal age (AMA) and noted that the patient’s obesity and AMA elevated her pregnancy to high-risk for complications.

On December 30, the patient returned for a follow-up visit and was documented as having bleeding. Her symptom list was updated with threatened miscarriage and AMA. An ultrasound was performed that confirmed a viable pregnancy with fetal tones of 139 beats per minute (bpm). The gestational age of the fetus was assessed as six weeks and six days, with an estimated due date of August 19.

Lab test results were noted as within normal limits, with the exception of a slightly elevated Hgb A1C at 5.7. Follow-up appointments were scheduled to take place every four weeks.

During follow-up visits over the next three months, the patient was seen by Ob-Gyn A and two of his practice partners, Ob-Gyn B and Ob-Gyn C. Examinations and lab testing all indicated the patient was carrying a normal female fetus. “Bleeding precautions” were also reviewed with the patient at one visit, but there were no notations of persistent or recurrent vaginal bleeding.

On March 27, the patient returned and was seen by Ob-Gyn A. The patient’s blood pressure was 127/82 mmHg and she was noted as having proteinuria. The physician recommended blood pressure monitoring due to the proteinuria. The patient was instructed to return in four weeks.

The patient returned in two weeks with reports of pressure and discomfort. The gestational age of the fetus was noted as 22 weeks, two days and the fetal heart rate at 145. The fetus was noted to be in the vertex position, and the patient was aware of fetal movement. The patient’s weight was 292 pounds and her blood pressure was 126/72 mm Hg. She still had proteinuria.

The patient returned two weeks later on April 30 and saw Ob/Gyn A. The patient’s proteinuria had resolved. The physician ordered a CBC and glucose tolerance test. There is no record that the patient complied with this order.

The patient maintained her regular appointment schedule for the next month, returning every two weeks. At her May 28 appointment, an ultrasound showed the fetus to be in the cephalic (vertex) position with a heart rate of 147 bpm. The patient’s placenta was noted to be grade II and anterior; her amniotic fluid index was 16.2, indicating a healthily progressing pregnancy.

The patient’s record indicates the following over the next several visits with Ob-Gyn B and Ob-Gyn C.

  • Continued examinations reflected the fetus to be healthy and testing in normal limits.
  • June 16: patient exhibited glucosuria; Ob-Gyn B ordered a two-hour glucose tolerance test. There is no indication the patient complied.
  • June 24: no glucosuria; ordered a three-hour glucose tolerance test. There is no indication that the patient complied.
  • July 9: no signs of glucosuria, with declining weight from 296 to 292. Ob-Gyn C instructed the patient to have a glucose tolerance test to rule out gestational diabetes. The patient did not comply.
  • July 16: Ob-Gyn C ordered glucose tolerance testing for the same day. The next day, the patient went to a testing laboratory for the test. The result was normal at 101 (range for normal limits is 70-199).
  • July 22: Ultrasound showed the fetus to be in the 62nd percentile. The patient’s placenta was now a grade III, indicating natural maturity of the placenta and anterior. Amniotic fluid measured 13 cm; blood pressure was 128/76 mmHg; and weight was 294.

At the July 22 visit, Ob-Gyn B noted a glucose tolerance test result of 150 and instructed the patient to proceed with a three-hour glucose tolerance test. The patient declined the test, preferring to do independent blood glucose monitoring at home, four times daily. The patient was instructed to return in a week.

On July 29, the patient returned and did not exhibit glucosuria. Ob-Gyn B performed a routine cervical examination and found the patient’s cervix to be closed, thick, and high. She was again advised to have a three-hour glucose tolerance test, but there is no record that the patient complied.

The patient returned on August 5 for her final prenatal visit with Ob-Gyn B. The gestational age was 38 weeks and heart rate was 148 bpm. The fetus remained in the vertex position and active. The patient’s blood pressure was 111/75 mmHg. She denied edema and did not exhibit proteinuria or glucosuria. The physician assessed the patient’s cervix to be “fingertip” dilated but still thick and high. The patient was again instructed to proceed with the three-hour glucose tolerance test but again there is no indication she complied with this instruction.

