Medical Malpractice Attorneys Knowledge Base

Important Articles on Medical Malpractice and other relevant legal issues written by ABPLA Board Certified Medical Malpractice Lawyers

Medical Malpractice Articles by Chris Searcy 
ABPLA Board Certified Medical Malpractice Lawyer

THE OBSTETRICAL BASICS OF LABOR AND DELIVERY!

HOW TO READ THE RECORDS; WHAT RECORDS YOU NEED

I.          SCOPE

In most jurisdictions, the vast majority of medical negligence cases, including obstetrical cases, will require review and testimony by medical experts. I advocate getting appropriate experts involved in the case as early as possible. The scope of this article is not to replace expert review by lawyer review. The scope of this article is to focus on the records needed for adequate expert review, and an understanding of those records to enhance the lawyer’s ability to analyze the case and communicate with appropriate experts.

II.        DISCOVERY OF EXISTING RECORDS THROUGH COMPREHENSIVE CLIENT INTERVIEW

 A.        In a medical negligence case involving obstetrics, the lawyer should usually inquire, not only about the pregnancy in question, but about the mother’s reproductive history. In doing so, the lawyer should determine what records are available as to the mother’s prior or subsequent reproductive history, as the lawyer will probably want to obtain those records.

 1.         Commonly, the incident your client has come to you about will not be her only experience with reproductive care. Frequently, she will have received reproductive care for other pregnancies or childbirths, and/or will have received routine gynecological care. These records can supply helpful background information as to the client, and in some instances, can be helpful on liability issues, if the prior records show the prior healthcare provider did what the subsequent healthcare provider failed to do.

B.        With regard to the pregnancy in question, the lawyer should get as accurate and detailed a chronological history as possible of what happened through the eyes of the client. In doing so, he should ascertain what physicians saw his client, in what facilities, and what was done on each of these occasions. From this interview, the lawyer will become apprised of what medical records are likely to exist with regard to the incident in question so that he can procure them for his review and for expert review.

 III.       RECORDS THAT SHOULD BE REQUESTED IN THE OBSTETRICAL BIRTH INJURY CASE

A.         Prior and subsequent reproductive care.

B.         Prenatal records.

1.         Most pregnant women have undergone a course of pre-natal care during their pregnancy. Oftentimes, a portion of these prenatal records will be contained in the mother’s hospital chart; however, frequently, the prenatal records in the hospital chart do not contain the complete prenatal records

from the physician’s office, and the physician’s prenatal office records should be requested whenever they exist.

C.        Emergency room records or outpatient records, if any.

1.         If the mother has complications during pregnancy, it is not uncommon for the physician to see her in the emergency room. Likewise, there are certain tests for fetal wellbeing that are done in an outpatient hospital setting. Therefore, in requesting the mother’s and baby’s hospital birth records, one should be sure that request includes any emergency room records and/or out-patient records.

 D.        Mother’s hospital records for birth admissions.

                         1.         One must be aware that the birth of a child in the hospital results in two separate hospital charts - a hospital chart for the mother and a hospital chart for the baby. If one requests the hospital chart for the baby, one will not receive the mother’s hospital chart. Thus, the lawyer must be clear to designate that he wishes to have the hospital chart for the mother pertaining to the birth.

E.        Hospital chart of baby pertaining to birth.

                         1.         Again, the hospital keeps totally separate charts on the mother and the baby. For the lawyer to receive the hospital records pertaining to the baby, the lawyer must separately request the baby’s hospital chart pertaining to the birth of the baby.

F.         Fetal heart monitor strips, and other special records not included in the charts of mother or baby.

1.         One of the most vital records concerning fetal wellbeing or lack thereof, is the fetal heart monitor strips kept on the baby while the mother is in labor and delivery. This consists of a tracing on continuous monitor strip paper. It shows how the fetal heart is reacting to the stress of contractions on a continuous basis. It is not customarily furnished as part of the mother’s or baby’s birth chart. To receive this vital record, the lawyer must specifically request it. Depending on the issues involved in the case, one may wish to request other special data not furnished as part of the chart, e.g. x-rays, laboratory slides, tissue specimens, etc.

G.        Policy and procedure manuals.

1.         If the hospital involved is accredited by The Joint Commission on Accreditation of Hospitals, which is usually the case, the hospital should have policy and procedure manuals for the obstetrics department which should include labor and delivery as well as post-partum. It should have a policy and procedure manual for pediatrics which should include the newborn nursery. It should have a nursing manual for each of these departments.

2.         Since violation of its own policies or procedures constitute evidence of negligence on the part of the hospital, it is very helpful to request these manuals if it appears to be a worthwhile case. Furthermore, these manuals provide your reviewing expert with a much more concrete idea of exactly what facilities and level of training were available at the hospital in question.

