Common allegations in 'routine' claims against OBs

Here are some common allegations in malpractice claims against obstetrician/gynecologists involving routine procedures:

. Too much or too little oxytocin was administered.

Many obstetricians adopt oxytocin protocols for the induction or augmentation of labor, which often dictate the frequency with which the oxytocin should be increased as labor progresses.

"But not every laboring woman has the same oxytocin needs," says Volpi. "Although two women may be receiving the same amount of oxytocin, they may have different responses to it."

Volpi recently defended two obstetrical malpractice cases with virtually identical facts, except for the oxytocin administration. "In the first case, the oxytocin was mechanically increased without an appreciation for the particular mother or infant," he says.

In the second case, the oxytocin was increased in a calculated manner in conjunction with the tolerance of the mother and infant. In the end, both patients received the same amount of oxytocin, and both infants alleged similar neurological injuries. "The treating obstetrician and labor & delivery nurses in the second case were able to defend their actions with more precision and credibility during their depositions, because they clearly tailored their care and treatment," says Volpi.

. An obstetrician's failure to perform a cesarean delivery in response to non-reassuring electronic fetal heart monitor tracings.

Many obstetricians use a baseline fetal heart rate or frequency of fetal heart rate decelerations to determine when a caesarean section is necessary. For example, an obstetrician might choose to perform a cesarean delivery when the fetal heart rate is 110 or less with recurrent late decelerations.

"But every fetus with a heart rate of 110 is not similarly situated," says Volpi. "A heart rate of 110 may be dangerous for a fetus with a previous baseline in the 160s. The same is not true for a fetus with abnormally low baseline in the 120s."

Several years ago, Volpi successfully defended an obstetrical malpractice lawsuit in which the allegation was that the treating obstetrician failed to diagnose and appropriately respond to fetal bradycardia as a result of electronic fetal heart monitoring tracings that showed a fetal heart rate in the 105 to 110 range. "The obstetrician really helped himself in this case by charting that the fetus had a lower-than-normal baseline heart rate throughout the pregnancy and that a heart rate of 110 at full term was not unexpected for this fetus," says Volpi.

The opposing attorney argued that the standard of care would always require an emergent cesarean delivery of a fetus with a heart rate persistently in the 105 to 110 range. "But the treating obstetrician artfully explained that not all fetuses are created equal and that a tailored plan of care is always best," says Volpi.

. A shoulder dystocia occurring during normal, spontaneous vaginal delivery.

Spontaneous vaginal deliveries are routine OB/GYN procedures but can turn into high-risk situations if a shoulder dystocia occurs.

Stella M. Dantas, MD, a Hillsboro, OR-based obstetrician, says management of shoulder dystocia "can result in a liability claim made if there is a brachial plexus injury." Dantas, who is chair of the American Congress of Obstetricians and Gynecologists' Committee on Professional Liability, states the following physician practices can mitigate risks:

• Understand how to call for help when shoulder dystocia occurs.
• Practice techniques for managing shoulder dystocia with drills and simulations.
• Ensure carefully documentation of delivery, including the maneuvers used, any suspected injuries, and follow-up plans for the infant.

"A physician must make sure the record demonstrates awareness of any risk factors, that the patient was informed of any significant risk factors, and that standard of care was provided and practiced," says Dantas.