Ob-Gyn B prepared orders for induction of labor on August 13. The patient was instructed to return in one week for re-evaluation before delivery. The patient did not return.

The patient came to the hospital in the early morning of August 14 in the early stages of labor. She was admitted and experiencing mild contractions every five to seven minutes; upon examination, her amniotic membrane was intact. Fetal heart rate was 125 bpm and reactive with moderate variability ranging from 110-160 bpm.

At 2:30 a.m., Nurse A examined the patient and assessed the patient’s cervix to be 1 cm dilated, 60 percent effaced, and the fetus to be at -3 station. At 2:50 a.m., Nurse A notified Ob-Gyn B of the patient’s arrival and examination findings. The physician gave orders to start the patient on oxytocin injection and increase until the patient became symptomatic of progressing labor, then to hold at the current dose.

The patient and fetus were monitored continuously. The fetal heart rate was reactive with moderate variability ranging from 110-160 bpm.

At 7:50 a.m., Ob-Gyn B came to the hospital and examined the patient. The patient’s cervix was dilated to 3 cm, firm, and posterior. The physician ruptured the amniotic membrane, which yielded a small amount of clear amniotic fluid. The fetal heart rate remained normal, reactive with moderate variability and no decelerations.

At 8:45 a.m., the patient requested an epidural. An anesthesiologist placed an epidural at 9:36 a.m. The patient’s contractions were now two to three minutes apart, lasting 50 to 60 seconds.

At 9:45 a.m., a late deceleration of the fetal heart rate to 100 bpm, lasting 70 seconds, was noted. The oxytocin was discontinued immediately, the patient was repositioned to her left side, and intravenous fluids given. There is no indication in the record that Ob-Gyn B was notified.

At 12:30 p.m., Ob-Gyn B performed a sterile vaginal exam and found the cervix to still be at 3 cm dilated. However, the patient was now 50% effaced and at the -3 station. Contractions were coming every two to three minutes for a duration of 50 to 70 seconds. Fetal heart rate was 140 bpm, reactive with moderate variability of 110-160 bpm and no decelerations.

Exams at 2:45 p.m. and 5:45 p.m. showed little to no change.

At 7 p.m., the patient’s cervix transitioned and was dilated to 10 cm. The physician instructed the nurses to have the patient begin pushing.

The patient had strong contractions every two to three minutes. But she made little progress with pushing. The fetus was vertex, but presumed to be in the occiput posterior position, in which the occiput faces posteriorly (absolutely straight without turning to any of the sides).

At 7:45 p.m., Ob-gyn B attempted to rotate the fetus. During this attempt, the fetal heart rate measured 125 bpm with decelerations to 90 bpm lasting 50 to 70 seconds. The physician employed the “tug of war” technique for the patient’s continued pushing.

At 8:25 p.m., variable decelerations in the fetal heart rate to 110 bpm were noted and the patient was instructed on altering her pushing technique. At 8:45, the variable decelerations reached a low of 80 bpm for 20 to 40 seconds. Variable decelerations to 110 bpm continued through 9:15 p.m.

After two hours of unsuccessful pushing, Ob-gyn B applied a vacuum to the fetal head to assist the delivery. Two minutes later, the vacuum popped off, was reapplied, and popped off again after another two minutes. The patient was instructed to push again, and the fetal head was delivered at 9:22 p.m.

Mild shoulder dystocia was encountered. The McRoberts maneuver was employed followed by application of suprapubic pressure. Within 30 seconds, the shoulder was released, and the baby girl was delivered at 9:23 p.m.

The baby weighed seven pounds, 13 ounces and measured 21 inches and was assessed to be appropriate size for her gestational age. Her APGAR score at one minute was 7/10; at five minutes it was 8/10.

In the nursery, a pediatric nurse noted flaccid muscle tone and no motor strength of the left arm. A pediatrician evaluated the baby the following morning on August 15 and found that the baby was not moving her left arm but was moving her fingers. Due to the shoulder dystocia, the physician palpated the baby’s clavicle for possible fracture but there was no evident crepitus.

The pediatrician discussed the examination with the patient and informed her that she suspected brachial plexus injury (BPI). The patient and baby were discharged the next day on August 16. Six months later, in February, a Mod Quad procedure was performed on the baby.

