Fetal Death- An Obstetrician’s Worst Nightmare

I started in private practice of Ob/Gyn in 1996.  American College of Obstetrics and Gynecology- ACOG- published its first guidelines on Vaginal Birth After Cesarean (VBAC) in 1982. It updated the guidelines several times since then with specific criteria and requirements. It was touted as very safe, with a low risk of uterine rupture of 0.6%. Uterine rupture could result in heavy vaginal bleeding, hysterectomy, fetal death or maternal death. We were of course taught all the possible signs of uterine rupture during labor in terms of the fetal heart rate tracing, signs and symptoms The biggest risk was thought more to be a “failed” VBAC which then resulted in a repeat cesarean and a higher rate of infection since the patient had labored.  Ob’s were given their monthly hospital statistics of their c/s rates and if they started getting higher- 25-30%- their charts were scrutinized.  ACOG and consumer rights groups issued a lot of literature regarding unnecessary cesareans and the rising C/S rates across the US.  Doctors were having to rush to their golf games, etc., etc. So doctors started attempting more VBAC deliveries.

For several years I worked for a group of high risk Obstetricians. I had a private practice during the week and also worked as a Hospitalist during nights and weekends. I handled all forms of high risk deliveries, preterm, pre-eclamptic, diabetics, etc. We had 24 hour in-house anesthesia, Level 3 nursery and excellent nursing staff.  In 2001 I delivered my last VBAC- the worst delivery of my career. It lead to a malpractice case and a medical board investigation and cost me a lot of heartache and money.

I remember my last VBAC patient, Mrs. B,  and her husband who were from another country.  Mrs. B spoke English, but her husband did most of the talking and answered all the questions I asked his wife.  “Our son,  who is five years old,  was delivered by cesarean section. I want her to have this baby normally because I want her up and around quickly so she can take care of the house,” stated her husband at her first prenatal visit.  The patient never expressed any concerns and always had her husband in the room during each visit.  Her mother, an Obstetrician,  came from overseas  and attended a few of her appointments as well.

The pregnancy was uneventful. The hospital where I worked began to require a consent form for a VBAC about the same time she was due to deliver. In fact, she was the first patient I had sign the consent form. It was a rather scary form. It listed all the possible complications of a VBAC including hemorrhage, hysterectomy, fetal death or maternal death. I  discussed the form at length with my patient and she subsequently signed.

She was triaged on labor and delivery a couple times but sent home for false labor. After one of the visits her husband called. “She is having a lot of pain. Could she be rupturing her uterus now? ” he asked.  I told him not to worry. I should have just scheduled the repeat C/S at this point but I told him that they had come this far and reminded him how important it was to him to try for a VBAC. She subsequently came in active labor a few days later and signed the consent form again.

The labor progressed relatively uneventfully. She pushed for sometime but the baby’s head wasn’t descending in the birth canal.  I could see the head without her pushing so I applied a vacuum a couple of times but couldn’t deliver the baby. During this time the baby was having variable decelerations consistent with pushing. In retrospect, I should have proceeded with a C/S but kept thinking she is so close to delivering and the baby’s heart rate is returning to baseline,  so I felt comfortable continuing. And then her contractions just stopped. She didn’t have any abnormal bleeding or signs of anything else.

It was at 7 pm. Shift change. The worst possible time to call for an emergency C/S. I called for a C/S. We moved relatively quickly, but not super stat. I cut through the skin, and the fascia then saw  that the uterus had ruptured. The placenta was apparently attached directly under the area of the uterus that had ruptured. So when the uterus ruptured the patient had a complete placental abruption. I found the placenta just floating separately. The baby was dead. It looked like a bomb had gone off inside the uterus.  I had never seen anything like that during the literally couple thousand cesareans I had performed up until that time. Fortunately the rupture avoided the uterine arteries which run along side the uterus so she had minimal bleeding and didn’t require a hysterectomy. I was pregnant myself at this time and started having contractions myself as I became very anxious after the delivery.  I went and hid in the call room and had a colleague cover me for my next delivery.

My colleagues and I all knew I would be sued. Everyone agreed that I was “lucky”  the baby died. In California, where I was working at the time, the cap for pain and suffering is $250,000. If the baby had survived it would more and likely have sustained hypoxic encephalopathy and would have required extensive care its whole life. I would have then been sued for economic damages which often is in the millions of dollars.

I had to deliver the news to my patient’s husband.  It was one of the hardest days of my career to date. I could hear my patient’s mother, the OB from India, screaming in the hallway following the cesarean.  I was set to fly out on vacation the next day. I cancelled my trip. I rounded on her five days in the hospital. She stayed on the Neurology floor- far from the crying newborn babies. Neither her husband nor the patient spoke to me her entire hospital stay.  I was forbidden to tell her the baby died. The family told my patient that the baby was in the intensive care unit. The second day,  the grandmother, in her limited English,  asked me to explain exactly where the rupture occurred.  The third day they requested all of her medical records. I felt ashamed and embarrassed each day I rounded on my patient. I felt like all eyes were on me. A couple of the days I saw the Ob/Gyn department head on the same floor. I imagine he was rounding on the patient as well and reviewing my notes (that had never happened before or since).

I was sued a few months later. I let the lawyers discuss the details. I moved to Texas a few months later as the San Francisco Bay Area became too expensive. I assumed my insurance carrier would settle the case for $250,000. I received a letter several months later stating that the case settled for $550,000. I was shocked. I called my lawyer. Apparently the wife sued for $250,000 for pain and emotional distress. The husband sued for $250,000 for loss of consortium. He couldn’t have sex with his wife because she was in pain. The grandmother also sued for $250,000 but apparently got $50,000.

Many of my obstetrical colleagues just consider malpractice settlements as the “cost of doing business.” Statistics state that the average Ob will be sued 2 1/2 times in their career,  2-3 times. However, those that have been sued know that it is much more than the cost of doing business. If a doctor moves or changes malpractice carriers, the settlement amount becomes an issue. It becomes a huge stain on a physician’s record. Even if you settle the case without admission of fault, you are presumed to be guilty of malpractice, especially with a large pay out.

Little did I know, the malpractice settlement was just the beginning of my nightmare.