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Houston Area Collaborative Perinatal Program October 3, 2018

Learn best practices for managing inductions and avoid potential litigation in obstetrics. A case review of Smith vs. Houston Suburban Hospital and Dr. X.

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Houston Area Collaborative Perinatal Program October 3, 2018

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  1. Houston Area CollaborativePerinatal ProgramOctober 3, 2018 BEST PRACTICES FOR INDUCTION MANAGEMENT: OB LITIGATION CASE REVIEW JEFFREY MCCLURE, JD HUNTON ANDREWS KURTH LLP KATHRYN MOELLER, BSN, LNCC BAKER WOTRING LLP

  2. Case Review: Smith vs. Houston Suburban Hospital and Dr. X

  3. 28 year old gravida 2, para 1 • 38 5/7 weeks gestation • Prior delivery at 35 weeks for pregnancy-induced hypertension • Elective induction – worsening edema, occasional increased systolic BP, favorable cervix, head un-engaged.  Appears in spontaneous labor. EFW 8 - 8½. • Cervical exam by nurse on admission: 2-3 cm, 80% effaced, minus 2 station. • Pitocin orders: 20 ml in 1000 cc Normal Saline via pump • Begin Pitocin at 2 mu/min & increase 2 mu every 15 minutes until contractions every 3 minutes with cervical change. Infusion not to exceed 20 mu/min.

  4. Fetal monitor tracing prior to AROM and Pitocin administration at 0815:

  5. Fetal heart tones prior to Pitocin administration

  6. 0815: Seen by Dr. X, AROM clear fluid, 3 cm, 100%. Pitocin started at 2 mu • 0830: Pitocin increased to 4 mu • 0845: Exam: 4 cm, 100%. Pain level 8. Demerol & Phenergan given. Up to BR.

  7. 0900: Return from BR, moderate variable decels. Pt to left side, IV fluids increased, PITOCIN OFF, scalp electrode placed by nurse.

  8. 0930: Decreased variability post Demerol & Phenergan. No decelerations. Epidural.

  9. 1000: Pitocin restarted at 2 mu 1030: FHTs 150s; mild variables; reassuring; contractions every 2.5 minutes. 1045: FHTs 150-160. Moderate variables; contractions every 2 minutes; on left side. Pitocin at 4 mu. 1110: Variables down to 90-110. To right side, fluids increased, oxygen per mask. SVE: 5 cm, 100%, -1 station. 1135: Dr. X given report on decelerations. Strip faxed to Dr. X. Amnioinfusion ordered. 1200: Contractions every 1.5-2.0. PITOCIN OFF. Decelerations after contractions.

  10. 1250: Dr. X progress note: Contractions every 1 minute. Pitocin off. S/P amnio-infusion. FHR with variable decels, some in late position, good recovery, good variability. Cervix 8-9, C, 0 station (caput at 2+). Fast progress, overall FHR reassuring. (Dr. X) 1300: Terbutaline IV given. Dr. X at nurses’ station.

  11. 1330: FHR 160s -170s. Contractions every 1.5 minutes. Moderate “variable” decelerations continue. -

  12. 1354: Dr. X at bedside. Anterior lip, 1+ station. FHR, good variability, variables. Will reassess in one hour. Back to her office. C/S discussed. 1415: FHRs 160s. Moderate variables. Contractions every 1.5-2.0 minutes lasting 60 seconds. Pitocin off. Oxygen remains on.

  13. 1505: Anterior lip. Pushed x 2, FHTs down to 60s. Pt. turned side to side, negative scalp stimulation. Abdomen palpation done with no increased FHTs. 1509: Dr. X called and on her way. Terbutaline given. Thick meconium fluid noted. 1513: OR team called. Another OB asked to stand in. Moved to OR. FHTs 50-60s. 1517: Delivery of infant.

  14. Hospital Guidelines • Documentation: Good documentation by primary nurse regarding strip interpretation and keeping Dr. X informed • Pitocin: Never exceeded parameters. Turned off at 1200 and never re-started. • Fetal Monitoring – case was litigated prior to 2009 changes to Category 1, 2 and 3 parameters. • Notification of Physician • Chain of command: Hospital policy followed by primary nurse who checked with charge nurse and supervisor

  15. Case Outcome • Terminal bradycardia – 13 minutes until delivery • FHTs 40s in OR prior to delivery • Baby Girl born with Apgars 0 (1minute), 2 (5 minutes), 3 (10 minutes) • Required full code • Cord gas 7.07, 61.5, 30.3, -13.1 • Birth weight 8# 12 oz. • Prolonged NICU stay • Ultimate diagnosis = Dystonic cerebral palsy

