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    Legally Speaking: Was this forceps delivery appropriate?

    The patient first presented to defendant ob/gyn PC for prenatal care on June 6, 2008, at age 23. Her estimated date of delivery was January 24, 2009. After the woman’s third visit, the certified nurse midwives (CNMs) in the group followed her, on numerous occasions, between September 5, 2008 and February 4, 2009. By November 21, uterine size discrepancy was noted. The woman’s lab test results and blood pressure remained within normal limits; there was never any edema. On January 26, an ultrasound and biophysical profile (BPP) were done. The BPP was scored 8/8 and estimated fetal weight (EFW) was 3800 g (8 lb 6 oz) (±555 g, at the 75.3 percentile). On January 30 defendant CNM A noted that the patient was post-term; a non-stress test was reassuring. On February 2 the mother was 0 cm dilated, -3 station, and she weighed 204 lb. On February 4, 2009 CNM A noted 0 cm dilated, 0% effaced, and -2 station and 202 lb at 41.4 weeks. BPP was 8/8 with EFW 9 lb or 4087 g (±613).

    Related: ACOG on operative vaginal delivery

    The woman was instructed to present to the hospital that evening for induction and did so at 8:18 p.m. She was counseled about mode of delivery and requested a trial of labor. She was 0 cm, 30% effaced; presentation was cephalic, at -2 station, and clinical pelvimetry was adequate. EFW was 4087 g. Fetal monitoring revealed the absence of contractions initially, with a slow onset thereafter, and a fetal heart rate (FHR) 122–140 bpm with mild to moderate variability, accelerations and no decelerations. Membranes remained intact. An 8:46 note by CNM A documented delivery route counseling for macrosomia and shoulder dystocia given; the patient was thoroughly informed of the nature of macrosomia and shoulder dystocia and the risks and benefits of vaginal delivery versus cesarean delivery, as well as available alternatives. The risks and benefits to both her and her fetus and reasonable expected outcome to each alternative were discussed and the patient requested trial of labor. Dinoprostonel was placed and the mother was transferred from the OB suite to a room at 9:40. FHR monitoring was continued, externally, with acceptable FHR.

    By 3:00 a.m. the patient was noted to have regular contractions. A pelvic exam performed 25 minutes later revealed 1 cm/ 90% / -2 station, and membranes intact. At 5:00, when the patient refused further pelvic exam and requested an epidural for pain management, she was transferred to an L&D room. An epidural was placed by 6:20 a.m. At 6:59, pelvic exam revealed that the mother was 4 cm dilated with 100% effacement without fetal descent. At 8:18 when she was 6 cm dilated, CNM B ruptured the woman’s membranes, and a Foley was placed. At 8:21 Dr C was noted to be attending to the patient. The patient remained 6 cm dilated, 100% effaced, and at -2 station. External fetal monitoring remained ongoing; the FHR was in the 150s with moderate variability, reactive, no decelerations. At 10:00, variability was minimal.

    NEXT: More case history

    Andrew I. Kaplan, Esq
    Mr. Kaplan is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP, specializing in medical malpractice defense and healthcare ...

    3 Comments

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    • UBM User
      I think that was a case of cephalopelvic disproportion, past dates with unfavorable cervix. Induction was not an option in that case. I believe straight forward cesarean section was the proper option.
    • UBM User
      There is definitely a problem with the case, as the other physician that commented stated: an injury, irrespective of having done what was necessary to deal with a complication, will always tilt the balance against the defendant. We as a professional group have abandoned the teaching of forceps. In my community, there is a recently graduated ob/gyn who has never used a forceps throughout his career. What not many people understand and what most of the plantiff lawyers will constantly encourage is to forget that in the middle of a fetal bradycardia, with the presentation well engaged in the pelvis, a cesarean section would have been more difficult and it would have caused more injuries to the mother as it might have need great deal of manipulation to disengaged the presentation. Forceps were definitely indicated and, if the operator is skillful as this was the case, it offers a more expedite form to delivery a fetus in trouble.
    • Anonymous
      It is no surprise to me nor should there be any surprise to any obstetrician reading this case that it was settled. Why? The answer is simply because their was an injury. Regardless of the whatever eloquent evidence-based explanation the defendant obstetrician and his/her experts can muster, med-mal insurance carriers are loath at risking a decision with a lay jury who, despite instructions to the contrary by the judge, will probably cast a verdict with their heart. In the past few months we were treated to professorial dissertations on the use of forceps and bemoaning their demise. A few months earlier, we read about the alarming cesarean delivery rate in this country. The fact that this baby's life was saved by a skilled obstetrician gets lost in the rhetoric of personal injury advocates who seek to secure payment for their clients and themselves. As a result, this is yet another example of why the CD rate will not likely change very much until we come to grasp with the realities of obstetrics. It is time for the Ob community and organized medicine (yes, that's you ACOG) to come to the defense of our specialty and not just issue insipid Bulletins that hint at what we are supposed to do and leave us bleeding in the battlefield when we "follow instructions."

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