ISMIE Mutual Insurance Company

Mutual Interests

Detecting and Treating Fetal Distress is Key to Avoiding Liability

Although widely acknowledged as a major risk management problem, failure to recognize and respond appropriately to fetal distress is still a leading cause of compensable damage in obstetrical malpractice cases. As a service to its policyholders and to improve patient care and reduce liability exposures, ISMIE’s Risk Management Department highlights the central issues taken from three recent malpractice cases. Each occurred in New York City Health and Hospitals Corp., as reported by the National Law Journal.

Case #1: A baby in a breech position showed signs of distress due to compression of the umbilical cord. During the delivery, the baby’s head was stuck in the mother’s uterus, and it took 10 minutes to deliver the child. The child was severely asphyxiated and sustained permanent brain damage.

The jury award: $116 million.

Case #2: The mother had severe pre-eclampsia, suggesting a Caesarian delivery; her two previous children had been delivered by Caesarian section. However, the mother was not examined for several hours, and hospital personnel were considering a vaginal delivery. The baby was delivered by C-section, but the delay lead to permanent brain damage and a mild case of cerebral palsy.

The jury award: $7.44 million.

Case #3: The mother had previously delivered a child by emergency surgery and should have been considered a high-risk patient. But she delivered the baby alone in her hospital room. The child was born with the umbilical cord wrapped around her neck. No hospital personnel were on hand to administer immediate resuscitation and lifesaving measures. Before the birth, the hospital’s residents had failed to perform a sonogram, which would have shown that the cord was wrapped around the baby’s neck. The child sustained severe, permanent brain damage.

The jury award: $76.4 million.

Risk Management's Response

Failure/inability to interpret fetal monitoring strips and/or to respond appropriately to fetal distress.

Causes:

Residents and/or nursing staff are not adequately trained to read/interpret fetal monitoring strips and cannot detect the signs of fetal distress.
Electric fetal heart monitoring is not employed, and/or monitoring equipment is not kept in good working order.
The hospital or OB department staff fails to follow (or there is a breakdown in attempts to follow) established policy on monitoring mothers in labor.
The mother's attending physician is not present or is inaccessible, delaying the decision to perform a C-section. The delay occurs because the residents are inexperienced in such decision-making or are not empowered to make such a decision, or the hospital is not equipped to perform emergency C-sections.

Recommended Risk Management Tactics

Training in reading and interpreting fetal monitoring strips (and/or in operating fetal monitoring equipment and responding appropriately to distress signals) for all residents and nurses who participate in deliveries.
Implementation and enforcement of hospital and/or OB Department policies regarding the attending physician's (essential) presence and/or ready accessibility during deliveries.
Hospital adoption of the American College of Obstetrics and Gynecology's 30-minute standard for emergency C-section preparedness.
Hospital or OB Department implementation of appropriate preventive maintenance for monitoring equipment. For more information on avoiding obstetrical malpractice liability, contact the ISMIE's Risk Management Department at (800) 782-4767 or (312) 782-2749, or e-mail riskmanagement@ismie.com.

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