Delay in performing cesarean delivery, hysterectomy
Presentation
A 42-year-old woman was receiving care from Ob-gyn A for her third pregnancy. The patient’s second child had been delivered by Ob-gyn A nine years earlier. The patient had a history of multiple uterine fibroids, some anterior in location, with the largest fibroid measured at 3 cm.
Physician action
Entries in the prenatal records indicated that the patient had tenderness during palpation of her uterus/fibroids throughout her pregnancy. An ultrasound showed fibroid degeneration and a necrotic fibroid. The patient wanted sterilization following the birth of this child.
Ob-gyn A scheduled an induction of labor on January 14, at 39 weeks. Despite the patient’s two previous vaginal deliveries, her last five weekly cervical exams demonstrated only “fingertip dilation” with the fetal head remaining high in her pelvis.
About two hours into labor, the patient stopped dilating at 8-9 cm. The baby experienced decelerations into the 60s with a lack of descent after an hour of pushing. The ob-gyn attempted to push the cervix back, but was unsuccessful. He commented that he was concerned the uterine fibroids were blocking the descent of the head.
Ob-gyn A performed an urgent cesarean delivery using a low transverse Pfannenstiel skin incision. He encountered “massive amounts of fibroids” in the lower uterine segment requiring him to make multiple incisions. After delivery, the closure of the uterine wall required several layers of sutures, as did the fibroids that were cut. The patient lost 1500 cc of blood. She was taken to the recovery room.
The baby experienced distress, but stabilized and was discharged on January 19.
Ob-gyn A saw the patient on rounds the next day and she appeared to be doing well. He turned her care over to his partner (Ob-gyn B) for the weekend. During this time, the patient was anemic and was given four units of packed red blood cells.
When Ob-gyn A returned to the hospital on postoperative day 4, the patient had a fever with a high white blood cell count from a presumed uterine infection. The patient was transferred to the ICU and Ob-gyn A consulted an infectious disease physician. The patient received multiple units of blood.
By January 19, the patient’s condition improved and she was transferred from the ICU to the maternity floor. However, she again developed fever and an increased white blood cell count despite receiving IV antibiotics. Ob-Gyn A consulted Ob-Gyn C, a gynecological oncologist, who recommended a hysterectomy.
On January 22, Ob-gyn C performed a hysterectomy and bilateral salpingo-oophorectomy with removal of peritoneal fluid, assisted by Ob-gyn A. She encountered dense adhesions, anatomic distortion caused by the fibroids, and inflammation of the peritoneum and soft tissue. Blood loss was extensive, and the patient received two units of packed red blood cells. The pathology report revealed acute endometritis and necrotic fibroids.
The patient’s condition further declined after the hysterectomy. A few hours after the surgery, her blood pressure dropped and she became unresponsive. A code was called and she was successfully resuscitated. She was diagnosed with disseminated intravascular coagulation (DIC), and was transferred to a regional medical center where she underwent additional surgery.
She died on February 17, after more than a month in the hospital. The pathologist determined the cause of death to be hemorrhagic shock from multi-organ failure.
Allegations
A lawsuit was filed against Ob-gyn A, alleging that he failed to meet the standard of care in the following ways:
- by inducing labor in a 42-year-old patient with extensive uterine fibroids;
- in his surgical management of the cesarean delivery; and
- in his failure to perform a hysterectomy at the time of the delivery.
Legal implications
The plaintiff’s expert criticized Ob-gyn A’s decision to induce labor rather than schedule a cesarean delivery. As expected, the patient’s labor stopped and an urgent cesarean delivery was necessary. Further, this expert questioned the low transverse incision, which placed Ob-gyn A directly in line with the patient’s uterine fibroids. A vertical abdominal wall incision or a wider transverse incision would have avoided having to cut through the uterine fibroids.
According to the plaintiff’s expert, the standard of care required Ob-gyn A to perform a hysterectomy at the time of the cesarean delivery. The patient was a 42-year-old woman who wanted sterilization following the birth of her child. A hysterectomy at this time would have avoided the postoperative complications and reduced the risk of postoperative fever and infection.
Regarding his actions, Ob-gyn A later stated that he did not perform a hysterectomy because they were able to achieve hemostasis intraoperatively; the patient’s vital signs and urine output remained stable throughout surgery; and the evaluation of vaginal bleeding was equivalent to a normal post cesarean delivery.
Physicians who reviewed this case for the defense agreed with the plaintiff’s expert about Ob-gyn A’s surgical management of the caesarean delivery. Because fibroids can bleed excessively and are prone to necrosis and infection, they felt he should have avoided cutting through the uterine fibroids.
Disposition
This case was settled on behalf of Ob-Gyn A.
Risk management considerations
Ob-gyn A was aware of the patient’s fibroids before delivery; however, they had not significantly changed or increased in size for approximately 10 years. In addition, the largest fibroid was 3 cm in diameter, and the patient had previously delivered 2 children vaginally with the fibroids known to be present.
The patient’s sonograms were reviewed by maternal-fetal medicine physicians during each of her pregnancies, and it was never suggested that a cesarean delivery should be done or that induction of labor was contraindicated. Consultants understood that this played a role in Ob-gyn A’s decision to proceed with induction of vaginal labor. Opinions were mixed on whether this decision was reasonable and within the standard of care.
The records indicated that Ob-gyn A discussed with the patient the possibility of needing to do an emergent hysterectomy due to the fibroids and excessive bleeding. Consultants had differing opinions regarding the choice not to perform hysterectomy at the time of the cesarean delivery. All agreed that a hysterectomy was indicated by postoperative day eight.
Above all, there was criticism of the cesarean delivery technique used by Ob-gyn A. One consultant felt that it was unwise to cut through the fibroids during delivery. If possible, avoiding the fibroids or removing those in the way would have limited the blood loss. Another choice would have been to perform a vertical (classical) incision versus the horizontal (transverse) incision, or to perform the horizontal incision higher on the uterus in the fundal area or on the posterior wall of the uterus. Consultants felt that the multiple incisions used by Ob-gyn A were problematic, and may have contributed to the poor outcome in this case.