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By Mark K. Delegal, Esq., and Jan Gorrie, Esq. Pennington, Moore, Wilkinson, Bell & Dunbar, PA Tallahassee, FL
News: A woman pregnant with identical twins was admitted to a hospital for her scheduled inducement. The admission and inducement had been arranged by her family practitioner, her principal caregiver throughout the pregnancy. He only was to have initiated the inducement process and was counseled to call an obstetrician and other specialists for the actual delivery.
He failed to do so. One twin was delivered without complications and is perfectly healthy. But the second twin’s umbilical cord prolapsed and now is severely mentally retarded and physically impaired. The complication resulted in a delay of about 30 minutes in the second child’s delivery due to the time needed to assemble the team of physicians needed to perform an emergency cesarean section.
The hospital, family practitioner, and anesthesiologist settled prior to trial for a combined $4.9 million.
Background: The woman, pregnant for the first time, was being cared for by her family practitioner in her hometown, a small, rural community. Until the time of delivery, he provided nearly all her routine prenatal care; an obstetrician had performed an ultrasound and amniocentesis. Pregnant with identical twin girls, her pregnancy progressed without any undue complications and she wanted the twins to be delivered at the local hospital.
The 60-bed hospital had a limited medical staff and few specialized allied health professional personnel. Since the family practitioner was not privileged at the hospital to perform the actual delivery, he was required by the hospital to obtain an obstetrical consultation.
During the morning, the woman, who was at term, was admitted to the hospital. As dictated by the hospital’s credentialing of the family practitioner, he consulted with a board-certified obstetrician prior to initiating the inducement. The obstetrician advised the family practitioner to proceed. The family practitioner was only to oversee the patient’ s labor, not the delivery. As soon as the mother was ready to start pushing, the family practitioner was to call in an obstetrician, anesthesiologist, pediatrician, and respiratory technician.
Labor was induced and progressed fairly normally until about 10:30 p.m. when the mother suffered an arrest of labor. Her labor failed to progress until about 5:30 a.m. the next morning. When her labor reinitiated the family practitioner, without calling in the team of experts or consulting with the obstetrician, instructed the mother to push. Without the obstetrician, anesthesiologist, pediatrician, or respiratory technician present, the family practitioner improperly but successfully used a vacuum extractor and delivered the first twin without complications.
While delivering the second twin, the umbilical cord prolapsed, compressing between the twin in the birth canal and the mother’s pelvis. The family practitioner was alone and had not assembled the required consulting physicians.
It took 30 minutes to assemble the surgical team and for it to perform the emergency Cesarean section. The second twin was delivered without a heartbeat and without respiration. The extended time in which the umbilical cord was prolapsed was too long. The infant was resuscitated but suffered profound brain injury.
The plaintiffs’ theory of liability against the family practitioner was that he failed to manage the mother’s arrest of labor, that he should have called an obstetrician to evaluate the arrest of descent and dilation. The plaintiffs maintained that, most likely had an obstetrician been called at that stage of labor a cesarean section could have been performed and both twins would have been born without complications.
Additionally, the plaintiffs claimed that having failed to recognize and evaluate the arrest of labor, the family practitioner failed to call in the team of experts obstetrician, anesthesiologist, pediatrician, and respiratory technician to the hospital prior to instructing the mother to resume pushing for the delivery of the twins as had been required by the hospital.
The plaintiffs also insisted that had a surgical team been present in the hospital at the time of the umbilical cord prolapse of the second twin, an emergency cesarean section would have been carried out more promptly and the second twin would have been born prior to any brain damage.
The plaintiffs also brought suit against the anesthesiologist because she had been called within five minutes of the second twin’s umbilical cord prolapse and it took her 15-20 minutes to arrive at the hospital even though she only lived 2.3 miles from the hospital. The plaintiffs maintained that the anesthesiologist’ s delay in responding to the emergency call resulted in the emergency cesarean section being further delayed.
The case was settled prior to trial for a combined $4.9 million among the parties, including the hospital, family, practitioner, and anesthesiologist.
What this means to you: Rural hospitals face many challenges. They struggle to maintain adequate nursing and allied health professional staff; they compete with larger, metropolitan hospitals for patients and funding; and they try to keep an active, viable medical staff.
This case certainly deals with the dilemma of a small, rural hospital stretching its medical staff by allowing family practitioners to have even limited obstetrical privileges. Unfortunately, until health manpower shortage area facilities are willing to draft, implement, and enforce strict credentialing/privileging criteria, this type of unfortunate scenario is likely to continue, says Ellen L. Barton, JD, a risk management consultant in Phoenix, MD.
From the time the family practitioner provided prenatal care and up to the inducement of labor, he had an obligation to inform the patient of the possible constraints he would be under, Barton says. Apparently this caveat was acceptable to the mother and the family practitioner agreed to initiate labor, she adds. Once the family practitioner initially carried out this duty to the patient, the physician was obligated to follow the hospital’s credentialing protocols, she adds. Following her admission, the family practitioner took step one in notifying and consulting with the obstetrician as required by hospital policy. However, that was the last appropriate step the family practitioner took, observes Barton.
"When the mother’s labor arrested, the family practitioner should have contacted the obstetrician for an additional consultation," Barton continues. "Although she did not go into the delivery phase, her condition had changed significantly and it should have been reported to the obstetrician. Despite failing to make the second consult, the family practitioner certainly should not have proceeded with the delivery specifically against the strict instructions given in the initial consult with the obstetrician. In addition, when the physician was noncompliant with the credentialing protocols, the hospital staff clearly had an obligation to intervene through a prescribed chain of command.
"For example, staff could have asked the family practitioner to call the team of experts as required, and if the family practitioner failed to comply, then the staff should have been empowered to contact either the administrator on call, chief of the medical staff, or other appropriate staff to request an immediate intervention. Accordingly, this case requires not only a review of the standards for credentialing and granting privileges, but also a review of hospital sanctions for physicians who fail to comply with hospital protocols, and a review of what hospital staff are required to do when a breach of protocol occurs," states Barton.
"Unfortunately, as long as there are medically underserved areas with critical health care manpower shortages, small, rural health facilities will continue to be challenged to work with what is available to them. Protocols and restrictions on privileges can be a viable mechanism for stretching the available medical staff; however, if not effectively enforced as seen in this case, they simply cannot serve their purpose," concludes Barton.
Doe v. ABC Hospital, et al., Union County (OH) Court of Common Pleas. Attorneys for the plaintiffs were John G. Lancione and John A. Lancione of Cleveland.