The Postpartum Phase Areas of risk

Presented by Stephanie Jones, Special Counsel

Obstetric Malpractice

Conference

June 2013

Postpartum Care

• Wellness approach to maternity care

• Obesity, multiple pregnancies, older mums, increased caesarean rate – medical model of maternity care

• With medical model - potential to increase postpartum injury, certainly surgical injury and infection rates

• Difficulty, as with most areas of medicine - competing causes of postpartum presentation

• Focus at presentations on high quantum intrapartum claims

• Postpartum and neonatal claims, perhaps less risk/frequency but can have devastating consequences for patient and family and can be equally high value

Overview

• Postpartum care

• Surgical injury – bladder and bowel

• Endometritis/infection

• PPH

• Perineal Tear

• Neonatal Care

• Hypoglycaemia

• Kernicterus

• Potential Damages

• Consequence of breach of duty

• Risk Management strategies

Risks of Caesarean Section

• Typical risks discussed with patients include:

• Infection

• Bleeding

• Atonic uterus

• Adhesions – bowel obstruction

• Injury to other organs, eg ureters, bladder, bowel

• Ileus

• Wound healing

• Death

Surgical injury (Bladder) – Case Study

• 34‐year‐old pregnant woman admitted to hospital

at term + 10. Course of pregnancy and past medical history unremarkable. Fetal ultrasound showed oligohydramnios.

• Induction attempted. Failure to progress, together with signs of fetal distress and suspected chorioamnionitis, an uncomplicated Caesarean section had to be performed a few hours later.

• Overnight she passed 1.8 litre bloody urine through a catheter, which was removed the next morning.

Surgical injury (Bladder) – Case Study

• During the following day - started to complain of tenderness and pain in lower abdomen. Catheterized once, which resulted in approximately 100 ml of bloody urine.

• Abdominal discomfort and pain of varying intensity persisted over the following days.

• The abdominal wall appeared somewhat indurated, but the laparotomy wound was unremarkable.

• An X‐ray film of the abdomen suggested a subileus, but bowel sounds were present and, following stimulation, she purged.

• Abdominal ultrasound showed a regularly involuting uterus, normal sized kidneys without evidence of urinary tract obstruction and moderate intra‐abdominal fluid accumulation, which was attributed to the recent section.

Surgical injury (Bladder) – Case Study

• Another laparotomy was considered, but not immediately performed after consideration of patient's overall condition - only moderate impairment of wellbeing, and surgical problem could not be identified.

• Fifth day post Caesarean, patient's serum creatinine had increased from 0.6 to 4.5 mg/dl and serum urea from 18 to 63 mg/dl. C‐reactive protein was elevated to 16.8 mg/dl. Uric acid was 8.4 mg/dl, and liver enzymes were normal.

• When asked, it transpired patient had probably passed only very small amounts of bloody urine during the previous few days.

• Upon physical examination she appeared well‐hydrated. Her abdominal wall was oedematous, although not acutely inflamed. The swelling was predominantly on her left side and extended to the left flank and thigh.

Surgical injury (Bladder) – Case Study

• The legs showed no signs of venous obstruction and foot pulses were palpable. No skin rash was detected. Doppler ultrasound showed regular kidney perfusion; there was no evidence for thrombosis of the renal veins or the vena cava inferior.

• Patient started to experience severe shortness of breath by day 7 post section.

• Further imaging showed significant swelling of the abdominal wall and the presence of ascites in the lower and upper abdomen, along with significant pleural effusion. A puncture of the ascites revealed a creatinine concentration of 15.8 mg/dl, more than twice as high as the serum creatinine level.

• A cystogram was performed which showed extravasation of contrast into the abdominal cavity. Subsequent laparotomy revealed a 3 cm lesion in the bladder wall.

Potential Issues Requiring Investigation?

• Was the bloody urine a cause for concern and at what point? Was this relayed to the doctor?

• Who ordered removal of catheter and was this appropriate?

• Was each occasion of bloody urine escalated?

• Was communication at handover adequate?

• Was X-ray the appropriate investigation in the context of symptoms? Was it reported correctly?

