27 y.o. G2P1001, BMI 30-34.9. During her 1st pregnancy, she was induced at 40 weeks for pre-eclampsia, progressed to 7 cm and then arrested for 4 hours, developed chorio and fetal tachycardia, and had a c-section done. This pregnancy BPs were normal, taking 81 mg ASA. She "strongly desired" a VBAC.
On 6/1/2022:
- 10:15 approx: Admitted to hospital for scheduled induction for TOLAC at 39 weeks 3 days. SVE 3/50%/-3, cephalic presentation.
- 12:00: Pitocin started at 12:00 at 1 mu
- 13:00: Pitocin increased to 3 mu
- 14:00: Pitocin increased to 4 mu
- 14:43: Seen by MD; no epidural at this time. SVE 4/60%/-3. FHR baseline 145, moderate variability. Contractions q 3-7 minutes. A/P: "Reassuring fetal status. Continue current management."
- 15:30: Pitocin increased to 6 mu
- 17:42: Seen by MD; no epidural at this time. 1+ extremity edema. Vitals WNL; no SVE done. FHR baseline 145, moderate variability. Contractions q 3-5 minutes. A/P: "Reassuring fetal status. Continue current management. Rec. AROM (if FHTs reassuring, etc.) when more active as she had chorio and AOD at 7 cm w/ last pregnancy."
- 19:48: Pitocin increased to 8 mu
- 20:56: Pitocin increased to 10 mu
- 21:42: Seen by MD. "Patient doing well, just received Nubain, considering an epidural soon." Vitals WNL, extremity edema "none." SVE 4/60%/-2. SROM w/ clear AF noted just after exam. FHR baseline 130, moderate variability, 15x15 accels, no decels. Contractions q 1-2 minutes. A/P: "Reassuring fetal status. SROM after exam, noted to be clear. Continue Pitocin for TOLAC. Consider IUPC if needed for mvu. Pt counseled about labor and what to expect."
- 21:56: Pitocin increased to 12 mu
- 22:25: Pitocin increased to 13 mu
- 23:49: "Patient wants to start off with a walking epidural. Will reassess in an hour."
On 6/2/2022:
- 01:08: Pitocin increased to 15 mu
- 01:54: Pitocin increased to 17 mu
- 02:30: FHR 150 baseline, moderate variability, no accels, no decels
-02:38: Seen by MD; "Patient with multiple questions and concerns about uterine pain. She had a walking epidural and now a full epidural. NAD; appears comfortable." Vitals WNL, SVE deferred. FHR baseline 140, moderate variability, no accels, no decels. Contracting q 3-4 minutes. "Patient reassured about tracing and contraction pattern. All questions answered. Continue current management."
- 03:00: FHR 150 baseline, moderate variability, 15x15 accels, no decels. Tachysystole noted for >5 contractions in 10 minutes.
- 03:44: Pitocin decreased from 16 to 8 mu
- 03:50: SVE by MD at 7/100%/0.
- 04:09: MD progress note: "Called by RN due to tachysystole. Patient with complaints of increased pain and is requesting pain meds. Discussed VE and IUPC placement and she is agreeable." Also documented vitals WNL and exam "NAD, appears comfortable." FHR baseline 150, moderate variability, 15x15 accels, no decels. Contracting q 1 minute. A/P: "Reassuring fetal heart tracing. Pt encouraged given current progress. IUPC placed. Pitocin halved for now. Pain management per anesthesia. IVF bolus."
- 04:30: FHR 190, minimal variability, early decels. Contracting q 1-2 minutes.
- 04:35: SVE 9/100%/0
- 04:38: Temp 99.2 oral.
- 04:39: Temp 101.5 axillary.
- 04:42: MD notified by phone "of SVE, epidural dosing w/ hydration, current temperature, FHT (minimal and tachycardia), order received to give Tylenol 1000 mg po now and [other MD] will follow up after."
- 04:59: Other MD notified by phone: "called unit and notified of axillary temperature, maternal and fetal tachycardia, epidural dosing for pain."
- 05:00: FHR 190, minimal variability, early decels. Contractions q 1.5-2.5.
- 05:02: "CANM aware of dx and treatment plan for chorio."
- 05:13: MD notified by phone: "Called unit, MD reviewed strip and aware of contraction pattern, order to half the Pitocin which is currently at 8mu and will decrease to 4 mu..."
- 05:30: FHR 195, minimal variability, no accels, early decels. Ctx q 1-2.5.
- 06:00: Pain rating 7, abdomen. Type: pressure. "Breathing well through contractions." FHR 195, minimal variability, no accels, early decels. Ctx q 1.5-2.5.
- 06:13: "Patient requesting doctor to bedside." Doctor notified by phone: "made aware of fetal tracing and maternal vital signs."
- 06:24: "Patient requesting to see doctor at bedside." MD notified by phone.
- 06:25: CRNA called to bedside for pain eval.
- 06:30: Pain rating 10; type: sharp, pressure. "Patient complains of pain left side. Anesthesia has been called to bedside." FHR 180, minimal variability, no accels, early decels. Ctx q 1.5-2.5 minutes.
