Excerpt from, “Patients’ Rights and Doctors’ Wrongs® – Secrets to a Safer Pregnancy and Childbirth”
Howard A. Janet, Esquire – CPFN Legal Advisor
and Giles H. Manley, MD, JD – CPFN Medical Advisor

Seven weeks shy of her due date, Diana awakens this Saturday morning to discover blood trickling from her vagina. Alarmed, she immediately calls her obstetrician’s office and learns her doctor is not scheduled to work. The obstetrician covering for him soon returns Diana’s call. She has never met this on-call doctor, but he seems to listen carefully and instructs her to go directly to the hospital.

Diana is admitted to the hospital at 8:40 a.m. The on-call doctor is not there. Thinking about their conversation, Diana realizes he didn’t tell her when he would arrive.

At 9:15 a.m., yet another doctor Diana has never seen before enters the picture—the hospital’s house obstetrician, who tells Diana he will manage her care until the on-call OB arrives.

Without examining Diana or inquiring about her prenatal care, the house doctor—relying on information from the attending obstetrical nurse—orders electronic fetal heart monitoring, injections of terbutaline (a medication to stop contractions), and an immediate fetal ultrasound. The objective of the emergency ultrasound is to rule out both placental abruption (premature separation of the placenta from the uterine wall) and placenta previa (abnormal positioning of the placenta at or near the internal opening of the cervix) as possible causes of the bleeding. Both of these conditions can be very dangerous to mother and baby.

At 9:40 a.m., the obstetrical nurse phones the radiology department to notify them the emergency ultrasound has been ordered. However, the radiology clerk mistakenly schedules it as a routine procedure. To make matters worse, no one on the OB team informs Diana about the need to perform the test immediately. The hospital staff keeps her completely in the dark.

At 10:30 a.m., the house obstetrician finally examines Diana and finds she is still bleeding. The ultrasound has not yet been performed, but the attending nurse has placed reminder call to radiology. This satisfies the house doctor, who leaves Diana to see another patient.

Although she does not know the fetal ultrasound was ordered on an expedited basis, after lying in the labor-and-delivery suite for nearly two hours, Diana begins to worry. What is taking so long?

So far, the baby’s heart rate has been reassuring, but at 11:19 a.m., the attending nurse notices it has slowed somewhat. The on-call obstetrician still has not arrived, and the house OB is performing a Csection on another patient. With no doctor to consult, the nurse relies on her own interpretation of the EFM tracings. When the orderly arrives at 11:33 a.m. to transport Diana to radiology, the nurse gives the go-ahead, even though she is concerned about sending her to the basement, so far away from the labor-and-delivery suite.

***

Now, Diana trembles as she lies under the thin sheet while a radiology technician performs the ultrasound. Her vaginal bleeding has increased. Why didn’t someone from the labor room come with me to monitor my baby? She is terrified something has gone wrong with her little girl, whom she plans to name Julia. Diana has never felt so alone.

It is 11:42 a.m. The ultrasound registers a dangerously low fetal heart rate of only eighty-seven beats per minute—well below 110, the low end of the normal range. It also reveals the placenta has partially separated from the uterine wall—the extremely dangerous condition the house doctor suspected when he ordered the test. Even worse, the separation appears to be evolving. But instead of notifying the OB staff upstairs of the emergency unfolding and rushing Diana back upstairs, the technician takes the time to complete the analysis that is part of a routine ultrasound.

By the time the x-ray technician finishes, it is six minutes past noon. The baby’s heart rate has dropped to sixty-eight beats per minute, yet the technician still does not notify the OB staff. Instead, she relays her findings to one of the staff radiologists, who merely prepares a report and sends it back to the OB floor with Diana.

At 12:45 p.m., the house obstetrician performs a second ultrasound at Diana’s beside in her labor suite. He confirms the abruption, as well as the baby’s precariously low heart rate. The house doctor then alerts the on-call physician, who orders an emergency C-section.

Although the on-call doctor—who sent Diana to the hospital more than four hours ago—has been at the hospital since a 12:15 p.m., he hasn’t even checked on Diana He has left her care entirely to the house doctor.