• Was ultrasound the appropriate investigation and was it interpreted and reported correctly?

• Should fluid balance charts have been completed? Were the midwives asking the patient about voiding?

• Issue of assessment of postpartum abdomen

• Should a cystogram have been performed earlier?

Potential Damages if claim successful

• Patient transferred to ICU, ultimately recovered and was discharged. She has no ongoing physical symptoms but brings a claim for psychiatric injury.

• If successful, depending on level of injury and impact of injury on ability to function, damages could be upwards of $500,000 in severe case

Surgical injury (Bowel) – Case Study

• Mother was born with a congenital cranio-facial abnormality known as Pierre Robins Syndrome (PRS). 4th pregnancy. Suspected baby was affected by PRS – mother’s care transferred to teaching hospital.

• Birth by elective caesarean section with ex-utero intrapartum treatment - a method of maintaining the utero-placental circulation during the section to permit airway to be established in baby prior to full delivery.

• A Redivac drain was inserted into her abdomen in view of the risk of bleeding.

• The day after the operation it was noted that mother had a swollen but soft abdomen, but no vomiting and she was feeling hungry so Redivac drain removed.

• Following removal of drain mother became increasingly distressed with abdominal pain and swelling.

Surgical injury (Bowel) – Case Study

• An abdominal X-ray was performed and a bowel obstruction suspected. Mother was reviewed by surgeon - diagnosis was post-operative ileus.

• The symptoms continued for a week although she was noted to be feeling better, and began to eat and mobilise. However, she had a persistently increased heart rate, an elevated white cell count, a reduced serum albumin, abdominal distension and oedema of the abdominal wall and legs with subsequent blistering.

• Almost two weeks after giving birth, mother complained of sudden onset of acute abdominal pain and was found to have a clinical picture consistent with sepsis.

• A CT scan suggested the presence of ascites and air in the peritoneal cavity, almost certainly due to a perforation of the bowel.

Surgical injury (Bowel) – Case Study

• Emergency laparotomy performed – mother found to have generalised peritonitis, with 2 litres of free pus and fluid. She developed acute respiratory multi-organ failure and died a week later.

Surgical injury (Bowel) – Potential Issues for Investigation

• Was diagnosis of ileus reasonable at the time?

• When should this have been revised?

• Were appropriate investigations carried out regarding the tachycardia, white cell count, abdominal distension and other symptoms?

• Should sepsis have been diagnosed earlier?

• Were care pathways being complied with and documented?

• Was a maternity early warning tool in place?

• Was communication at handover adequate?

• Was care of the patient escalated when it should have been?

•

Surgical injury (Bowel) – Potential damages if claim successful

• Loss of dependency claim brought

• 4th child died from PRS.

• Patient left 3 children and husband

• Patient worked part time

• Able to claim for loss of her income and loss of her domestic services and husband’s nervous shock

• Settled for $700,000 for dependency claim for 3 children and $175,000 for nervous shock claim

Surgical injury – Risk Management

• Consider Maternity Early Warning Tool

• Evidence-based policy re detection of variances

• Handover

• Communication

• Escalation

• Appropriate investigations

• Continuity of Care

• Standard of Care

• Adequate monitoring and documentation?

• May be an ileus – May not

Endometritis – Introduction

• Endometritis refers to inflammation of the endometrium, the inner lining of the uterus.

• Symptoms include lower abdominal pain, fever and abnormal vaginal bleeding or discharge.

• Risk factors include Caesarean section, prolonged rupture of membranes and long labour with multiple VEs.

• Very little information available on statistics.

• 1.8% of all births in Queensland during the 07/08 financial year resulted in sepsis.

• Compare this to almost 40% of admitted patients who suffered from peuperal fever at the Vienna General Hospital between 1846 and 1849, prior to the germ theory of infection

Endometritis – Case Study

• 24 year old G1P1, presented with ruptured membranes at 38+6 with cervical dilatation of 2cm.

• Given oxytocin to induce labour. Progressed slowly to active phase but 9 hours later was only 5cm dilated. Syntocinon was increased.

