Page 28 - OB Risks - Delivering the Goods (Part Two)

SVMIC Obstetrics Risks: Delivering the Goods

9:00 am, the patient was taken to the operating room for
C-section and the OB was again paged at 9:10 am and

9:14 am. Finally, at 9:24 am, the OB was in the OR and the
C-section was performed. As the abdomen was open, it

was noted that the fetus was in the abdominal cavity. The
fetus was delivered at 9:27 am with APGARS of 0, 0, and

1 and a cord PH of 6.75. A heart rate was obtained at 10
minutes after delivery.

On May 7 an MRI was read as brain injury and EEGs
th
showed severe generalized suppression. The infant was
extubated and expired at 12:22 pm.

Weak points were identified:

1. The OB was not immediately available for the VBAC
attempt.

2. There was augmentation with Pitocin.

3. The contractions were very poorly monitored by the

nursing staff.

4. The nursing staff ignored the elevated blood pressures

and did not report them to the on-call OB.

5. The on-call OB took too long to respond to the
numerous documented pages and to arrive to deliver.

6. Although not stated in the above facts, there was a
letter from the Chairman of the Obstetrics CQI

Committee in the on-call OB’s file regarding his long
history of poor response times.

Page 28