Peer Review Monthly: The case of the delayed C-section-Individual vs. system issues in peer review

From time to time, this column will present real peer review cases that have been modified to assure they are not identifiable. This week’s case deals with a serious event in obstetrics care and the systems that provide support.

Reason for admission/services:
The patient is a 25-year-old primipara who presented to the hospital at 38 weeks with early contractions. She was admitted for induction of labor due to a non-reassuring non-stress test. On admission to the labor and delivery department, relatively normal fetal heart rates tracings were noted with some variable deceleration.

Two and half hours after admission, the patient experienced more variable decelerations that were still felt to be within a reasonable range. At that time, the anesthesia department was not aware of the case. Three hours after admission, the patient experienced profound fetal bradycardia and the obstetrician made the decision to immediately proceed with a C-section. When the labor and delivery department tried to contact the anesthesia department, the obstetrician learned that no in-house anesthesia provider was immediately available (one provider was doing an emergency case and the second had just begun an elective case). A third anesthesiologist was contacted and arrived at the hospital in 25 minutes. The obstetrician started the C-section 35 minutes after making the decision. The newborn was delivered without vital signs and could not be resuscitated. The mother had a normal physical recovery.

The case was referred to the peer review committee to address the following question: Did the timeliness of the C-section meet the standard of care? This question really has three components:

• The standard itself
• The roles of the physicians and nursing staff involved
• The systems required to assure those individuals can meet their responsibilities

This is the type of case that is ideal to discuss at a multi-specialty peer review committee meeting because it involves providers from different specialties and raises questions beyond the technical issues of the case.

The C-section standard of care itself is very clear. The American College of Obstetricians and Gynecologists’ guideline indicates that for an emergency C-section, the baby should be delivered no longer than 30 minutes after the decision is made. The 30 minutes is not an average to be strived for but an absolute outer limit. Also, the clock stops when the baby is delivered, not when the anesthesiologist arrives in the labor and delivery. It was clear in this case that the delivery did not meet that standard.

Three questions are typically posed in these cases: 

• Could the decision have been made sooner?
• Could the anesthesia provider have arrived sooner?
• Could alternative delivery methods to C-section have been used? (This is an important question to ask but will not be fully answered in this column.)

Regarding the first question, the obstetrician (OB) reviewer confirmed that the patient’s pattern prior to the sudden change did not meet the criteria for an emergency C-Section. An important principle of peer review is to not use the outcome, no matter how disastrous, to influence the retrospective review of the information the providers have at the time they make clinical decisions.

Regarding the second question, the OB reviewer questioned whether the OB communicated with the anesthesia department that there may be a potential need. The reviewer also asked the anesthesia representative on the committee whether the anesthesia department typically checks with the OB department regarding potential need before beginning an elective case. Following letters of inquiry to the OB provider, the labor and delivery staff and the anesthesiologists, the committee determined that the anesthesia department was not called earlier to let them know that the obstetrician had induced labor, and the anesthesia department did not check in with OB prior to starting the elective case, which prevented immediate availability. A review of the policies for the labor and delivery and anesthesia departments indicated no clear language regarding individual obligations for communicating potential needs.

The peer review committee decided that a best practice would be for both the OB and anesthesia departments to communicate with each other early on in a case, but since the current policies were not clear for either provider, it could not hold the individuals accountable in this instance. The committee recommended both departments modify their policies to enhance proactive communication.

This is an example of how a peer review committee needs to take in account both providers’ competency and the systems in which they deliver care. The goal of effective peer review is to improve patient care, not just to decide if the practitioner’s care was appropriate.

How do you think your peer review committee would have handled this case?  

Robert Marder, MD, CMSL is the vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.