OB on the Scene – And Reviewing All the Strips?

In any accredited hospital are nurses trained and assigned to monitor patients in labor for signs of fetal distress. And when those signs manifest, the job of these nurses is to contact the delivering physician.

Because of their close interaction, doctors develop a level of trust in these nurses’ skills and judgment. When it comes to a nurse’s summary – or silence – on fetal activity prior to the physician’s actual arrival, however, an obstetrician’s trust is best directed inward.

Dr. O was following a 24-year-old patient who was expecting her second Cesarean delivery. Her prenatal course at 37 weeks was unremarkable.

At 11 p.m., the patient called Dr. O complaining of labor-type pain every 10 minutes. The patient followed Dr. O’s instruction to go to the hospital. There, a registered nurse placed the patient on a fetal monitor at 11:47 p.m. and called Dr. O to report the patient’s arrival. Dr. O instructed the RN to prepare the patient for a repeat C-section and to call him and his assistant when the patient was ready. Dr. O told the nurse that he could arrive on 10 minutes’ notice.

When Dr. O arrived at the hospital at 1:15 a.m., an LVN attending the patient was ready to move the patient to the operating room. No one on the nursing staff told Dr. O of any problems, so he went to the lounge to await anesthesia and to change clothes. When Dr. O returned to the OR, a registered nurse who had taken over for the LVN showed Dr. O a section of the fetal monitoring strip that concerned her.

When Dr. O reviewed the 90 minute strip, he noticed that its first 25 minutes showed minimal to normal variability and no decelerations. After this time, the patient had apparently been moved to the recovery room area and a different monitor applied. This strip was much worse, with what appeared to be late decelerations.

Seeing this information, Dr. O told the RN to get his assistant for immediate surgery. Dr. O began surgery at 1:40 a.m. and delivered the infant at 1:48. With an Apgar of 0, the infant needed full resuscitative efforts for survival.

When Dr. O reviewed the chart after the delivery, he noted that when the admitting RN transferred the patient to the recovery room area at 12:15 a.m., the patient was placed with a licensed vocational nurse who did not read fetal monitoring strips. Even the second registered nurse, who appreciated the seriousness of the patient’s problem, failed to check the fetal heart tones in the OR before and after the epidural.

When the severely neurologically impaired minor sued the multiple health care practitioners responsible for his care, his expert’s theory against Dr. O was that had he reviewed the strips upon arrival, he would have appreciated the need to deliver the infant emergently, thus resulting in less neurological injury.

Overshadowing Dr. O’s acts, of course, was the hospital staff’s failure to warn him of problems with the fetal heart rates in the period before his arrival. As it turned out, the plaintiff’s attorney obtained a large enough settlement from the hospital to not proceed against Dr. O.

Dr. O’s case shows that even competent, alert nurses (let alone those without proper training) can miss a fetal heart pattern that would prompt a physician to change course. Physicians who rely solely on the hospital staff for a summary of fetal activity – without reading the full strips themselves – could end up accepting undue liability risk.

Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.