  16. Defendants’ Testimony • Assigned nurse, charge nurse, Dr. X and L&D supervisor all testified that strip was reassuring despite variable decelerations because of variability and lack of late decelerations • They also testified that appropriate interventions were taken when terminal bradycardia began followed by appropriately prompt C-section

  17. Plaintiffs’ Expert Testimony • Plaintiffs’ MFM expert:testified that C-section should have been performed at 1130 am because strip showed minimal to absent variability and persistent late decelerations • Also, nurses should have used chain of command after 1130 • Claimed hours of late decels after 1130 caused injury • Not critical of handling of bradycardia at 1505

  18. Plaintiffs’ Expert Testimony • Plaintiffs’ L&D Nursing expert:testified that strip was non-reassuring most of the day and nurses should have used chain of command after 1130 • Also claimed primary nurse should not have been assigned to the patient because she had not taken an advanced EFM course • Not critical of handling of bradycardia at 1505

  19. Plaintiffs’ Expert Testimony • Plaintiffs’ Pedi Neurologist expert:testified that brain injury was entirely caused by the 13 minutes of bradycardia prior to C-section (a profound near total asphyxia) • Because of lack of injury to other organs, fetus was not injured by hours of partial asphyxia during labor • Plaintiffs’ Neuroradiology Expert: testified brain injury pattern fit with a profound near total asphyxia and not a partial prolonged asphyxia • Side note: Hospital radiologist interpreted the brain imaging as normal

  20. Defense Expert Testimony • Defense MFM and L&D Nursing experts:testified that decelerations were variables and not lates and that there was good variability throughout strip, along with episodes of acceleratoins • Supportive of handling of bradycardic episode and testified it was not foreseeable • Defense Causation Experts: agreed with plaintiffs’ neonatologist and neuro-radiologist that injury was caused by acute near total asphyxia just prior to C-section

  21. Other Guidelines ACOG & AWHONN (2009) Category I - All of the following • Baseline rate110-160 bpm • Baseline FHR variability – moderate • Late or variable decelerations – absent • Early decelerations – present or absent • Accelerations – present or absent

  22. Category II: Baseline rate: bradycardia not accompanied by absent variability. Tachycardia. Variability: Minimal baseline variability. Absent baseline variability with no recurrent decelerations. Marked variability. Accelerations: Absence after fetal stimulation Periodic or episodic decelerations: Recurrent variable decelerations with minimal or moderate variability. Prolonged deceleration more than 2 minutes, less than 10 minutes. Recurrent late decelerations with moderate variability. Variable decelerations with other characteristics such as slow return to baseline, overshoots, or “shoulders.”

  23. Category III: • Absentbaseline variability and any of the following: • Recurrent late decelerations • Recurrent variable decelerations • Bradycardia • Sinusoidal pattern

  24. Positives - Negatives Things health care providers did “right” • Never increased Pit above 2-4 mu, since there was cervical change and regular ctx at that level • Pit turned off at 0900 in face of moderate variables and nursing interventions with FSE placed for better assessment of strip • Pit only restarted at 1000 after variables resolved • With variables to 90 bpm at 1110, nursing interventions taken and exam – 5 cm • Dr. X notified at 1135 about variable appearing decels in late position and strip faxed • Pit stopped when ctx were 1.5-2 min. apart at noon • Ways care could have been improved.

  25. Positives - Negatives Things health care providers did “right” • Dr. X came to floor at 1250 and wrote a detailed note about her strip interpretation, ordered Terbutaline • Dr. X remained on unit for an hour reassessing strip as reassuring and performing second vag exam • Immediate interventions for FHR to 60’s • Called Dr. X and administered terbutaline four minutes after start of bradycardia • Moved to OR 4 minutes after notifying Dr. X • Asked another OB on unit to stand in for Dr. X in OR • Ways care could have been improved.

  26. Positives - Negatives Ways care could have been improved • Notify Dr. X closer to 1110 when variables to 90s occurred? • Turn off pit closer to 1110 when variables to 90s occurred instead of at noon when ctx were 1.5 – 2 min. apart? • Try to elicit accel during periods of min variability? • Do vaginal exam and notify Dr. X at 1454 about exam and persistent variables since she wrote in note timed at 1354 “Will reassess in one hour” ? • Call Dr. X sooner that 4 minutes after HR dropped to 60s? • Activate OR team and move to OR sooner that 8 minutes after HR dropped to 60s?

  27. Outcome by today’scriteria All testimony by defendant nurses and physician and defense experts would have evaluated this strip as Category II until terminal bradycardia. Clinical condition of newborn and brain injury pattern on imaging support caregivers interpretation that fetus was well oxygenated until the terminal bradycardia

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