• Despite adequate contractions she had no progress for next 4 hours. Fetus developed tachycardia with a baseline of 170bpm.

• Caesarean section performed. Given perioperative prophylactic antibiotics.

• 3 days post op – evaluated for fever of 38°C. No recordings of maternal temperature prior to this. Denied nausea or vomiting but complained of increased abdominal pain since the night before. Resident’s orders were to continue to monitor temperature.

Endometritis – Case Study

• By day 4, the temperature was 39°C and the registrar arranged a blood test.

• The results were available (revealed a septic picture) the following morning but were not conveyed to medical staff and the registrar did not follow them up. The registrar made comments about mother and baby bonding and possible PND and was planning for discharge.

• By day 5 the patient was very unwell. The abdominal pain had increased and the patient was suffering from flu-like symptoms and a rash, along with foul smelling lochia. A vaginal swab was not taken.

• The blood cultures ultimately grew Group A streptococcus, endometritis was diagnosed and appropriate antibiotics commenced. However, patient was ultimately transferred to ICU and diagnosed with endocarditis.

Endometritis – Potential Issues for Investigation

• Was the Syntocinon appropriately managed?

• Was slow progress escalated?

• Was no progress escalated?

• Was there an estimate of the size of the baby?

• How often should maternal temperature be recorded intrapartum and postpartum?

• What further investigations were required regarding complaints of increased abdominal pain?

• When should the blood test have been taken?

• When should the antibiotics have been commenced?

• Would earlier treatment have been likely to make a difference to outcome?

Endometritis – Potential Issues for Investigation

• What was the results notification/follow up process in place at the hospital?

• Often see comments querying mother baby bonding where mother systemically unwell

• Should a vaginal swab have been taken?

• Was the patient questioned regarding vaginal loss?

Endometritis - Potential Damages if claim successful

• In this case, the mother recovered reasonably well and was ultimately able to return to work and care for her children.

• Her heart required ongoing monitoring.

• The claim was able to be settled for $150,000.

Endometritis – Risk Management

• Always consider sepsis in recently delivered women who feel unwell and have pyrexia

• Policy should at least set out need to:

• Document maternal temperature

• Escalate when pyrexia present

• Undertake further investigations where appropriate, eg bloods, swabs, urine,

• Follow up investigations in a timely way

• Commence appropriate intravenous antibiotic therapy – don’t wait for results

• Review antibiotic treatment once result available

• Consider relevant parameters for when review by consultant must be requested immediately

• Escalate if patient deteriorates

Exclude competing causes for maternal infection

• Genital Tract:

• Endometritis

• Urinary Tract:

• Pyelonephritis

• Breast:

• Breast engorgement,

• Mastitis

• Wound:

• Surgical site infection

• Pulmonary:

• Pneumonia,

• atelectasis

• Vascular:

• Pelvic thrombophlebitis

Postpartum haemorrhage - Introduction

• As at 2008, nearly one quarter of all maternal deaths worldwide were attributable to postpartum haemorrhage

• Clinically the most common cause is uterine atony

• Increased risk – macrosomic babies, multiple pregnancies, prolonged first stage of labour

• Highest rates of PPH in instrumental vaginal birth. Risk significantly higher with induction.

• PPHs that did occur following caesarean birth 65% more likely to be severe than those occurring in vaginal birth (Queensland Government StatBite#35 Labour and

Delivery Characteristics associated with Primary Postpartum Haemorrhage, Queensland, 2008)

Postpartum haemorrhage – Case Study

• Patient had 2 children, pregnant with 3rd

• Low platelets during pregnancy

• Breech presentation – planned caesarean

• Waters broke – fetal distress

• Emergency caesarean performed by locum obstetrician

• Small extension of uterine incision – EBL 1L - PPH

• Uterus externalised, tear repaired, haemostasis

Postpartum haemorrhage – Case Study

• Uterus slow to contract initially

• Syntocinon administered

• Handover deficient – recovery nurse not informed of tear or EBL. No midwife in recovery

• Observations fairly stable until 0836 hours (29 mins after transfer) although BP was low

