The Doctor’s Advocate | Third Quarter 2017
An Ounce of Prevention
Obstetrical Closed Claims: What Can We Learn?
Spotlight on Preventing Obstetrical Claims is our second CME course featured in The Doctor’s Advocate. The course includes this article and five more that focus on lessons learned from malpractice claims reviews and expert opinions. We provide insights into the most likely risks encountered by obstetricians and shine a light on preventive actions. This course is approved for AMA PRA Category 1 CreditTM. To get started, read this article, then go to thedoctors.com/OBclosedclaimsCME to read the additional articles, take the post-test, and complete an evaluation.
To learn more about events that place obstetric professionals at risk, The Doctors Company examined 960 closed claims and 226 open claims reported between 2007 and 2015. Our analysis shows that the most common patient allegations in obstetrical claims continue to be delay in treatment of fetal distress (17 percent), improper performance of vaginal delivery (16 percent), and improper management of pregnancy (12 percent). (See Figure 1.) Let’s look at these three allegations in more detail.
Delay in Treatment of Fetal Distress Allegations
The most frequent allegation in obstetrical claims is delay in treatment of fetal distress. Analysis of these cases revealed that the most common reason for the delay was physician failure to act when presented with Category II or III fetal heart rate (FHR) tracings predictive of metabolic acidemia. Other factors contributing to patient injury in cases of delayed response to fetal distress included:
- Improper selection and management of therapy when faced with maternal illness or signs of chorioamnionitis.
- Inadequate patient assessments when fetal monitor tracings indicated that the neonate’s conditions were deteriorating.
- Lack of communication among physicians and nurses when a member of the team recognized distress.
- Inadequate patient monitoring.
Improper Performance of Vaginal Delivery Allegations
Improper performance of vaginal delivery was the second most common allegation. Factors that contributed to patient injury were the selection and management of therapy related to delivery (45 percent), complications that were known risks of the procedure (38 percent), insufficient documentation of clinical findings and informed consent (25 percent), and communication between patient/family and providers regarding other treatment options (17 percent).*(See Figure 2.)
The selection and management of therapy allegations are related to decisions about labor and delivery. Several claims involved neonates who were not assessed for possible macrosomia; where assessments were performed, documentation was either inadequate or absent.
When Category II and III FHR tracings are present, timely decisions must be made about continuing to deliver the neonate vaginally or moving to an operative vaginal delivery or cesarean section. The consequences for making the wrong decision or delaying the decision to perform an emergency cesarean section can be significant.
Brachial plexus injuries can be one consequence of an incorrect selection and management of therapy related to delivery. In 49 percent of these cases, mothers with significant risk of shoulder dystocia were allowed to attempt a vaginal delivery. While the presence of risk factors cannot always predict shoulder dystocia, the first step toward loss prevention is an accurate prenatal assessment to identify patients who may be at risk. Because the occurrence of shoulder dystocia is unpredictable, a well-orchestrated plan of action is necessary to prevent complications that could lead to brachial plexus injury, brain damage, or—on rare occasions—even neonatal death. Early identification enables the physician to take preventive actions:
- Have—and document—informed consent discussions with the patient regarding vaginal versus cesarean delivery.
- Implement management protocols that include tracking diagnostics.
- Schedule reassessments.
- Monitor periodic weights and measurements closely.
Improper Management of Pregnancy Allegations
Improper management of pregnancy refers to care provided during the months of pregnancy and is related to failure to follow testing protocols for neonatal and maternal conditions and infections that resulted in harm to the neonate. Examples included gestational diabetes, congenital abnormalities, group B streptococcus (GBS) infection, and eclampsia.
Patient assessment was found to be the most frequent contributing factor (37 percent) for this allegation and included failure to order diagnostic tests and to appreciate and reconcile relevant signs, symptoms, and test results. The second-highest contributing factor was the selection and management of therapy (29 percent) involving the management of pregnancy conditions and inappropriate medication for the medical condition. The third-highest factor, at 28 percent, involved patients who were noncompliant with appointments or with the plan for their pregnancy. (See Figure 3.)