At 1:47 p.m., a full hour after ordering an emergency C-section, the on-call doctor finally begins the procedure. Baby Julia is born at 1:52 p.m. She has suffered irreversible brain injuries consistent with a severe lack of oxygen shortly before birth.

***

Today, Julia is a teenager. Despite the many challenges she and her mother confront when they wake each morning, they always seem to manage a smile. Diana finds comfort in believing Julia knows her parents love her with all their hearts. But Diana often cries herself to sleep at night, thinking about Julia’s future—a future that won’t include many of the joys experienced by healthy children and adults. Diana realizes her daughter will never act in a play or compete in sports. She will never go on a date or plan her wedding. She will never have children, but will always be childlike herself.

Knowing Julia’s life didn’t have to turn out this way only deepens Diana’s sorrow. She feels betrayed by the doctors and hospital staff she entrusted with the birth of her precious daughter.

What Went Wrong and Why

Expectant mothers experience third-trimester vaginal bleeding in approximately six out of 100 pregnancies. The causes and consequences of such bleeding range from inconsequential to severe. Even in very serious circumstances, permanent injury to the baby can often be prevented through timely recognition, appropriate corrective measures, and a speedy delivery, when necessary.

Diana’s story focuses on one of the most troubling causes of third-trimester vaginal bleeding—placental abruption, or separation of the placenta from the uterine wall before birth. When placental abruption develops, the flow of oxygen and vital nutrients to the baby decreases or stops altogether. More than 30,000 incidents of placental abruption occur annually in the United States.

Failure to Properly Follow Up on Suspected Partial Abruption

A Potential Emergency
Diana’s story involves a litany of missed opportunities and demonstrates how one bad decision can snowball, with life-altering consequences. Virtually every member of the obstetrical team—the oncall obstetrician, the house doctor, the obstetrical nurses, the radiology technician, and the radiologist—mishandled Diana’s and baby Julia’s care.

The OB team allowed a potential obstetrical emergency, a partial abruption, to evolve into a profound catastrophe. They allowed Diana’s placenta to continue separating prematurely from the uterine wall and her vaginal bleeding to increase, reducing the flow of blood (and oxygen) between mother and baby. This caused Julia’s heart to slow dramatically, and eventually led to her brain damage.

Both the on-call obstetrician and the house obstetrician suspected a partial abruption, but they dropped the ball when it came time to conscientiously following up—even after the abruption was verified and Julia’s dangerously slow heart rate was discovered.

Had the obstetricians, obstetrical nurse, radiology staff, and those responsible for establishing safe procedures at the hospital met applicable standards of care, the events of Julia’s birth would have played out very differently.

Zone of Safety
Once a partial abruption is suspected, especially one with ongoing vaginal bleeding, the condition should be treated as an emergency until proven otherwise. An immediate C-section may be necessary to save the mother’s life, prevent a debilitating birth injury to the baby, or both. That means keeping the expectant mother in the labor-and-delivery suite—the zone of safety—where operating rooms are located, and necessary obstetrical and anesthesia staff can be quickly assembled.

If vaginal bleeding has ceased for twenty-four consecutive hours and the fetal heart rate is thoroughly reassuring, consideration may then be given to moving the expectant mother to the obstetrical high-risk ward.

Bedside Ultrasound
With a working diagnosis of placental abruption, an expectant mother should be fully evaluated within the zone of safety the obstetrical suite provides. A properly equipped and staffed obstetrical department should be able to quickly verify a suspected abruption. Basic ultrasound machinery is all that is necessary.

The hospital had the equipment and personnel to perform Diana’s ultrasound in the labor-and-delivery suite. However, the obstetrical staff sent her down to the basement, where the radiology department was located. Just as the in-house obstetrician performed the second ultrasound at Diana’s bedside in the labor-and-delivery suite, the first ultrasound should have been performed there. The failure to do so after a working diagnosis of placental abruption clearly breached the standard of care.

With a bedside ultrasound, Diana’s test results would have been available to the OB staff immediately. Her partial abruption would have been detected sooner, before Julia’s heart rate slowed and while mother and baby were still safely in the labor-and-delivery suite.

The house doctor started down the right path when he ordered an immediate ultrasound, but he took a wrong turn when he chose not to perform the ultrasound on the spot.

