Baby's death prompts changes in OB unit

The major improvements in patient safety in the obstetrics unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston were prompted by a series of tragic errors that led to a stillbirth in 2000.

In August 2005, Benjamin Sachs, MD, chief of obstetrics and gynecology at the hospital, published an article that described numerous judgment errors and miscommunications in the baby's case.1 He said the case was an example of how medical mistakes can be the result of an accumulation of smaller miscues. The case became a "burning platform" that led to a "major reorganization of the way care is provided," he wrote.

Sachs provided this summary of how the adverse event unfolded: A couple arrived at midnight to deliver their first baby. Hospital staff noticed that the mother's blood pressure was high, but blamed pain from her contractions. Later, a resident noticed an unusual fetal heart rate on the monitor. However, she could not get the attention of the attending physician, who had been awake for 21 hours and was running between several patients.

The woman's regular obstetrician was not on call, so the doctor gave her the drug misoprostol, which triggers labor, because she was past her due date, and sent her home. Because of her slightly high blood pressure, she should have been monitored in the hospital, Sachs said in the article. On the way home, she felt contractions and returned.

When she arrived, her blood pressure was higher, which raised the possibility of preeclampsia. Between 4 a.m. and 5 a.m., doctors missed a chance to stop the sequence of miscues when the resident did not go above the attending physician with her concerns about the baby's unusual heart rate. Sachs believes the physician's judgment may have been impaired because he was on duty for so long. He said doctors should have performed a caesarean by 5:30 a.m. "'This would probably have resulted in a live birth without complications," Sachs wrote.

When an emergency caesarean was ordered at 6:45 a.m., they found the placenta had separated from her uterus and her uterus had ruptured. The baby was stillborn. The mother spent three weeks in the hospital.

In the article, Sachs apologized to the family. BIDMC investigated the case immediately, and Sachs urged an immediate settlement before the family sued. The hospital settled in 2001 for an undisclosed amount.


  • 1. Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA 2005; 294:833-840.