Delay in treating fetal distress is the most common medical malpractice allegation made against ob.gyns., a study showed.

Of lawsuits filed against ob.gyns, 22% alleged that physicians did not treat fetal distress in a timely fashion, according to a study by the Doctors Company, a national medical liability insurer. The analysis, published in May, found that the most frequent contributor to the delayed treatment was physicians’ failure to act when presented with category II or category III fetal heart rate tracings predictive of metabolic acidemia.

The Doctors Company reviewed 882 obstetrics-related claims in its database that closed from 2007 to 2014. Of the claims, improper performance of vaginal delivery was the second most common allegation at 20%, followed by improper management of pregnancy at 17%.

Other allegations included delay in delivery, improper performance of operative delivery, improper choice of delivery method, and diagnosis-related claims.

Almost half of the cases involving improper performance of vaginal delivery related to brachial plexus injuries due to shoulder dystocia. Several of these cases involved vacuum extraction or forceps deliveries where the patient failed to progress or the mother was obese, according to the study. In some cases, neonates also had skull fractures and hematomas from high forceps deliveries. Maternal injuries included pelvic lacerations, tears, and fistulas.

Of the claims related to improper management of pregnancy, the cases involved failure to test for fetal abnormalities when indicated, failure to recognize complications of pregnancy, and failure to address abnormal findings. Case outcomes included intrauterine death, placental abruption, neonatal infections, neonatal brain injury, twin-to-twin transfusion, and maternal preeclampsia that led to stroke.

Expert physician and nurse reviewers at the Doctors Company also identified factors that contributed to patient injuries within the claims. The most common contributor to injuries – found in 34% of claims – was the physician’s selection and management of therapy. This included poor decisions regarding labor and delivery, augmentation of labor, methods of delivery, or timing of interventions.

Patient assessment issues were the second most common contributor to patient injuries at 32%. Such problems occurred when physicians disregarded available information (test results or documented findings in the medical record) and failed to order diagnostic tests for strep infections, elevated blood sugar, and hypertension.

In some cases, doctors ignored abnormal findings, such as the size of neonates, signs of preeclampsia, glycosuria, and elevated urine protein level, according to the report.

Poor technical performance (18%) also was a driver of patient injury. Examples included injuries related to known risks disclosed to the patient prior to the procedure, such as postpartum hemorrhage, brachial plexus injuries, and punctures or lacerations. Other contributers to patient injuries were failed communication between providers or between providers and patients, lack of documentation, and patient factors such as nonadherence to treatment plans.

The majority of the study’s findings pertaining to common medical malpractice allegations encountered by ob.gyns. were not surprising, said Dr. Susan C. Mann , an ob.gyn. at Beth Israel Deaconess Medical Center, Boston.

Ob.gyns. face daily challenges that can contribute to lawsuits, including competing demands and lack of time, said Dr. Mann, who is a member of the Doctors Company obstetrics advisory board. That’s why she recommends preparing for critical scenarios ahead of time to help prevent adverse events and possible litigation.

“Working closely with labor and delivery staff is very important to identify patients who have risk factors and [for] coordinating the plan of care with the team,” Dr. Mann said in an interview. “Training together for emergency drills for stat cesarean deliveries, shoulder dystocias, and postpartum hemorrhage is very useful. Having a common language to describe fetal heart rate tracings and shoulder dystocia documentation is helpful as well. Finally, establishing a culture in which providers feel comfortable speaking up and where there is a moral imperative to share safety concerns provides a safety net for both patients and providers.” 
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