Legal Review & Commentary

Over $4.6 million award for failure to maintain adequate blood supply resulting in death of mother

News: This case involves the death of a 36-year-old woman following the caesarean section delivery of her first child. The infant was healthy, but the patient developed a postpartum hemorrhage shortly after delivery, and the hospital claimed it did not have an adequate blood supply. Without this blood supply, doctors were unable to properly manage the patient’s condition and did not think they could successfully operate on the patient in order to alleviate her hemorrhage. This inability to manage the bleeding or replace her lost blood resulted in the patient’s eventual death. A jury awarded just more than $4.6 million to plaintiff.

Background: On Jan. 17, 2008, a woman arrived at the hospital for the delivery of her first child. The patient was given a labor-inducing medication on Jan. 18, 2008, and after several hours of unsuccessful labor, her obstetrician decided to perform a caesarean section. A healthy infant boy was delivered by caesarean section at 6:50 p.m. The patient was stable, but her uterus was suggestive of atony, which was addressed with medication and a uterine massage.

A few hours later, the patient was noted to be bleeding heavily, and an on-call obstetrician was contacted. The on-call obstetrician responded to the page as she drove to the hospital, and she instructed the hospital staff to type and cross the patient’s blood. The on-call obstetrician then requested two units of blood for the patient. The patient’s blood type came back as Type A-. About 9 p.m., the on-call obstetrician instructed the staff to immediately begin transfusing the blood, but at 9:18 p.m. the blood transfusion still had not begun. The hospital staff informed the on-call obstetrician that Type A- blood was not in supply, and the on-call obstetrician immediately ordered two units of Type O- blood, four units of red blood cells, four units of fresh frozen plasma, and two additional units of fresh frozen plasma to be placed on hold for transfusion.

The patient continued to bleed and was treated again for atony. It was at this time that the on-call obstetrician began planning surgical procedures to treat the bleeding. She discussed a hysterectomy procedure with the patient. At 9:41 p.m., the staff provided two units of O- blood and began transfusing. The patient’s obstetrician arrived at the hospital at 10 p.m. and requested all available blood be given to the patient. The hospital staff informed the obstetrician that no more blood was available. The on-call obstetrician contacted another hospital to inquire about transferring the patient there for additional blood and a radiation procedure that could be performed only there. The patient was airlifted to the second hospital. Her condition significantly deteriorated during the transfer, and she suffered a fatal cardiac arrest shortly after her arrival to the second hospital.

Plaintiff revealed during trial that the hospital did have blood available for transfusion, but failed to use it. Plaintiff reached a settlement agreement with defendant doctors, but the hospital was unwilling to negotiate. Plaintiff took the position of defending the doctors, undermining the hospital’s cause of death opinion, proving the hospital’s violation of the standard of care, and establishing damages. Plaintiff retained experts in blood management, perinatology, and cardiovascular pathology to support its case against the hospital.

The hospital argued that the patient’s doctors were negligent as they should have performed surgery to stop the patient’s bleeding. They also argued that defendant doctors did not need additional blood to perform surgery. An expert pathologist testified for the hospital that the patient did not die from blood loss, but instead died from peripartum cardiomyopathy.

The jury found that the settling physicians were not at fault and placed 100% of the negligence on the hospital. The jury awarded just over $220,000 in past economic loss, $750,000 in past non-economic loss, $1.4 million in future economic loss, and $2.25 million in future non-economic loss, for a total of just over $4.6 million. Defendant hospital filed post-trial motions for a new trial and a new trial on damages. The district court denied the motions, so the hospital appealed the decision. The appellate court affirmed the district court’s decision. In 2012, the hospital decided to suspend obstetrics services.

What this means to you: Maternal hemorrhage is a probably the most common cause of maternal mortality. Since this condition is highly preventable, the goal of the healthcare providers is early recognition and treatment of this precarious condition. As such, many healthcare institutions have formulated guidelines to handle these emergencies.

The facts in this case reveal that this 36-year-old female, pregnant with her first child, was admitted to the hospital at 41 weeks gestation. The gestational age of the fetus is considered postdated, because the optimal gestational age is 39-40 weeks gestation. The age of this patient, along with it being her first pregnancy, put her in a high-risk category. What is not mentioned in the summary is whether she was treated as high risk during her prenatal course and why she was not delivered before 41 weeks. These two factors put her at greater risk for heavier than normal postpartum bleeding.

Upon admission it is noted that the patient received a labor-inducing drug and after several hours required a caesarean section to deliver her infant. The documentation in the admission history and physical should have included the calculation of a Bishop score, a numeric score from 0-10 which measure certain pre-natal criteria and would indicate the success of the induction efforts. A higher Bishop score equates to a better chance at a vaginal delivery. This score provides the obstetrician with very useful information regarding the management of the labor. However, the patient was allowed to labor and eventually did require a caesarean section.

Herein lays the crux of the case. According to the summary, it appears as if, despite the notation of suggestive postpartum uterine atony, which is a precursor of hemorrhage, the attending obstetrician left the hospital instead of closely monitoring the patient’s condition. Had the physician been present during this critical time, early recognition and treatment of this condition could have occurred, and this life-changing event possibly could have been prevented. Instead, the on-call attending obstetrician was notified by the nursing staff, and by the time the on-call obstetrician came into the hospital and decided on the treatment plan, her efforts were fruitless.

Furthermore, the issue regarding the lack of adequate prenatal diagnostic workup such as a routine type and screening for possible transfusion, accurate communication to the on-call obstetrician by the nurses regarding critical components of the patient assessment, lack of communication of the gravity of the situation to the blood bank, and a lack of an organized approach to responding to hemorrhage were evident and further delayed a crucial treatment plan.

This case presents several opportunities for improvement. The attending obstetrician failed to stay with the patient despite evidence of post-partum uterine atony, which delayed any lifesaving intervention. Although the hospital had a massive transfusion policy, it is clear that the nursing staff failed to follow the policy. They were clearly not familiar with the indications and process for its activation. Additionally, they relayed incorrect information to the obstetricians regarding the availability of blood products and failed to articulate to the blood bank the gravity of the patient’s condition. This incorrect information directly affected the physician’s treatment plan for this patient.

Corrective actions for this case could include the following: Simulation training in managing postpartum hemorrhage for all obstetrical staff with subsequent mock scenarios and drills that would be an important educational component to the staff. Also helpful would be the formulation of a post-partum hemorrhage algorithm with assigned roles for the obstetrician, charge nurse, and primary nurse allowing for smooth handling of the emergency while giving guidance to all practitioners as to the appropriate treatment plan for each decision matrix.

An educational initiative for reinforcing the indications and use of the massive transfusion protocol is warranted. A revision to the obstetrical history and physical form should be made to include the documentation of Bishop scores for all obstetrical patients admitted for induction of labor. A subsequent medical record review or audit should be undertaken to ensure compliance with the documentation standard. Additionally, training in effective communication techniques such as SBAR (situation, background, assessment, and recommendation) would be helpful in assisting clinicians in relaying critical information in a concise and organized fashion, especially in an emergency situation.

Reference

A11-1212 Minnesota Court of Appeals (2012), 86-CV-09-5000 Wright County District Court (2010).