Ref. # 92987
A Michigan woman experienced arrest of descent during the first stage of labor. After two hours of full dilation and pushing, an attempted vacuum extraction by the family practice osteopath failed. Cephalic molding was noted and the head descended to a +1 to +2 station. The OB attempted a forceps delivery and failed. A cesarean was performed using a low transverse incision. Upon opening the mother's abdomen the OB noted distortion of the anatomy and considerable edema. There was difficulty identifying the vesicouterine flap, even while using "L" forcep assistance. The incision was made high to avoid the bladder. After successful delivery, the infant was noted to have a rather large cephalhematoma secondary to extremely long pushing. After delivery of the placenta an exam showed the bladder had been unroofed. There was also an extension down the posterior in the midline of the bladder to the trigone. With surgical assistance the OB repaired the bladder and vaginal lacerations. During closing, urine was noted from the left ureter with probable passage to the right. Eight days later a cystourethroscopy showed urine coming from the area of the right ureter. A balloon occlusion catheter was inserted into the right kidney pelvis with some difficulty. Subsequently a nephrostomy tube was inserted, followed by an exploratory laparotomy and open cholecystectomy. The postnatal course was rocky, including hypertension and vesicouterine fistula. Home health care was required as well as additional surgeries. A medQuest osteopathic OB/GYN opined the repair of the lacerations of the bladder and vagina, while difficult, should have been surmountable. It was negligent to conclude the operative procedure with a known hole in the bladder and questionable patency of the ureters. Ureteric stents should have been inserted and the bladder properly repaired. Following this, closure of the anterior vagina would have been easy, as the stents would have identified the lateral edges of the repair. With proper repair of the pelvis, the woman would have avoided repeat procedures and diminished bladder capacity.