• No fundal height taken nor massage performed

• 0815 moderate ooze PV

• 0836 BP dropped to 89/51 from low 90s

Postpartum haemorrhage – Case Study

• 0841 Pulse rose from 74 to 79

• 0846 Pulse rose to 94, BP 54/22 and large blood loss observed soaking pads, blueys and linen

• Recovery nurse called other RNs for assistance

• RN checked fundal height and massaged fundus then initiated 1L Hartmann’s

• Recovery nurse telephoned anaesthetic registrar – ordered gelofusion

• GP obstetrician overheard and came to assist. Aware Syntocinon had been ceased

Postpartum haemorrhage – Case Study

• No blood taken for G&H and cross match – in accordance with hospital policy

• GP Obs organised cross match at 0930

• Locum obs arrived and ordered recommencement of syntocinon. Diagnosed atonic uterus. Fundal massage produced large blood clots

• Likely patient bleeding into uterus shortly after arrival in recovery

• Attempts made to locate obstetrician. General surgeon located to assist with surgery

Postpartum haemorrhage – Case Study

• Transferred to OT at 1000 hrs. Large blood clot evacuated. Uterus large and atonic. No obvious bleeding point. Hysterectomy

• 14 units of packed cells administration and 10 of FFP. One pool of platelets transfused at 1230 after arriving from another hospital

• Cardiac arrest on table

• Transfer to larger hospital

• Died the following day

Postpartum haemorrhage – Coroner’s Findings

• Main issues:

• Standard of obstetric services at Hospital – related to below issues

• Protocol re FBC, G&H and Xmatch – Locum not aware was not hospital policy. Had FBC and G&H been taken patient may have survived. All elective and emergency CS patients should have a current G&H and FBC attended prior to surgery – to be implemented statewide (NSW)

Postpartum haemorrhage – Coroner’s Findings

• Main issues:

• Handover from OT to recovery – anaesthetic registrar’s instructions to recovery nurse limited to ensuring Syntocinon administered and BP checked. No handover from locum obs. Recovery nurse had no awareness of PPH policy. If handover had included need for fundal height and massage, obs may have become aware recovery nurse not trained in this

Postpartum haemorrhage – Coroner’s Findings

• Main issues:

• Level of training and experience of recovery nurses – locum not aware of inexperience of recovery nurse with PPH. Hospital administrators must ensure rostered staff have skills and training to identify and deal with crisis or at least identify it and seek assistance. If trained, moderate ooze might have resulted in call to doctor. BP and pulse between 0841 and 0846 should have resulted in immediate call for assistance. Recovery nurse felt priority was to clean patient.

Postpartum haemorrhage – Coroner’s Findings

• Main issues:

• Policies re diagnosis and treatment of PPH – ‘guidelines alone are of little significance if they are not accompanied by appropriate training and a system in place to ensure they are known and understood by staff’

• Other issues

• Availability of certain drugs – Misoprostol and Novoseven – coagulation properties – not available at hospital. DG of Health should review and formulate policy re minimum requirement for hospitals to stock particular range of drugs

Postpartum haemorrhage – Coroner’s Findings

• Other issues

• Documentation – When a critical incident occurs the need to record accurately and while memories are fresh is imperative. Need to re-enforce to all staff the need to make accurate and timely notations

Postpartum haemorrhage – Coroner’s Findings

• 2 primary factors that contributed to death

• Failure to take FBC and G&H and/or cross match prior to CS

• Allocated recovery staff had no experience in identifying a PPH, understanding the significance of fundal height or trained in fundal massage

• Failure to apply an holistic approach to overall care. Too great a willingness between various disciplines to compartmentalise their perceived area of responsibility.