IV.       INTERPRETATION OF OBSTETRICAL RECORDS

A.         Prenatal record

1.         Most obstetricians use printed form charts to record their prenatal care of the patient. Most of these charts are somewhat uniform in nature. They should include information as to:

 a.         age

b.         pregnancies and births

c.          last menstrual period

d.         estimated date of confinement

e.          menstrual history

f.          past medical history of patient

g.         past medical history of patient’s family

h.         physical examination and findings

i.          increased risk or high risk factors

j.          impression or diagnosis

k.         monthly and then weekly physical exam and testing including:

1.         blood pressure

2.         weight

3.         pulse

 4.         edema

5.         fundal height

6.         position

7.         fetal heart

8.         station

9.         dilitation

10.       effacement

11.       albumin

12.       sugar

l.          Progressive notes as to occurrences, testing, or further impressions or diagnoses.

2.         The purpose for ascertaining and keeping this data on pregnancies is to allow the physician to predict what is likely to happen with his patient, so that he can be ready to handle it in the appropriate way. Oftentimes, a very forceful case can be built simply by having an expert explain the significance of the prenatal data, demonstrating how it warned the obstetrician of a potential complication, and then showing that the obstetrician totally failed to heed the warning.

B.         Emergency room records or outpatient testing.

1.         If your client tells you that she was seen either in the emergency room or some other department of the hospital during her prenatal course, you can rest assured that the hospital will have a record of it. These outpatient records can often have a material bearing on the case, and they should always be obtained. If your client describes going to the hospital for a non-stress test (NST) or an oxytocin challenge test (OCT), you should be aware that this means that your client went to the hospital and was attached to the fetal heart monitor and that a fetal heart monitor strip was made for that occasion. In such instances, you should request the actual fetal heart monitor strip for the NST or OCT, as well as the outpatient record.

C.        Mother’s hospital chart for birth of child.

1.        Most hospitals use a standard printed chart for recording labor and delivery data on the patient. While there is some variation, most of the charts contain areas for the following information to be recorded periodically upon examination:

a.         temperature

b.         pulse

c.         respiration

d.         blood pressure

e.         quality of contractions

f.          duration of contractions

q.         frequency of contractions

h.         fetal heart rate

i.          effacement

j.          dilitation

k.         station of descent

1.         condition of membranes or amniotic fluid

2.         A one page labor progress chart can contain a tremendous amount of information with regard to events transpiring over many hours. One needs to take the time to correlate each entry in the chart with the category under which it is entered and the time under which it is entered.

3.         The chart of most mothers will contain another printed form with information entered into it entitled “labor and delivery summary”. It will usually contain information pertaining to the following:

a.         reproductive history

b.         presentation

c.         complications

d.         rupture of membranes

e.         augmentation

f.          induction

g.         mode of delivery (spontaneous, low forceps, mid forceps, etc.)

h.         placenta

i.          episotomy

j.          surgical procedures

k.         delivery anesthesia

                                    l.          delivery room medications

m.        chronogloqy (EDC; time of admission to hos­pital; time membranes ruptured; time onset of labor; time complete cervical dilitation; time delivery of infant; time delivery of placenta)

n.         APGAR scores of infant

o.         resuscitation of infant

p.         medications for infant

q.         condition and transfer to newborn nursery

4.        There are various other records throughout the chart which are kept simultaneously such as physician’s progress notes, orders, supplementary nursing notes, laboratory data, etc. One must be cognizant that these data exist and must be construed in correlation with the labor and delivery progress chart and the patient’s description of events to get a complete time/substance understanding of the events of the hospital.

D.        Baby’s hospital chart for birth of baby.

1.         Most hospitals keep an initial newborn profile containing various data about the infant, an initial newborn exam by the pediatrician, an initial newborn exam by the newborn nursery nurses, and a nursing flow sheet for the newborn nursery. These are the records that are most vital to an understanding of the infant’s course. One must bear in mind that they must be construed with other simultaneous entries in the chart such as physician’s orders, physician’s progress notes, laboratory data, radiology, etc.

2.         The nursery flow sheet should contain periodic entries for the following data with regard to the infant:

a.         suck

 b.         emesis

 c.         stools

d.         abdominal distention

e.         cry

f.          activity

g.         irritability

h.         oral reflex

i.          muscle tone

j.          color

k.         intake

l.          output

n.         quality of respirations (regular, shallow, deep, etc.)

o.         retractions

 p.         apnea

q.         temperatures

r.          pulse

s.          respirations

t.          weight

            E.         Fetal monitor strips or other special tests.

1.         Where there is an indication that the mother has been hooked up to a fetal heart monitor, the hospital is required to save the fetal heart monitor strips that show a continuous time tracing reflecting the uterine contractions and the fetal heart rate.

