A 32-year-old G2P1001 patient presented to the hospital at 39 weeks and 2 days with painful contractions every 4 minutes. SVE showed 1.5/70/-2. She was admitted with a plan for repeat c-section that evening. Several hours later, she was taken to the OR for c-section. The operative report findings mention a "thinned out lower uterine segment," and state that "[t]he lower uterine segment was incised with one swipe only in a transverse fashion with the scalpel. The infant's head was noted to be in occiput posterior position at the hysterotomy site... the laceration on the face was noted and the NICU team was called for assistance...."
The baby was found to have a 2.5 cm facial laceration on his left cheek, which was repaired by a plastic surgeon shortly after birth. The plastic surgeon noted that it was "through the skin and into subcu tissue" of the cheek.
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Do you believe there might have been medical error?
This is a poor result, but in the presence of a thinned out lower uterine segment, with the face imediately beneath the thinned out lower uterine segment, a laceration of the newborn's skin is recognized complication and not evidence of negligence.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Clearly, the laceration is caused by the scalpel used to incise the lower uterine segment.
What makes you a good expert for this case?
I have delivered approximately 7,000 babies, approximately 20% of those by cesarean section.
How often do you encounter cases similar to this one in your practice?
I can think of six or seven lacerations in my career, fortunately, none of them full thickness.
Do you believe there might have been medical error?
One of the primary duties of the operating position, upon getting ready to enter, the lower, uterine segment, is to assess whether or not I love you doing segment is very thin or thick. If the segment is filled to be thin, awareness of what is directly beneath i.e. the infants, face, ear, etc. can be palpated. If this is the case, special measures can be taken to gently incise low urine segment with a scalpel we are very little pressure is applied. If the segment is extremely thin, it’s possible to even enter it bluntly with a finger. it would appear from the description that no regard was made to this, or if there was, very little attention to technique was practice resulting in the injury of the infant.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
From the pictures, it is very clear that the only thing that could’ve happened was a scalpel, pressing through, not only the lower, uterine segment, but the infants cheek. With respect to the infant, there was pressure applied to the scalpel so that Not only was the skin broken, but the tissue beneath. There is nothing else to explain this as shown clearly in the pictures.
What makes you a good expert for this case?
I have practiced Ob/Gyn for 33 years. I have had many cases where the lower uterine segment was very thin. And in all such cases, careful, palpation, and attention to technique allowed me to deliver infants without any injury. This is not an uncommon situation and happens quite frequently. The hospital where I worked, had a residency program, and this was stressed to the residence to consider palpation to lower region segments so that one could identify positioning of the fetus, the closeness of facial component is the load in segment, and appreciation of the thickness or thinness of the lower uterine segment.
How often do you encounter cases similar to this one in your practice?
Again, this is not an uncommon situation and happens quite frequently. One may encounter this several times a week, or you may go several weeks without encountering this. However, it again goes back to attention to details, such as outpatient, identification, understanding of the fact that if a woman is in labor for several hours, this could be the situation. This is something that should be understood for any general OB/GYN practicing today.
Do you believe there might have been medical error?
Unfortunately it is possible to lacerate the infant when opening the uterus and there is not a guaranteed way to prevent this. Most every obstetrician has had the experience of lacerating a baby in this way, generally the laceration is not deep and is easily fixed, heals well. I do not think there is anything resembling malpractice in a case like this. It is a known complication of a cesarean section.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Certainly, it was caused by the scalpel used to open the uterus However it is not a medical error as noted
What makes you a good expert for this case?
I do c sections very frequently
How often do you encounter cases similar to this one in your practice?
I have seen lacerations before, several times, similar to this one.
Do you believe there might have been medical error?
In evaluating the case of the 32-year-old G2P1001 patient who underwent a repeat c-section at 39 weeks and 2 days, it is my professional opinion that the unfortunate outcome—a 2.5 cm facial laceration on the newborn—was the result of medical error. Several factors contribute to this conclusion. First, the operative report describes a "thinned out lower uterine segment," a condition requiring heightened surgical caution, particularly in the context of a repeat c-section. Secondly, the "one swipe" technique employed in incising the lower uterine segment was inconsistent with the caution warranted by the patient's risk profile. Additionally, the baby's occiput posterior position at the time of the incision introduced another layer of complexity that necessitated a more careful approach. Given these considerations, the significant laceration sustained by the newborn, requiring immediate plastic surgery, indicates that the standard of care was not met in this case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The operative report identified a "thinned out lower uterine segment," which should have triggered an elevated level of surgical caution, given that the patient was already at increased risk for complications due to her previous c-section. However, the surgical approach did not align with this need for heightened vigilance. The "one swipe" technique used to incise the lower uterine segment was precipitous, especially considering the patient's identified risk factor of a thin uterine wall. Further complicating the situation was the baby's occiput posterior position at the hysterotomy site. This should have prompted even greater care in the surgical procedure. The swiftness of the incision, when combined with the baby's position and the mother's thin uterine wall, resulted in a 2.5 cm laceration on the newborn's face. This laceration was not a benign outcome; it required immediate intervention from a plastic surgeon and penetrated into the subcutaneous tissue of the cheek. The causal chain here is clear: the decision to proceed with a rapid incision technique, despite several complicating factors, led directly to the harm suffered by the newborn. As such, it is my professional opinion that the injury was a result of medical error, signifying a breach in the standard of care.
What makes you a good expert for this case?
I’ve had 25 years OB GYN experience and have served on the peer review committees of many institutions. The physician here had a duty to both mother and baby. As such, informed consent should have been obtained regarding this type of complication as recommended by C Esposito et al “ Fetal laceration during caesarean section and its medico-legal sequelae”: Med Sci Law, 2015.
How often do you encounter cases similar to this one in your practice?
I’ve had a facial laceration during a stay c section but it didn’t require this type of extensive treatment.
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