• Cause of death – Multisystem Organ Failure due to or following PPH

Postpartum haemorrhage – Further Investigation

• Media – two vital blood warming machines were faulty – theatre staff could not operate

• RCA

• Special Commission of Inquiry

• Health Care Complaints Commission – referred recovery nurse to Professional Standards Committee, which appealed to Tribunal – unsuccessful – did not amount to unsatisfactory professional conduct

• Expert opinion suggested highly unusual that obstetrician did not review patient in recovery post-operatively

Postpartum haemorrhage – Further Investigation

• Rising pulse rate usually first sign of PPH – expert DON

• Operation report short on detail

• Responsibility of surgical team to handover patient

• No midwife in the theatre complex

• Key skill needed was fundal height and massage – key indicator re internal haemorrhage

• No MET call policy

PPH - Potential Damages if claim successful

• If a claim was brought, it would likely again involve a loss of dependency claim by the 3 children and potentially a nervous shock claim by the husband.

• Damages could be anywhere from $500,000 to $2m depending on wife’s occupation, life expectancy and age of dependent children

Postpartum haemorrhage – Risk Management

• G&H and FBC ?Xmatch for all CS patients

• Midwife caring for patient in recovery

• Ensure recovery nurse has appropriate handover and operation report

• Documentation – accurate and timely notations

• Escalation

• Training of recovery nurses in fundal assessment

• Skill mix

Postpartum haemorrhage – Risk Management

• Current evidence-based policies and awareness and understanding including locums

• Availability of coagulation medication

• Holistic care

• Equipment failure

Perineal Tear – Introduction

• Most common maternal morbidity associated with vaginal birth

• In Queensland in 2010 genital tract trauma affected 71.5% of women giving birth vaginally

• Majority were minor

• 2.4% of trauma reported involved the anal sphincter (3rd and 4th degree) (Queensland Health Perinatal Data Collection)

Perineal Tear – Case Study

• In February 2008, mother admitted to hospital for induction of labour - 10 days overdue

• Had a normal vaginal delivery the following day - large baby in excess of 4kgs.

• Midwife attending the delivery diagnosed a second degree tear, and sutured the tear in the delivery room herself.

• Midwifery notes did not detail how the midwife had diagnosed a second degree tear, or what steps she had taken to repair the tear, or to ensure that an adequate repair had taken place.

• Subsequently, mother was unwell with abdominal pain, and was diagnosed with suffering from gallstones for which she underwent a procedure in September.

Perineal Tear – Case Study

• Mother suffered with symptoms of faecal urgency and incontinence following the delivery of her baby, but did not understand that these might be related to the birth. It was not until 2010 (2 years later) that she sought medical attention.

• Mother was referred to colorectal specialist and was informed she had sustained a third degree tear following the delivery of her baby and her tear had been inappropriately repaired.

Perineal Tear – Potential Issues for Investigation

• Adequacy of perineal examination especially in light of large baby

• Lack of documentation

• Adequacy of repair

• Skill of repairer

• Delayed diagnosis of 3rd degree tear

• Adequate history taking from mother postpartum

Perineal Tear - Potential Damages if claim successful

• Undiagnosed or inadequately repaired 3rd and 4th degree tears can have devastating effects on women and may result in an inability to care properly for children, inability to work, often psychiatric injury

• Depending on severity of physical and psychiatric injuries, damages could be up to $500,000, or more if mother can never work again

Perineal Tear – Risk Management

• Be aware of risk factors for anal sphincter injury

• Educate patients re antenatal risk reduction

• Be aware of intrapartum clinical measures to reduce risk

• Ensure perineal examination meets the standard expected

• Consider lighting and maternal positioning

• Consider whether examination and repair should occur in theatre - Aseptic technique

• Systematic perineal assessment involving visual, VE and PR

• Does repairer have necessary skills? – 3rd and 4th degree performed or supervised by obstetrician

• Escalate where required

• Ensure adequate follow up

Neonatal Care

• Difficulty with some neonatal symptoms, is again competing causes. For example, one sign of potential hypoglycaemia can be a disinterest in feeding but this can also occur during day 1.

• Recent study – neonatal claims made up 11% of all incident investigation associated with childbirth and neonatal period

• Expect it to be a growth area – certainly based on trend with hypoglycaemia claims

Hypoglycaemia – Introduction

• At birth all babies must initiate glucose production and absorption. Certain babies may be unable to make the appropriate metabolic adaptations to extra uterine life and are considered ‘at risk’ of severe and/or persistent hypoglycaemia.

