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Exploring Transparency Through Apology and Disclosure

Exploring Transparency Through Apology and Disclosure

John O’Grady, MD: We began discussing issues of apology and regret in our last conversation. Let’s say I've just been involved in an unfortunate case involving a major fetal complication, namely a shoulder dystocia and there are problems with how the case was managed. The patient was an obese para 2, having previously delivered 2 infants (8 lbs and 8 lbs 5 oz) following rapid labor on each occasion. Each infant was born without complication or need for anesthesia and with only minor vaginal tears.  For her present pregnancy her antepartum course was medically unremarkable although throughout her prenatal care, she was a poor historian and difficult to examine. She was a frequent no-show and resistant to recommendations. I felt I never had much rapport with her in the office.  Her lab work throughout was normal and a GTT was interpreted as normal. The fetal weight estimate at 38 weeks was < 3500 grams. 

Following the commencement of labor, she went to the hospital directly without calling my service. After her arrival at the hospital, there was a delay in calling me. Unfortunately, she experienced a precipitous delivery. I was contacted only after the infant’s head presented. Fortunately, I was on the unit evaluating another patient. When I arrived, the nurse reported rapid cranial delivery followed by retraction. Mom was out of control, in knee-chest with the head protruding. The scene was a bit chaotic. I have to admit that I froze and then did a number of things inconsistent with my practice and how I was trained. Eventually we delivered a 3950 gram boy with Erb Duchenne-type palsy. His dysfunction has not improved since the delivery about 24 hours ago. There was also a postpartum hemorrhage due to uterine atony, requiring interventions of fluid, uterotonics and finally, the transfusion of 2 units.

Now, what should I do? The family is not happy.  I feel terrible about this case. I know that care was delayed and that nursing did not do a good job performing their intrapartum care or assisting me in this difficult delivery.  I also know that I did not conform to my own standards in effectuating delivery. Given that the patient was unpleasant in the few interactions I had with her prior to delivery, the current events have certainly likely made things worse. I am concerned about the possibility of being sued and worry that anything I say to the family will only make things worse. I am also worried that if I apologize or try to explain the events that led to her baby’s injuries, anything I disclose will be used against me should litigation be initiated.  How would you counsel me? 

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