California – Obstetrics – Induction For A Patient With A Bishop Score Of 4 And Continued Pitocin Use Despite Fetal Heart Tracing Abnormalities

A 24-year-old female was transferred from a physician to an obstetrician.  The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009.  Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.

The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009.  The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery.  The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.

The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening.  The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again.  During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor.  When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.

At 8:18 p.m., she was only dilated 4-5 cm.  The patient had spontaneous rupture of the membranes with thick meconium noticed.  At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes.  On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy.  The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate.  Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4.  When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby.  Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.

State: California


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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