• Hypoglycaemia is a BGL less than 2.6 mmol/L

• Severe hypoglycaemia is:

• a BGL less than 1.4 mmol/L or

• a BGL less than 2.6 mmol/L despite greater than 10 mg/kg/min of glucose

• Definition of persistent or recurrent hypoglycaemia is controversial. Two options include:

• any three BGLs <2.6 mmol/L

• hypoglycaemia (BGL <2.6mmol/L) persisting/recurring after 72 hours

Hypoglycaemia – Case Study

• Established labour - 38 weeks. Non-insulin dependant gestational diabetes.

• Labour progresses slowly but well. Forceps delivery required to deliver a 4120g baby with Apgars of 9 at 1 and 9 at 5.

• Some disinterest in feeding noted by midwifery staff. Managed with encouragement, observing attachment and giving EBM as necessary which appeared to be reasonably well tolerated.

• Disinterest in feeding continues throughout day 1. Mum comments bub seems very sleepy and at times a bit jittery. Mum is told this is within normal limits 24 hours post birth.

Hypoglycaemia – Case Study

• As is third baby – mum left to own devices somewhat.

• At 11pm Mum reports bub is lip smacking with jerky movements. Paediatrician notified - requests midwives continue to monitor baby, giving EBM/formula, he will review in morning. Midwife feels uncomfortable but is about to finish shift so handed instruction over.

• Overnight, baby noted to be very sleepy and floppy at times with a complete disinterest in feeding. There are further jerky episodes. Midwife decides to do a BSL - 0.8mmol.

• Paediatrician immediately notified - requests that transfer to SCN and 10% dextrose. Ultimately baby has MRI - brain damage consistent with severe neonatal hypoglycaemic injury.

Hypoglycaemia – Potential Issues for Investigation

• Was the disinterest in feeding appropriately managed and escalated?

• What investigations were required when mother reported baby was jittery?

• Were appropriate investigations commenced when mother reported lip smacking and jerky movements?

• What else could midwife do when she felt uncomfortable about paediatrician’s advice?

Hypoglycaemia - Potential Damages if claim successful

• Severe neonatal hypoglycaemic injury can have significant impact on a child’s development including the potential for CP and severe spastic quadriplegia

• In the most severe cases, the child needs full time care for the rest of their life.

• Damages would be similar to CP claims – very state focused but upwards of $9m plus costs in most severe cases where claimant has close to normal life expectancy

Hypoglycaemia – Risk Management

• Systems – Appropriate policy re management essential

• Prevention

• Identify infants at risk

• Early skin to skin contact

• Early and frequent feeds

• Maintain temperature

• Detection

• Monitor clinical symptoms

• Appropriate maintenance of bedside glucometer and adequate training in use essential

• Be aware of policy requirements re when to screen, eg if babies have one or more risk factors (set out both maternal and neonatal risk factors in policy), if they are unwell or if they have any unexplained abnormal signs

Hypoglycaemia – Risk Management

• Be aware of policy requirement re confirmation of glucometer BGL by blood gas machine or laboratory analysis.

• Be aware of signs of hypoglycaemia

• Appropriate prompt treatment

• Babies with signs specific for hypoglycaemia require urgent paediatric review.

• Exclude underlying causes

• Follow up

• Consider early MRI imaging

Kernicterus - Introduction

• Neonatal jaundice - normal physiological process in newborns - develops in estimated 60% of term babies and 85% of preterm babies having visible jaundice

• Approximately 8% to 11% of newborns develop significant hyperbilirubinemia, a condition that, if unmonitored, unrecognized, or not treated in a timely manner, could result in kernicterus, a preventable and potentially catastrophic form of permanent brain damage.

Kernicterus - Introduction

• Initial signs include:

• lethargy

• hypotonia and poor suck progressing to:

• hypertonia

• high pitched cry and eventually to:

• seizures and coma

• Serious long-term complications, such as CP, seizures, sensorineural hearing loss, or gaze abnormalities, develop in at least 70% of infants, and at least 10% of infants who develop kernicterus die.