Case Study: Shoulder Dystocia and Documentation
A 30-year-old gravida 5, para 3 was seen by her physician for prenatal care. The physician had delivered her two previous infants without incident. The patient had well-controlled gestational diabetes with the second pregnancy and delivered an 8-pound-10-ounce infant at 39 weeks. Gestational diabetes was again present with this pregnancy and continued to be well controlled per finger stick glucose testing and home testing logs. An ultrasound at 36 weeks showed that the size of the fetus was within normal limits. Despite fundal height measurements within normal limits, Leopold’s maneuvers created the expectation of a large infant. The patient was 5 feet 6 inches tall and weighed 267 pounds at her 40-week office visit.
Because the patient had a history of delivering a large infant, suffered from obesity and gestational diabetes, and was going to be delivering post term, the physician felt it prudent to discuss risk factors for shoulder dystocia with the patient. She explained shoulder dystocia, discussed the maneuvers sometimes used to relieve a shoulder dystocia, and mentioned that no one would press on the patient’s fundus at any time. The physician discussed the risk factors of a shoulder dystocia delivery versus a cesarean section (including the increased cesarean risks related to obesity) and the possibility of a cesarean delivery if labor progressed abnormally.
The patient was opposed to a cesarean delivery but stated she understood the discussion. She preferred not to have labor induced prior to 40 weeks but agreed to do so by 41 weeks if no labor occurred. The patient asked appropriate questions regarding the delivery of an infant with shoulder dystocia, and the physician documented the discussion in the prenatal record.
Two days later, the patient presented to labor and delivery with regular contractions. She was dilated 3 centimeters, 50 percent effaced, and at a -3 station. The patient’s labor progressed on a normal curve, and she was given Nubain at 6 centimeters of dilation. An hour later, the infant was ready to deliver but showed the classic “turtle sign” following delivery of the head. The physician had prepared the nurses for a possible shoulder dystocia; therefore McRoberts, supra pubic pressure, and posterior arm maneuvers were employed rapidly with subsequent delivery of an 8-pound-13-ounce infant. Facial bruising and decreased left arm movement were noted upon delivery.
The documentation included a description of the time of head delivery recorded by the bedside nurse, the exact maneuvers used, and the total time of the dystocia (3 minutes and 27 seconds). Apgars were 5 and 8, respectively. The infant was subsequently diagnosed with Erb’s palsy that resulted in limited use of the left arm despite pediatric follow-up.
The physician’s documentation of the predelivery counseling and detailed delivery note of shoulder dystocia maneuvers allowed this case to be defended more easily. Although risk factors for shoulder dystocia do not always result in actual shoulder dystocia, the presence of risk factors without patient counseling could be detrimental to the defense of a subsequent shoulder dystocia delivery claim. In this case, multiple defense experts were able to testify that the standard of care was met, that the patient was aware of risk factors, and that the documentation defended these assertions.
Risk Mitigation Strategies
The following strategies can assist obstetrical physicians and nurses in reducing risk and improving quality of care:
- Require periodic training and certification for physicians and nurses to maintain competency and facilitate conversations about FHR tracing interpretations. Use the standardized National Institute of Child Health and Human Development terminology when describing strips.
- Use technology that allows physicians to review FHR patterns from remote locations so that physicians and nurses are able to see the same information when discussing the next steps in labor and delivery care.
- Avoid delay in activating the emergency cesarean section team. Physicians who choose to attempt operative vaginal deliveries when faced with Category II or III FHR tracings indicative of metabolic acidemia should activate the contingency team to be available for an emergency cesarean section delivery in case the operative delivery fails.
- Consider multidisciplinary simulation drills for metabolic acidemia, maternal hemorrhage, respiratory arrest in mother or newborn, shoulder dystocia, placental abruptions, amniotic fluid embolism, ruptured uterus, use of forceps and vacuum extraction, and meconium aspiration.
- Conduct an accurate prenatal assessment to identify patients who may be at risk for shoulder dystocia.
- Document informed consent discussions regarding vaginal versus cesarean delivery.
- Monitor periodic weights and measurements closely.
- Use prompts or checklists to help document thorough assessments, rationale for recommended care, information shared with patients and families, care provided, and outcomes of care.
- Create a high-risk follow-up tracking mechanism to monitor all office diagnostic test results and scheduled repeat or serial testing.
- Schedule appropriate follow-up office visits frequently enough to provide adequate monitoring of the pregnancy and of pending test results.
- Promptly refer the patient for consultations with specialists when indicated.
Find full details on this complimentary course and explore all of our education and CME options at thedoctors.com/cme. Look for more CME opportunities in future issues of The Doctor’s Advocate.