Continuous EFM
The attending obstetrical nurse compounded the mistake of authorizing the orderly to transport Diana to radiology by failing to accompany Diana in order to constantly monitor the fetal heart rate on the way to radiology, while Diana was awaiting the ultrasound, and during the return trip. Julia was completely unmonitored during these critical periods.

The house obstetrician appropriately ordered electronic fetal heart monitoring, but failed to specify EFM was to be maintained continuously. That omission left room for the attending nurse to misinterpret his order.

In circumstances like Diana’s, where a suspected partial abruption has not stabilized, uninterrupted EFM must be maintained until vaginal bleeding has ceased for at least twenty-four hours, and fetal heart rate tracings are completely reassuring.

Obstetrician Should Have Interpreted Tracings
The attending obstetrical nurse missed still another opportunity to keep Diana in the labor-and-delivery suite. Before disconnecting the EFM just prior to transporting Diana to radiology, she observed the EFM tracings had revealed a troubling drop in Julia’s heart rate. This non-reassuring fetal heart pattern gave the nurse second thoughts about sending Diana downstairs, but she sent her anyway, without first alerting the house obstetrician to the change in Julia’s condition and getting his input.

The obstetrical nurse had an explanation: She thought her actions were justified because an obstetrician was not immediately available to interpret the fetal monitor printout. She thought wrong.

This nursing error deprived Diana and her baby of the crucial benefit of having an obstetrician analyze vital EFM data. Diana’s nurse should have torn off at least fifteen minutes’ worth of the tracings and taken them into the operating room where the house obstetrician was performing a C-section. As soon as circumstances permitted, he could have evaluated the tracings and issued appropriate orders right there in the OR. An obstetrician is expected to multi-task under such circumstances. Appropriate orders would have included an immediate bedside ultrasound while preparations began for an emergency C-section.

Communication and Other Basic Breakdowns
Diana and Julia were victims of breakdowns in even rudimentary aspects of obstetrical care.

The communication gaffe between the obstetrical nurse and the radiology clerk resulted in the clerk’s scheduling the ultrasound as a routine procedure, exponentially increasing the delay and risk of performing Diana’s ultrasound in radiology, rather than in the labor-and-delivery suite. There is no room for sloppy communication in obstetrics or any field of health care.

Both the obstetrical nurse and the house doctor knew Diana’s transport to radiology was delayed, but they failed to find out why. Had they investigated, they would have learned the ultrasound had been mistakenly scheduled as routine. This error would have been corrected, and valuable hours would have been saved.

What to Expect from an On-Call Obstetrician
Where was the on-call obstetrician who was covering for Diana’s private physician while all this was unfolding?

First, he took his time getting to the hospital. Once there, he was slow to check on the patient he had sent directly to the hospital hours earlier—a patient he had never seen before and whose medical history he did not know. He had every reason to suspect Diana was facing a potential obstetrical emergency, yet he did not provide her with the timely bedside management of her condition she expected and deserved.

In essence, the on-call OB treated Diana like a second-class citizen, sloughing off primary responsibility for her care to the hospital’s in-house obstetrician. Would he have treated one of his own patients that way? The on-call physician should have provided Diana and Julia with the same attention and quality of care he would give one of his own patients. Anything less is unacceptable.

What to Expect from a House Obstetrician
Typically, the responsibilities of the house obstetrician include evaluating patients as quickly as circumstances dictate after they arrive on the obstetrical floor, treating patients who do not have private doctors, and dealing with emergencies. The house OB may confer with a private obstetrician regarding the patient’s status to ascertain whether the private physician’s presence is necessary.

If the on-call OB or the patient’s regular physician negligently exposes the patient to a significant risk of injury, the house obstetrician is expected to intervene. That obligation is imposed only if the house doctor knew, or should have known, about the deficiency in care and was available to help. The on-call obstetrician, not the house OB, is primarily responsible for the patient’s care.

On this busy Saturday, the in-house obstetrician did himself and Donna a grave disservice by not insisting the on-call doctor come to the hospital to attend to his patient; the need for his presence was clear. The house obstetrician was managing the care of several other patients, including preparing to perform a C-section on one. However, instead of summoning the on-call obstetrician, the house OB allowed himself to be taken advantage of, seriously jeopardizing Diana’s and Julia’s well-being.

