Learning From Lawsuits: Verdict Review – Wrongful Maternal Death Case Involving Obstetrical Hemorrhage

In this blog, I’ll be reviewing a maternal wrongful death case involving obstetrical hemorrhage.  I’ll identify how to diagnose obstetrical hemorrhage, and review the incidence of obstetrical hemorrhage within the United States.  Following a review of case facts, I’ll highlight key standard of care takeaways that support obstetrical hemorrhage prevention, early identification, and intervention.  The provided takeaways are evidence based practices which serve to reduce the incidence of maternal morbidity, and mortality associated with obstetrical hemorrhage.     

Definition: Obstetrical hemorrhage is defined as a cumulative blood loss of greater than or equal to 1,000 ml. of blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after childbirth, regardless of the mode of delivery (AGOG, 2021). 

Incidence: Obstetrical hemorrhage remains one of the leading causes of pregnancy-related deaths worldwide. In the U.S., during 2017 – 2019, obstetrical hemorrhage accounted for 12.1% of the total pregnancy-related deaths (CDC, 2023).

Case Facts:  A 36-year-old mother experienced profound uterine bleeding immediately after cesarean section for a twin delivery.  The patient was transferred to the post anesthesia care unit (PACU) where she continued to have severe bleeding, vital sign instability, and experienced hemorrhagic shock.  The patient received fluid resuscitation with blood products, and intravenous fluids.  Blood products were not promptly available.  The patient was transferred to the intensive care unit (ICU) where her vital signs continued to worsen.  The Obstetrician urged for an immediate hysterectomy.  After the patient was transferred to the ICU, the anesthesiologist left the hospital for another case at a different hospital, and there was no anesthesiologist available.  A hysterectomy was eventually performed. Due to the postpartum bleeding, and insufficient fluid resuscitation with blood products, the patient developed disseminated intravascular coagulation (DIC).  The patient was pronounced dead shortly after the DIC diagnosis was made. The anesthesiologist settled out.  The case continued to trial against the hospital and Obstetrician.

Plaintiff’s Allegations: The plaintiffs’ counsel contended the patient needed operative intervention much sooner to stop the uterine bleeding.  Plaintiffs’ counsel also contended the hospital blood bank did not promptly deliver the needed blood products. Lastly, the hospital failed to perform lab tests to assess the extent of the patients bleeding.

Defendant’s Allegations: The hospital contended the death was due to the negligence of the other physicians, including the anesthesiologist, for failing to promptly respond to, and manage the evolving shock. 

Physical Injuries Claimed by Plaintiff: Death; loss of love, companionship, comfort, care, assistance, protection, affection, society, moral support; loss of training and guidance; loss of financial support; the reasonable value of household services.

Gross Verdict (Award): $10,850,000 (100% against the hospital.  The obstetrician received a 12-0 defense verdict)

Standard of Care Takeaways:

• Hospital systems should require the performance of antepartum (prenatal), intrapartum (during labor), and postpartum (after delivery of the placenta) hemorrhage risk (re)assessments.
  • These standardized risk assessments are performed in an effort to identify patients at medium or high risk for obstetrical hemorrhage, and guides necessary interventions.
• Use of a stage-based management plan should be adopted that requires the performance of quantitative blood loss (QBL) measurements for every delivery.
  • With the use of a standardized stage-based management plan, best practice interventions are prompted, and are specific to the hemorrhage stage (stage 1-3).
• Standardized hemorrhage medication kits, and supply carts should be readily accessible on every unit caring for obstetrical patients.
  • Care units include labor and delivery, emergency departments, intensive care units, and operating rooms.
• Multi-disciplinary, role-specific obstetrical hemorrhage education, and simulation drills (including all members that care for obstetrical patients) should occur at the time of new hire orientation, whenever there are changes to the policy or procedure, or every one to two years.
• Every organization should have established criteria for identifying obstetrical hemorrhage cases requiring quality review. The quality review process serves as a quality improvement effort, and guides future continuing education.
• Patient education should be provided specific to hemorrhage risk factors, as well as signs, and symptoms of hemorrhage that must be reported.

Closing Remarks: Professional organizational standards exist specific to prevention, early recognition, and timely treatment of obstetrical hemorrhage.  Obstetrical risk reduction strategies should involve adoption of obstetrical hemorrhage safety bundles, perinatal quality review processes, as well as multidisciplinary data review by means of  audit and feedback methodologies.  

Resources:

AGOC, 2021. Postpartum Hemorrhage

Centers for Disease Control and Prevention, (2023). Healthy People 2020. https://www.cdc.gov/nchs/healthy_people/hp2020.htm

Centers for Disease Control and Prevention, (2023).Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

The Joint Commission, 2023). R3 Report Issue 24: PC Standards for Maternal Safety.  https://www.jointcommission.org/standards/r3-report/r3-report-issue-24-pc-standards-for-maternal-safety/#.ZAdWsB_MJPY

P.S. COMMENT AND SHARE: Have you been involved in a maternal wrongful death case involving obstetrical hemorrhage?  What was the case theme?  What were strengths, and weaknesses of the case?

Barber Medical legal Nurse Consulting, LLC is available to support medical record review of obstetrical care involving a hemorrhage, perinatal quality consults, and obstetrical hemorrhage education.  Email: Contact@barbermedicallegalnurse.com.