- 06:36: Strip reviewed by MD.
- 06:44: Strip reviewed by MD; also "CANM aware of EFM tracing."
- 06:47: Pitocin stopped. "IUPC not tracing due to placement."
- 06:51: SVE 10/100/1.
- 06:52: MD at bedside; STAT c-section called for non-reassuring fetal heart tracing.
- 06:56: Rolling to OR.
- 06:58: In room / anesthesia ready.
- 07:00: FHR 100 bpm, minimal variability. Maternal HR 150.
- 07:04: Incision time. Fetus was found to be in the abdomen.
- 07:05: Time of delivery. 4.31 kg female, Apgars 1, 4, 4. Cord blood gas pH 6.85. Intubated in the delivery room and sent to NICU for 72-hour cooling protocol.
Files:
No questions yet!
Do you believe there might have been medical error?
1. Patient was afforded a walking epidural. There is no evidence of benefit of walking in high risk delivery. (Bloom SL, McIntire DD, Kelly MA, Beimer HL, Burpo RH, Garcia MA, Leveno KJ. Lack of effect of walking on labor and delivery. N Engl J Med. 1998 Jul 09;339(2):76-9.) 2. Response to multiple calls regarding tachysystole did not result in discontinuing the pitocin. 3. Patient likely dehisced between 0600/0630, while she was on pitocin.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient had a prior c-section, putting her at risk for uterine dehiscence. She was started on pitocin which was continued through tachysystole. The IUPC was failed to register contractions, due to dehiscence, but this was not acted upon. The patient reported the uterine pain from the dehiscence, but this was not acted upon. By the time the c section was performed, severe fetal acedemia and hypoxia had occurred. To a high degree of medical certainty, the continued use of pitocin led to the uterine dehiscence which then led to the acidosis and fetal hypoxia.
What makes you a good expert for this case?
I’ve been on multiple peer review committees in the past and have reviewed hundreds of tracings over my 23+ years as an OB GYN.
How often do you encounter cases similar to this one in your practice?
We see patients desiring TOLAC maybe about a dozen times per year. We screen patients very closely. About half decide to have a repeat c section, but some go through with it. The patient must have a clear understanding of the endpoints necessitating a repeat c section.
Do you believe there might have been medical error?
Uterine rupture occurs in approximately 0.5% of attempted VBACs. Approximately 50% of newborns are compromised as in this case. It's a poor outcome, but no medical error occurred - a recognised risk of VBAC.. The surgery was appropriately timed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Because there was no medical error.
What makes you a good expert for this case?
I have delivered somewhere between 6,000 and 7,000 patients, including VBACs and one ruptured uterus during an attempted VBAC.
How often do you encounter cases similar to this one in your practice?
See the data provided in the first answer.
Do you believe there might have been medical error?
This patient already has two known risk factors heading into the procedure, she is obese and has had a prior C-section. We don’t know the estimated fetal weight, or if he has any comorbid medical conditions. Given her obesity, I believe placement of an interviewer and pressure catheter as soon as possible, would’ve been beneficial as an obese. Patient is difficult to monitor for contractions, let alone, knowing how effective they are. Given the rapid increase in Pitocin seen early on, this could have been avoided through this procedure. There were episodes when the patient should have been examined, but was not, this valuable information was not provided. Finally, once the patient developed signs of Choreo, and the fetus was starting to show signs of compromise, the C-section should have been ordered at that point. The patient developed pain sometime later, which was the start of her uterine rupture, which for the fetus, who is now compromised at this point, only compromised the fetus further, as evident by the poor Apgars and acidotic pH. Therefore, based on these factors, I do not feel this entire plan of action with satisfactory to protect both the mother and the fetus. Sheldon Linn
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If he just was showing signs of early compromise, secondary to the chorioamnionitis. The mother began expressing pain, despite what seem to be an adequate epidural. This was a clear indication of uterine rupture. Are you doing rupture? Would only serve to further compromise a fetus who is in a compromised position by the chorioamnionitis. The fetal heart rate tracing showed earlier deterioration which should’ve been acted upon. Given the acidotic pH and poor Apgar’s, the fetus was most likely infected, and then later compromise by lack of oxygen secondary to the uterine rupture.
What makes you a good expert for this case?
I’ve been in practice for 34 years up till my retirement date, which was July 2022. During this time I supervised the residence in our residency program, attended morbidity and mortality, meetings, both in gynecology and obstetrics, and have served as an expert witness for several cases now. Two of which are still ongoing. I practice both sides of the expert witness role, i.e. I don’t tend to only do plaintive or defense, and therefore will only look at cases that have merit where I believe strongly, there was an error or lack of such.
How often do you encounter cases similar to this one in your practice?
Fortunately, where I practice, we were very careful and in tune to risk factors in the individual patient undergoing Trial of labor, after having a cesarean section. We were fortunate to have very few instances where there were ruptured that affected the fetus. I believe this was due to a heightened awareness of the risk of patients undergoing these procedures, as well as their individual risk factors.
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