Kernicterus - introduction

• Some believe has been reemergence – potential factors:

• discharge of newborns from hospitals to homecare just days before jaundice peaks,

• inadequate and delayed postdischarge follow-up care

• The uncertainty about which infants could develop kernicterus makes the problem a serious patient safety and risk management concern.

Kernicterus – Case Study 1

• Ohio hospital and paediatrician

• Although developed cephalohaematomas, a risk factor for the development of hyperbilirubinemia, discharged from hospital on a Saturday, within 24 hours of delivery.

• Scheduled for first follow-up appointment 5 days after discharge

• Mother called paediatrician day after discharge to report cephalohaematomas appeared larger. Paediatrician did not offer to see the baby.

• $4 million settlement

• Anonymous Twenty-Seven Year-Old Mother v. Anonymous Pediatrician and Hospital

Kernicterus – Case Study 2

• Born 20 days before due date

• Elevated bilirubin level of 14 (reference range 0.6 to 10.5)

• At discharge, parents instructed to bring baby to the hospital the next day (a Sunday) for blood test.

• Parents complied but sent home without learning test results. Hospital laboratory technician saw bilirubin level was 18.6 and called the paediatrician’s office but no answer.

• No attempt made to inform another healthcare provider of results.

Kernicterus – Case Study 2 continued

• Next day, mother called paediatrician’s office for test result - told office would call her if a problem.

• Three days after blood test, paediatrician called parents, telling them office had just received test and it was elevated.

• Parents asked to bring baby to hospital for repeat test - bilirubin level of 27.2

• Infant transferred to another institution for treatment of hyperbilirubinemia - later diagnosed with bilateral sensorineural hearing loss, requiring hearing aids.

• Settled for $600K

Kernicterus – Case Study 3

• Newborn diagnosed with jaundice - received no treatment before discharge.

• 4th day of life, each of his parents made phone calls, several hours apart, to an on-call paediatrician, informing him baby looked “yellow” and experiencing feeding difficulties. The on-call paediatrician did not realize that each call concerned the same infant and did not ask to see the child.

• Twelve hours after parents made second call to paediatrician, took infant to hospital, where test results indicated hyperbilirubinemia.

Kernicterus – Case Study 3 continued

• Instead of initiating immediate treatment, the on-call paediatrician transferred the infant’s care to a neonatal specialist the next day.

• The plaintiffs sued the on-call paediatrician, the hospital, and the attending paediatrician. The latter two settled, and the case was tried against the on-call paediatrician. The jury apportioned 15% of the liability against the hospital, 70% against the attending paediatrician, and 15% against the on-call paediatrician.

• The Californian jury awarded $84.25 million Andrew Leyvas v. Norma Paragas, M.D. Alameda County CA, Sup Ct.No. 798868 4OH.

Kernicterus – Case Study 4

• 10 hours after birth, infant examined by a paediatrician; about 7 hours later, a nurse recorded the presence of jaundice but did not notify the paediatrician.

• Approximately 24 hours after birth, nurse on next shift noticed jaundice but didn’t notify paediatrician.

• Paediatrician performed a circumcision approximately 33 hours after birth and then discharged infant.

• Infant appeared jaundiced at discharge, with “moderate icterus on head, mild icterus on body.”

Kernicterus – Case Study 4 continued

• Nurses provided ‘handout’ about neonatal jaundice to parents but gave no counselling re ‘abnormal’ jaundice.

• About 78 hours after discharge, mother took him to paediatrician, after calling to report infant still appeared yellow, was sleepy and lethargic, and was not feeding as vigorously as he had earlier. Paediatrician ordered oral antibiotic for an ear infection.

• The next day, mother called paediatrician, reporting increase in appearance of jaundice.

Kernicterus – Case Study 4 continued

• Infant admitted - bilirubin level 34.6/100 ml. Treated with phototherapy. Second test revealed elevated bilirubin level - blood transfusion not ordered.

• Next day, child exhibited sharp, high-pitched cry and movements described as arching or hyperextension of neck.

• Diagnostic imaging and other tests performed, and infant discharged.

• Within the next 16 months, infant diagnosed with cerebral palsy, subsequently attributed to kernicterus.

