Diagnostic Delay Results in Infant Death

Case Summary

Following her arrival in the labor and delivery room, the patient experienced a sudden onset of severe abdominal pain with vaginal bleeding.

The nurse then transferred the patient to another room. However, the nurse failed to notify her superiors.

The patient continued to experience severe pain and bleeding. Moreover, 40 minutes lapsed prior to the patient’s physician ordering a STAT Caesarean section when learning of his patient’s condition.

The decision to incision time was 18 minutes. Furthermore, the delivery of the neonate occurred 58 minutes after the recorded onset of symptoms.

The patient was found to have a classical ruptured Caesarean incision with significant hemoperitoneum bleeding. The physician then delivered the neonate, who had a poor Apgar score—which is a score physicians use to evaluate newborns’ health. Ultimately, the neonate died several weeks later.

Case Theory

The World Health Organization recommends labor induction for women who have reached 41 weeks’ gestation, without a spontaneous onset of labor. Many physicians elect Caesarean section, which is shown to prevent infant mortality.

With a history of previous Caesarian birth, many uterine ruptures happen during a trial of vaginal birth. In approximately 40% of trials of vaginal birth after Caesarian attempts, Caesarian delivery is ultimately required.

Due to this patient’s history, a change in the birthing plan was warranted. The physician should have been contacted emergently, and a Caesarian birth should have been performed STAT.

The 40-minute delay in addressing the probable rupture is paramount to the outcome in this case. A previous Caesarian delivery with an unspecified additional uterine surgery added to the patient’s risk of uterine rupture. Furthermore, a Caesarian delivery should have lowered the threshold for emergent intervention. Time to delivery is key. The amount of time to react and alert the proper medical staff likely resulted in a catastrophic outcome.

The failure of the patient’s nurse to notify her superiors in a timely manner is negligent. Physicians could have managed or prevented the uterine rupture. Furthermore, physicians could have mitigated the risk of neonate death.

Expert Witness Q&A and Specialties

• Obstetrics and Gynecology Physician
• NICU Nurse
• Maternal Fetal Medicine Specialist

Nursing/NICU Expert

NICU/Nursing expert witnesses can opine on the care provided for emergent deliveries and the post-operative care of C-Section infants.

Questions for Nursing/NICU experts

1. What are some potential complications in patients undergoing TOLAC?
2. What is the appropriate management for patients undergoing a TOLAC who experiences a sudden onset of severe abdominal pain and vaginal bleeding?
3. Does advanced gestation lead to additional risks with TOLAC?
4. Did a delay in notification deviate from the standard of care?
5. What are the expected symptoms in a neonate born during uterine rupture?
6. Does a placental separation and uterine rupture lead to higher neonatal mortality rates?
7. Does the gestational age of neonates affect the outcome in TOLAC infants?

Fetal Medicine Expert

Maternal Fetal Medicine experts practice in the field of general obstetrics and gynecological care with advanced experience in neonatal care and high-risk cases. These experts can opine on the standard of care for neonatal and high-risk cases.

Questions for Fetal Medicine experts

1. Does a delay in notification to superiors constitute a deviation from care?
2. What are the signs of a potential uterine rupture?
3. Was this patient at an elevated risk for uterine rupture?
4. How does a uterine rupture affect fetal viability?
5. Do severe pain and bleeding warrant an immediate Cesarian birth in a TOLAC patient?
6. What relative and absolute contraindications for a TOLAC do you typically consider?
7. What is the appropriate management for a patient with suspected uterine rupture?
8. How can uterine rupture lead to non-reassuring fetal status and poor neonatal outcomes?
9. What is the potential a 58-minute delay from symptoms to delivery contributes to neonatal death and rupture?