Clinical Review

Reducing the legal risks of labor induction and augmentation

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Specific tactics minimize the chance of adverse oxytocin-related outcomes—and a flurry of allegations


 

References

WHAT’S YOUR VERDICT?

Does this patient have grounds for a lawsuit?

At 41 weeks’ estimated gestation, Elena, a 32-year-old primipara with an uneventful antepartum course, is scheduled for induction of labor for postdates. On admission she is 1 cm dilated and 70% effaced, with the fetal vertex at –3 station. Fetal heart rate monitoring shows a normal baseline, moderate variability, and accelerations. No decelerations are observed.

After the membranes are ruptured artificially, labor progresses slowly, and chorioamnionitis is suspected.

Fetal tachycardia with minimal variability and variable decelerations develops. Oxytocin is titrated to achieve uterine contractions every 2 minutes. Elena eventually becomes completely dilated and pushes for 95 minutes. During this time, the fetal variable decelerations increase in duration, with loss of variability and continued tachycardia.

Because of these findings, delivery is expedited with a vacuum extractor. The newborn is depressed, admitted to the neonatal intensive care unit for respiratory support to “rule out sepsis,” and is later found to have neurologic injury.

In your opinion, does Elena have grounds for a lawsuit?

If such a case spurs a lawsuit, as it often will, the plaintiff’s attorney is likely to declare any or all of these allegations:

  • failure to discontinue oxytocin in light of nonreassuring fetal heart rate
  • failure to identify and respond to uterine hyperstimulation
  • failure to identify and respond to fetal distress
  • failure to react in a timely manner to fetal distress
  • inappropriate delivery method
  • failure to use a fetal scalp electrode
  • failure to recognize and act upon arrest of dilatation in a timely manner

These allegations are only the most probable ones in circumstances such as Elena’s. When unanticipated morbidity or death occurs after oxytocin is used, physicians and nurses may find themselves facing any of the 18 allegations listed in the TABLE—or even others.

In court, these allegations will be based on the opinions of independent physicians, certified nurse-midwives, and registered nurses with the education, experience, and credentials to qualify as “experts.” Courts usually allow experts when the substance of the allegations is beyond the public’s general knowledge.

Although allegations often include inaccuracies, erroneous assumptions, and conclusions based on “information and belief” rather than scientific evidence, they remain part of the claim until disproved over the course of the legal proceedings.

TABLE

18 common allegations in oxytocin-related litigation

1. Unnecessary induction due to lack of medical indication
2. Failure to establish fetal well-being prior to initiating oxytocin
3. Failure to adequately monitor fetal heart rate during oxytocin infusion
4. Failure to adequately monitor uterine contractions
5. Failure to place a spiral electrode and/or intrauterine pressure catheter
6. Failure to discontinue oxytocin in light of nonreassuring fetal heart rate
7. Failure to identify and respond to fetal distress
8. Delay in identifying and responding to nonreassuring fetal heart rate
9. Failure to notify provider of nonreassuring fetal heart rate
10. Failure to identify and respond to uterine hyperstimulation and/or elevated resting tone
11. Inappropriate titration of oxytocin not based on accepted protocols
12. Administration of oxytocin without a physician’s order
13. Failure to follow physician’s order
14. Failure to order a cesarean section when fetal heart rate became nonreassuring
15. Delay in cesarean section after being ordered by the physician
16. Failure to follow hospital policies and procedures
17. Inadequate policies and procedures governing oxytocin administration
18. Failure to initiate chain of command

Elective inductions can spell trouble

Although the rate of induction has more than doubled since 1989, to 20.6% of births or more than 840,000 pregnancies in 2003,1 still no consensus exists for patient selection. In some centers, inductions are reserved for women with medical indications only, whereas in others, more than half are elective.2

Because of this divergence, when there is a negative outcome after an elective induction, the obstetrician can anticipate an allegation of unnecessary induction due to lack of a medical indication.

Fetal monitoring

Proven or not, it’s the norm

Although we lack overwhelming proof of its superiority to intermittent auscultation,3 electronic fetal monitoring (EFM) is used in most labor and delivery settings during oxytocin administration for induction or augmentation of labor—and fetal heart rate and uterine activity typically guide initiation and titration of oxytocin.

Nevertheless, because EFM is the unofficial standard, an obstetrician who chooses to use intermittent auscultation of fetal heart rate during oxytocin infusion can anticipate strong criticism if the delivery results in a compromised neonate.

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