Kernicterus – Case Study 4 continued

• The Idaho Supreme Court noted the following:

• Hospital had no policies or protocols in place about identifying or managing jaundice.

• Nurses failed to notify paediatrician about observations of jaundice, despite hospital policy re notifying of abnormal symptoms.

• Nurses did not warn mother that infant’s jaundice may be abnormal and that serious brain damage could occur if it worsened and was not treated in a timely manner. Nurses did not suggest testing of bilirubin level to paediatrician even though hospital had a procedure in place for nurses to advocate on behalf of patients

Kernicterus – Case Study 4 continued

• Hospital did not have policy to test cord blood to determine incompatibility between the infant’s blood and mother’s.

• Upon readmission, incorrect chart documentation led physicians to erroneously believe that infant and mother had same blood type.

• The defendant paediatrician testified that had he known of discordance, he would have treated the jaundice more aggressively.

• Sheridan v. St. Luke’s Regional Medical Center et al.

Kernicterus - Potential Damages if claim successful

• Again, brain damage caused by Kernicterus can result in CP - damages are again upwards of $9m plus costs for most severe cases

Kernicterus – Risk Management

• Ensure evidence–based policy that deals with the following:

• Prevention

• Frequent feeding

• Ingestion of colostrum to increase stooling which prevents reabsorption of bilirubin

• Identification

• Universal screening?

• Testing of pregnant mothers or cord blood for ABO incompatibility

• Awareness of signs of hyperbilirubinaemia

Kernicterus – Risk Management

• Ensure evidence–based policy that deals with the following:

• Appropriate Treatment

• Education of parents

• Signs of adequate hydration

• Feeding

• Signs of Jaundice

Kernicterus – Risk Management

• Discharge, for example

• All newborns who are visibly jaundiced in the first 24 hours of life should be investigated prior to discharge.

• Never discharge a baby with conjugated hyperbilirubinaemia without attempting to find the cause.

• Assess all babies for risk of developing severe hyperbilirubinaemia at hospital discharge - particularly important if before 72 hours of age, as likely to still have a rising total serum bilirubin level.

• Advise parents to contact healthcare professional if:

• their baby becomes jaundiced, jaundice is worsening or persisting beyond 14 days

• their baby is passing pale stools

Outcome of breach of duty

• Patient complaint

• RCA or other internal investigation

• M&M committee

• Perinatal mortality committee

• HQCC

• PIPA claim

• Police Investigation

• Coroner’s investigation or Inquest

Outcome of breach of duty

• Board investigation or referral to panel or tribunal

• Private Health Regulatory Unit

• Workplace Health and Safety

• TGA

• WorkCover

• Media coverage

http://www.google.com.au/url?sa=i&rct=j&q=risk+management+funny&source=images&cd=&cad=rja&docid=PTfoGzQ8voFekM&tbnid=EfswQoOz9UZWTM:&ved=0CAUQjRw&url=http://www.thesniper.us/?p=4055&ei=q8VkUYjtN4mtkAXJ6ICwBg&bvm=bv.44990110,d.dGI&psig=AFQjCNEkCCj2DrIeBp20pyZ6iksX9wZR3Q&ust=1365645049028947

Risk Management Strategies - Summary

• Be prepared

• Evidence-based research/education

• Warning tools

• Staff to patient ratio and skill mix

• Training and orientation

• Adequate supervision

• Equipment checks

• Policy review, awareness and compliance

• Escalation plan

Risk Management Strategies - Summary

• Provide excellent care

• Evidence-based

• History taking

• Adequate monitoring

• Appropriate investigations

• Appropriate treatment

• Holistic Care

• Follow up

Risk Management Strategies - Summary

• Communicate

• Patient

• Management of expectations antenatally

• Keep informed

• Consequences of non-intervention

• Education

• Colleagues

• Handover

• Escalation/referral

• Document

• Early incident investigation policy

The Postpartum Phase Areas of risk

Presented by Stephanie Jones, Special Counsel

stephanie.jones@minterellison.com

Obstetric Malpractice

Conference

June 2013