California – Obstetrics – Pregnancy And Delivery Complicated With Obesity, Hypertension, Shoulder Dystocia, Variable Decelerations, And Meconium

A 17-year-old obese female first presented to an obstetrician on 11/9/2008.  The patient was pregnant for the first time. Her estimated gestational age was 15 weeks and 4 days.  The patient saw the obstetrician on several occasions during the ensuing 5 months. The patient’s last prenatal visit was on 4/17/2008.  On that day, the patient had a markedly elevated blood pressure of 178/108. The obstetrician did not immediately schedule an induction of labor or otherwise address the patient’s hypertension.

On 4/18/2008, the patient was admitted to the hospital.  There was no documentary evidence that the obstetrician advised the patient to admit herself on that day.  On 4/19/2008, a vacuum assisted vaginal delivery was performed by the obstetrician. The hospital records showed that the head of the patient’s newborn son was delivered in the occiput anterior position at 6:40 p.m.  The patient’s newborn son’s body followed approximately 3 minutes later, concluding 1 hour 13 minutes of second stage of labor. A median episiotomy was cut.

The delivery was complicated by shoulder dystocia, variable decelerations, and meconium.  The patient’s newborn son was admitted to the NICU due to respiratory distress and meconium aspiration syndrome, which required intubation and ventilation.  The applicable standard of care requires that a physician and surgeon, in the course of rendering prenatal care, identify and address all high-risk factors including but not limited to risk factors for shoulder dystocia and the development of gestational hypertension and/or preeclampsia.  The applicable standard of care requires that when considering an operative vaginal delivery, as was done in this case, the physician and surgeon advise the patient of the risks, benefits, and other available options. Also, upon recognizing a shoulder dystocia, the physician and surgeon should institute six different measures rapidly: 1) discontinue oxytocin, 2) cease application of forces, 3) instruct the mother to cease pushing, 4) lower the head of the bed, 5) call for assistance, and 6) start a clock.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she failed to schedule the patient for immediate induction of labor or otherwise address the patient’s markedly elevated blood pressure on 4/17/2008, address or document that she addressed the high-risk factors, advise the patient of the risks, benefits, and other available options for a successful delivery, assess or document that she assessed the estimated fetal weight, station, position, and the application of negative pressure necessary to carry out a successful operative vaginal delivery, and institute the six measures to be followed upon recognizing a shoulder dystocia.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and an education course for at least 40 hours for every year of probation.

State: California

Date: November 2016

Specialty: Obstetrics

Symptom: N/A

Diagnosis: Obstetrical Complication

Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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