Is One hour and ten minutes too long to get a hemorrhaging patient with placenta previa into the OR and C-sectioned delivered

A couple of points seem unclear or questionable. With a diagnosis of placenta previa, the facts that a “doctor tried to check her” (If this means sterile vaginal exam to assess cervical dilation) and the performance of a vaginal ultrasound should be relatively (some would say absolutely) contraindicated, as both could poke at the placenta should the cervix be open and cause or exacerbate a hemorrhage. Query if the diagnosis was a marginal previa where the tip of the placenta was at the internal os of the cervix instead of entire placenta. When was the decision to deliver actually made? ACOG guidelines discuss an ideal decision-to-delivery time as being 30min and maximum of 75 minutes, but it is unclear here if the decision to deliver was made before or after the vaginal ultrasound. More importantly, what was the skin incision to delivery time? The fact that the delivery was via general anesthesia would seem to imply that they actual surgical part of the delivery process was likely emergent, but the time should be available in the report. Also, what was the cause of the bleeding? Was there placental abruption where the placenta was separating prematurely? Was it preterm labor where the uterus is contracting against a précis blocking the cervix? Was a K-B test done that could have determined if there was abruption? Finally, were umbilical cord blood gases obtained, and did the initial neonatal testing demonstrate hypoxia or anemia? Also, what were the final fetal heart monitoring strips show? What were the vaginal ultrasound results? The clinical vignette presented here seems to have deviated from standard practice, but a couple details seem so far off that it begs the question whether some details were missing or incorrect or not.

If truly extra, unnecessary steps (attempted exam, vaginal ultrasound) were taken that lengthened the interval between when the decision to deliver should have been made (I.e., on a patient with known previa with severe enough bleeding to necessitate delivery which is a decision based on fetal status rather than either of the above tests unless the vaginal ultrasound was the only way they could have assessed fetal well-being?) and when delivery occurred, then that delay in delivery could have resulted in hypoxic brain injury/hypoxic-ischemic encephalopathy.

There is no reasonable explanation to obtain a vaginal probe ultrasound and somebody with a hemorrhaging placenta previa. If the intent was to quickly assess the fetus, and abdominal ultrasound would have sufficed or even a Doppler.

In this case, the delay in delivery could have caused hypertension, hypoxemia, or both in the infant.

This case involves a 5/21/2013 birth. Mother had been treated by a doctor in Brooklyn who failed to commence progesterone therapy for the incompetent cervix until 23 weeks while the literature indicates that this should have been commenced in the 16 week. ---- This allegation is weak, while many do start at 16 weeks, it would not be considered below the standard of care. Also progesterone is not a treatment for incompetent cervix, the only treatment for incompetent cervix is a stitch. This woman had a series of premature births one of which resulted in death. Premature birth is an indication for progesterone, but not below the standard of care to not use; as many do not use. The previa and the PTB are not additive in terms of risks, they each represent separate distinct risks The doctor had told her to go to a tertiary referral center because he didn’t feel comfortable continuing to care for her as high risk and he recommended that she go there immediately if there were any contractions or vaginal spotting. Mother was waiting for her first appointment to be scheduled at the tertiary referral center (Hospital A). ----Good call, and excellent care She was then told to remain in bed and allowed to get up only to use the bathroom. She was not on continuous fetal heart monitoring while in the antepartum ----Not clear from info given if she needed to be on continuous monitoring or not, may or may not be a deviation from care. Was it a departure to fail to deliver for an hour and 15 minutes.---- Assuming they weren't waiting on anesthesia, yes. This mother was at extremely high risk and if she had any breakthrough bleeding shouldn’t have been taken immediately and the C-section should have been in 30 minutes. Did they take unneeded time to do a vaginal sonogram prior to doing the C-section. ----- Yes, furthermore, if you suspect previa you would do an abdominal US Alternatively, if the vaginal sonogram was necessary was a departure to take so long taking the sonogram and getting this patient to the OR given her previa and heavy bleeding: The child was born with Apgar scores of 3, 4 and 6 at 1, 5 and 10 minutes and is today severely brain damaged. -----Likely this case would do well in front of a jury

This case involves a 5/21/2013 birth. Mother had been treated by a doctor in Brooklyn who failed to commence progesterone therapy for the incompetent cervix until 23 weeks while the literature indicates that this should have been commenced in the 16 week. ---- This allegation is weak, while many do start at 16 weeks, it would not be considered below the standard of care. Also progesterone is not a treatment for incompetent cervix, the only treatment for incompetent cervix is a stitch. This woman had a series of premature births one of which resulted in death. Premature birth is an indication for progesterone, but not below the standard of care to not use; as many do not use. The previa and the PTB are not additive in terms of risks, they each represent separate distinct risks The doctor had told her to go to a tertiary referral center because he didn’t feel comfortable continuing to care for her as high risk and he recommended that she go there immediately if there were any contractions or vaginal spotting. Mother was waiting for her first appointment to be scheduled at the tertiary referral center (Hospital A). ----Good call, and excellent care She was then told to remain in bed and allowed to get up only to use the bathroom. She was not on continuous fetal heart monitoring while in the antepartum ----Not clear from info given if she needed to be on continuous monitoring or not, may or may not be a deviation from care. Was it a departure to fail to deliver for an hour and 15 minutes.---- Assuming they weren't waiting on anesthesia, yes. This mother was at extremely high risk and if she had any breakthrough bleeding shouldn’t have been taken immediately and the C-section should have been in 30 minutes. Did they take unneeded time to do a vaginal sonogram prior to doing the C-section. ----- Yes, furthermore, if you suspect previa you would do an abdominal US Alternatively, if the vaginal sonogram was necessary was a departure to take so long taking the sonogram and getting this patient to the OR given her previa and heavy bleeding: The child was born with Apgar scores of 3, 4 and 6 at 1, 5 and 10 minutes and is today severely brain damaged. -----Likely this case would do well in front of a jury