 

Allegations
A lawsuit was filed against Ob-Gyn A, Ob-Gyn B, and Ob-Gyn C for failure to recognize and disclose the risks of vaginal delivery for a patient with AMA and possible gestational diabetes and using improper maneuvers in a shoulder dystocia event resulting in the baby’s BPI.

 

Legal implications
Consultants for the defense were supportive of the physicians. The consultants felt the diagnosis of gestational diabetes was irrelevant because the baby was not macrosomatic and the physicians had no reason to anticipate a shoulder dystocia. In addition, one consultant pointed out that shoulder dystocia is not predictable. There were some weaknesses with regard to lack of documentation of the discussion of risk factors and the estimation of fetal weight.

These consultants also pointed out that the patient was not compliant with requests for glucose tolerance testing. If she had been compliant and gestational diabetes diagnosed, the patient may have elected to have a cesarean delivery and the BPI could have been avoided.

Consultants for the plaintiff were more critical of the physicians for failing to diagnose and properly manage gestational diabetes resulting in abnormal growth of the fetus, shoulder dystocia, and BPI. The use of the vacuum and the application of fundal pressure were also criticized.

One of the consultants was critical of the physicians for failing to explain the importance of the glucose tolerance testing to the patient. This consultant also believes that the BPI implies that excessive and negligent traction was used to deliver the baby.

 

Disposition
This case was settled on behalf of Ob-Gyn A, Ob-Gyn B, and Ob-Gyn C.

 

Risk management considerations
In this case, the patient saw three different physicians, all in the same office. While it can be helpful for a patient to establish a relationship with each physician, it is also important that all providers work together to provide continuity of care. Additionally, a tracking system is important to monitor referrals and diagnostic tests ordered. Finally, having a protocol in place for timely completion of progress or encounter notes helps to promote accurate and up-to-date charting for each member of the health care team.

Studies have shown that if a patient has good rapport with his or her physician, it can make a significant difference on whether that patient files a claim in the event of a poor outcome. Having a good patient-physician relationship with open communication can help build the necessary trust for productive conversations and thorough patient education. 1

Continuity of care was a critical component in this case. According to the American Academy of Family Physicians, continuity of care is “the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care.” 2

In obstetrics, with patients being seen so frequently, having more than one provider available to accommodate patients can be beneficial.  However, it is important for each obstetrician that sees the patient to review the prior chart notes to see what may have changed since the last visit.

A lack of tracking test results was also a component of this case. There were several indications in the patient’s record of glucose testing being ordered. But no results or documentation of a patient discussion on why the testing was necessary or not completed were included in the record. This lack of documentation and tracking can give the appearance that the glucose testing “fell through the cracks.” Having a tracking system in place can help ensure that any requested testing or referrals are received and reviewed with the patient. 3

A last consideration is timely medical record documentation. According to the Texas Medical Board, physicians “shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible.” 4   There were instances where the patient was seen twice in the same week. Timely completion of progress notes can help further ensure that the patient’s chart is accurate and available for any member of the health care team at the time of care.

 

Sources

1.Carroll AE. To Be Sued Less, Doctors Should Consider Talking to Patients More. The New York Times. June 1, 2015. Available at https://www.nytimes.com/2015/06/02/upshot/to-be-sued-less-doctors-should-talk-to-patients-more.html. Accessed September 2, 2020.

2.Continuity of Care, Definition of. American Academy of Family Physicians. Available at https://www.aafp.org/about/policies/all/continuity-of-care-definition.html. Accessed September 2, 2020.

3.Luckie M. Closing the loop: tracking test results and referrals. the Reporter, Volume 4, 2012. Texas Medical Liability Trust. Available at http://resources.tmlt.org/PDFs/Reporter/2012_Volume4.pdf. Accessed September 2, 2020.

4.Texas Administrative Code Title 22, Part 9, Chapter 165, Rule 165.1. Texas Medical Board. Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed September 2, 2020.

 

Wayne Wenske can be reached at wayne-wenske@tmlt.org.

Jennifer Templin can be reached at jennifer-templin@tmlt.org.

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