Hospital Policies and Protocols
To ensure proper obstetrical care for patients admitted with a possible abruption, hospital officials are expected to have safe, standardized operating procedures in place. But that’s not enough. They also must take steps to ensure those protocols are followed by all hospital staff and physicians with practicing privileges in the hospital.

Not a single member of Diana’s heath care team appeared to know Diana should be kept in the zone of safety and her baby needed continuous fetal monitoring. Appropriate, strictly enforced hospital policies would have ensured Diana remained in the labor-and-delivery suite, with her baby undergoing continuous electronic fetal heart monitoring.

Failure to Inform the Expectant Mother
Diana was kept out of the loop entirely. No one informed her about the need to verify her condition quickly or the possibility of an emergency C-section. She was left to either rely on intuition or call upon information she had acquired on her own. Eventually, Diana’s intuition kicked in, but she didn’t have the knowledge to be certain her concerns were valid, and she didn’t understand time was of the essence.

Diana relied 100 percent on her doctor’s knowledge and reliability to attend closely to her needs during labor and delivery. She did not educate herself independently, in advance of delivery, about how health care providers should handle a potential obstetrical complication such as a suspected placental abruption.

Failure to Respond Appropriately to a Known Partial Abruption and Fetal Bradycardia

A Confirmed Emergency
It’s one thing to fail to respond properly to a suspected emergency; it’s another thing entirely to fail to respond to a confirmed, known emergency. In this case, hospital personnel observed an evolving placental abruption and a sustained, severe drop in fetal heart rate. Yet, they continued to subject Diana and her baby to further lapses in care. As the potential emergency ripened into a frightening reality, hospital personnel continued a pattern of indifference toward both patients’ health and safety.

Radiology
Ultrasound technicians should be acutely aware an abruption of recent origin may signal a true medical emergency, posing grave risks for the mother and the baby, in particular. They should be equally aware that, after they confirm both the presence of an acute abruption and a persistently low fetal heart rate via ultrasound, there is no longer any doubt that an emergency exists. The presence of ongoing vaginal bleeding is not required to validate it, although Diana not only continued to bleed, but the flow of vaginal blood actually increased.

After an emergency of this nature is confirmed, it no longer matters whether an ultrasound was ordered routinely or emergently. The ultrasound procedure should be ceased and a member of the patient’s obstetrical team notified immediately. In a hospital setting, the patient should be returned to the labor-and-delivery suite immediately and an emergency C-section performed without delay.

The radiology technician performing Diana’s ultrasound observed the abruption and low fetal heart rate. Apparently oblivious to the gravity of the situation, she notified no one and continued to take and evaluate images. She checked Julia’s bone length, head size and body weight, and methodically went through the rest of the steps associated with a routine ultrasound for a baby of her gestational age.

The radiologist who arrived to interpret the ultrasound images also proceeded on a business-as-usual basis. In violation of the most minimal standard of care, he simply entered the red-flag findings on Diana’s chart and took no steps to alert anyone about the emergency at hand.

Back on the Obstetrical Floor
Eventually, Diana was returned to her labor-and-delivery suite, along with her hospital chart. Although the radiology report contained all the evidence he needed, the house OB performed a repeat ultrasound at Diana’s bedside. Again, the results verified the diagnosis he initially suspected—a placental abruption.

By that time, every minute counted. Incredibly, Julia’s delivery was still delayed. None of the evidence seemed to light a fire under anyone—not firsthand observation of the evolving abruption, not the ultrasound results, not the dangerously low fetal heart rate, and not Diana’s increased vaginal bleeding.

The evidence did prompt the house obstetrician to telephone the on-call OB, who was elsewhere in the hospital. After conferring, they decided to wait for the on-call OB to perform Diana’s C-section. When further delay should have been unthinkable, another hour was wasted as a result of that fateful decision.

What should the house doctor have done instead? He should have called for anesthesia on an emergency basis, cut into Diana’s abdomen and delivered Julia within a few minutes. At that point, every minute Julia remained in her mother’s womb meant another minute without oxygen and more extensive brain injury.