Page 47 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

the plaintiffs asserted that the memory of an event so long

after the event itself was inaccurate. It is important to note
that if an unanticipated outcome results in an adverse event,

the documentation after the fact can make the information in
the record appear suspicious and self-serving and reduce the

credibility of all the documentation in the record.

The next two cases are examples of how inadequate
documentation affects a case’s defensibility.

C A S E S T U DY

An 18-year-old prima gravida at 42 weeks gestation
presented to labor and delivery in early labor. Because

she was one-centimeter dilation and the baby was high in

the birth canal, augmentation of labor was initiated with a
Pitocin drip. The patient’s labor progressed uneventfully
until the second stage of labor, during which she became

ineffective at pushing. At this point, the physician explained

to the patient verbally that forceps could be used to assist
with the delivery and the patient gave verbal consent for
him to proceed. The physician employed the use of low

forceps and delivered a 7-pound, 15-ounce baby boy with

APGARS of 7 and 9 at 5 and 10 minutes.

The infant sustained a scalp laceration, caput,

cephalohematoma, intracranial hemorrhage, and seizures.
He was transferred to a tertiary care facility for neurology

consult and possible surgery. During the hospitalization,
serial CTs of the brain were performed but the hematoma

remained stable and no surgery was needed.

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