Allegation:
The deceased maternal patient’s family alleged that the labor and delivery team failed to appropriately manage a post-partum hemorrhage which caused the patient’s death.
Case Details:
A patient presented to the hospital for a planned c-section. Her history was significant for a prior myomectomy with fibroid reoccurrence and two caesarean section deliveries. Preoperatively the patient received 1000 ml of crystalloids.
07:10 | A healthy infant was delivered with no apparent complications. After closing the uterus, however, the OB encountered dark venous blood in the peritoneum. He decided to reopen with the patient under general anesthesia. When he did, he discovered oozing blood and uterine atony. He removed a fibroid, and assuming he had addressed the bleeding issue, closed.
Intraoperatively the patient received 550 ml blood, 1000 ml HEXTEND®, and 3500 ml crystalloids for a total of 6050 ml of fluid replacement (including the preoperative amount). The anesthesiologist documented an estimated blood loss of 2500 ml.
10:15 | The patient was escorted to the PACU by the anesthesiologist. Her blood pressure was 141/113, and her pulse was 149. The anesthesiologist left the PACU to round on other patients.
10:25 | The patient’s blood pressure had fallen to 78/42 and her pulse was 78. The anesthesiologist was paged to the PACU. He ordered stat arterial blood gas test, complete blood count, and transfusion of two units of packed red blood cells. He contacted the OB and requested that he return to the patient’s bedside. He then left the PACU.
11:20 | After unsuccessful prior attempts, the PACU team was able to draw blood, which was then sent to the lab.
11:30 | The patient’s blood pressure had fallen to 62/41, her pulse was 62, her oxygen saturation level was 98%.
11:40 | The anesthesiologist was paged. He returned to the PACU and intubated the patient for agonal rhythm and oxygen saturation level of 50%.
11:45 | The lab reported hemoglobin 3.3, hematocrit 9.8, and platelet count 71.
12:00 | The patient was transfused with packed red blood cells.
12:10 | The anesthesiologist signed out to the hospitalists.
13:20| The patient arrested, was resuscitated, and was transferred to the ICU.
13:20-16:00 | The patient received transfusions of blood, fresh frozen plasma, cryoprecipitate, and D50; magnesium sulfate; pantoprazole; vitamin K; and dopamine.
16:30 | When an abdominal ultrasound identified additional hemorrhage, the OB decided to bring the patient back to the OR for a hysterectomy.
16:50 | When she was opened, the OB noted an additional 1800 ml of blood in the abdomen. He performed a hysterectomy. He could not identify a bleeding source.
20:00 | The patient’s temperature was 92.7; her abdomen was distended; her pupils were dilated, fixed, and non-reactive; and she was oozing blood from multiple sites.
21:10 | The patient coded and could not be resuscitated. Her cause of death was recorded as a cardiac arrest secondary to acute blood loss anemia due to postpartum hemorrhage and disseminated intravascular coagulation.
The patient’s husband filed a lawsuit against multiple members of the labor and delivery team. He alleged they failed to appropriately manage the hemorrhage which caused his wife’s death.
Expert Testimony
There were both positive and negative reviews among the defense experts. Multiple experts were critical of the anesthesiologist for ordering excessive crystalloid infusions without ensuring adequate blood products and clotting factors. They also questioned the anesthesiologist’s decision to leave an unstable patient in the PACU on multiple occasions. The consensus was that defending the anesthesiologist’s actions would be complicated.
Another defense issue that arose during litigation involved the hospital’s massive transfusion policy and protocol. During depositions, the OB, anesthesiologist, other members of the labor and delivery team, and administrators testified they were unaware of such a policy. However, the hospital ultimately produced the hospital’s massive transfusion policy and protocol that had been in effect during the patient’s labor and delivery. It had been signed by the OB, in his role as the chair of the ob-gyn department.
Resolution
The attorney representing the patient’s family made a policy limit demand of all defendants plus participation by the hospital’s excess carriers. Due to inadequate standard of care and causation expert support and other issues that made this case challenging to bring to trial — including an extremely sympathetic family and high damages — the case was settled.
Risk Reduction Strategies