2.         Where there is an abnormality in the fetal heart monitor tracing, the labor nurse is supposed to write on the tracing her impression what has caused this abnormality to show that she recognized it, assessed it, and if appropriate, did something about it.

3.         Normal fetal heart rate is thought to be between 120 beats a minute to 160 beats a minute.

4.         Normal uterine contractions are usually not more than a minute in duration, and usually are not more than every two minutes in frequency.

5.         A well compensated fetus will have a heart that fine tunes itself to the fetus’ requirements with each beat; therefore, on an internal monitor, the well compensated infant heart will show good beat to beat variability.

6.         One of the most significant parameters for deter­mining fetal wellbeing is to observe the way the fetal heart reacts to the stress of a uterine contraction. During the height of a uterine contraction, the pressure of the uterine contraction generally exceeds the pressure of the blood flow through the fetal placental unit, and therefore, the fetus is deprived of any blood flow during the height of the contraction. In a well compensated fetus, the function of the fetal heart is not disturbed and proceeds during the contraction similarly to the way it had been proceeding between contractions.

7.         A drop in the fetal heart of more than seven beats per minute can be called a deceleration of the fetal heart.  Decelerations of the fetal heart are classified by where they appear in relation to the uterine contractions. Variable decelerations seem to have no fixed relationship to uterine contractions. Early decelerations seem to reflect a mirror image of the uterine contraction. Late decelerations occur when the deceleration begins after the beginning of the contraction and the deceleration continues after the contraction. Late decelerations are the most ominous pattern for a fetus, and late decelerations for three contractions in a row or more, usually are an indication for emergency C-Section.

8.         It is helpful to have your expert write his interpretation of the fetal heart patterns and contraction patterns right on a monitor strip so that you can use that monitor strip in cross-examining the healthcare providers and witnesses for the other side.

V.        THE OVERALL PICTURE

1.         You must bear in mind that the hospital chart that one receives on a patient is a compilation of many different charts that were being simultaneously kept in various areas of the hospital on the same patient. One must further keep in mind that much of the information on a patient and much of the interplay between the patient and the healthcare providers is never entered into the hospital records. To attempt an accurate understanding of the times/substance events that occurred, one must get a comprehensive and detailed description of what happened from the client’s point of view, including the events that occurred as well as what was said and what was overheard. One must further obtain all of the applicable records, and analyze them to get a chronological picture of when the various entries occurred in relationship to each other.

VII.     COMPREHENSIVE CLIENT INTERVIEW AND SUMMARY THEREOF

1.         In most cases, it is not necessary to reduce to writing a comprehensive and detailed summary of the story of one’s own client. However, in a medical negligence case, where you are relying heavily on expert analysis of records, you are only providing your expert with half the cards in the deck, if you fail to provide him with a detailed summary of your client’s recollection. Many events of significance are not recorded, and many statements of healthcare providers, which are admissible as declarations against interests, are not entered into the records. Additionally, if a healthcare provider is smart enough to realize he has goofed while the patient is still in the hospital, he may intentionally fail to record for posterity the fact that he screwed up. Thus, providing a detailed chronology of the events by your client will help to ascertain whether the hospital records appear to be reliable or not.

2.         Time flow chart.

a.         It is extremely helpful to take all of the various records in the patient’s chart, as well as the description of events by your client, and try to get a beginning to end chronology of the events so that you have a start to finish time sequence, rather than a chart with twenty independent start to finish time sequences. This can be of great assistance not only to you but to the experts reviewing the case for you.

3.         Appropriate expert review.

a.         Generally in a case involving a birth injury to a baby, you will want to have the matter reviewed at least by an obstetrician/gynecologist (preferably with a sub-specialty in maternal/fetal medicine), a pediatrician (preferably with a sub-specialty in neonatology), a pediatric/neurologist, a labor and delivery nurse, and/or a newborn nursery nurse. It is helpful to bear in mind that the lawyer will generally have forensic skills that exceed the forensic skills of his medical experts. Accordingly, it is helpful to have teaching sessions with your experts so that they can teach you the principles involved. When you have become thoroughly conversant with the principles involved, you can better add your forensic skills to those principles for the benefit of your client.

PERTINENT PORTIONS OF MEDICAL RECORDS

I.                      PRE-NATAL RECORDS

                         Initial History

                         Subsequent pre-natal visits

II.                    MOTHER’S HOSPITAL CHART

Summary of labor and delivery

                         Labor records

                        Oxytocin record

                        Labor graph

                        Delivery summary

III.                   INFANT’S HOSPITAL CHART

                        Admission/nurses’ notes

                        Newborn hospital summary

                        Newborn record

                        APGAR score sheet

When you choose an ABPLA board certified attorney you can rest assured that you have one of the best malpractice lawyers in the country.