Did a 35-year-old female, 32 weeks pregnant with twins, with a history of laparoscopic adjustable gastric band (LAGB) procedure and two previous cesarean sections (C-sections), body mass index (BMI) of 45, diagnosed with pre-eclampsia with severe features and Hemolysis, Elevated Liver enzymes, and Low Platelet count (HELLP) syndrome, receive appropriate postoperative care following an emergent C-section, considering her subsequent development of sepsis, bowel perforation, and severe peritonitis?

From the Guidelines

The OB-GYN doctor's failure to promptly address the patient's bowel perforation despite clear clinical and radiological signs constitutes a significant deviation from the standard of care, as emphasized by the 2017 WSES guidelines for management of intra-abdominal infections 1. For this malpractice lawsuit, I recommend focusing discovery requests on three key areas: the physician's qualifications and experience with high-risk cases, the standard of care for recognizing and treating bowel perforation following C-section, and the decision-making process that led to delayed intervention. Some key points to consider in the discovery requests include:

• The patient's risk factors, including her history of lap band procedure, previous C-sections, and BMI of 45, which should have alerted the physician to the potential for complications 1
• The presence of free air on imaging, which is a clear indicator of bowel perforation, and the physician's failure to respond promptly to this finding 1
• The physician's knowledge of sepsis indicators, including fever, tachycardia, and tachypnea, and their failure to recognize these signs in the patient 1
• The decision-making process that led to delayed intervention, including any consultations that were sought and the rationale for not performing timely surgical exploration 1

Requests for Admission should establish undisputed facts about the timeline, the physician's awareness of symptoms, and deviations from standard care. These would include admissions regarding:

• The patient's symptoms, including severe abdominal pain, fever, and respiratory difficulty
• The physician's knowledge of the patient's symptoms and their failure to respond promptly
• The presence of free air on imaging and the physician's failure to perform timely surgical exploration
• The patient's risk factors and the physician's failure to take these into account when making treatment decisions

Requests for Production should seek all relevant medical records, including:

• Operative reports from the initial C-section and the subsequent emergency surgery
• Nursing notes and other documentation of the patient's symptoms and treatment
• Imaging studies, including CT scans, and their interpretations
• Hospital policies for surgical complications and the physician's adherence to these policies
• The physician's training records and any documentation of their experience with high-risk cases

Interrogatories should probe the physician's decision-making process, asking:

• Why surgical exploration was delayed despite progressive symptoms
• What differential diagnoses were considered and why bowel perforation was not suspected earlier
• What consultations were sought and what advice was given
• What specific training the physician had for managing surgical complications in high-risk obstetric patients
• How the physician's experience and qualifications prepared them to handle this complex case

The case appears strong for the plaintiff given the documented delay in addressing a surgical emergency despite multiple warning signs, including free air on imaging, rising lactic acid, fever, and severe pain inconsistent with normal post-C-section recovery, as highlighted by the 2022 OBA guidelines for operative management of acute abdomen after bariatric surgery in the emergency setting 1.

From the Research

Requests for Admission

• Admit that the patient's condition of pre-eclampsia with severe features and HELLP syndrome required immediate medical attention 2.
• Admit that the patient's history of lap band procedure and two previous C-sections increased the risk of complications during the emergent C-section.
• Admit that the OB-GYN doctor's decision to perform the emergent C-section with an assistant who was not a physician may have contributed to the complications that arose.
• Admit that the patient's symptoms of severe abdominal pain, tachypnea, and lactic acid 3.4 within 24 hours post-delivery were indicative of sepsis and bowel perforation.
• Admit that the CT scan showing pneumoperitoneum, dilated small bowel, and free air under the diaphragm confirmed the diagnosis of bowel perforation.
• Admit that the OB-GYN doctor's failure to take the patient back to the OR for exploratory laparotomy despite the diagnosis of bowel perforation was a deviation from the standard of care.
• Admit that the patient's condition deteriorated over the next 48 hours, requiring transfer to the ICU and eventually to another hospital for emergency surgery.
• Admit that the surgical findings of severe peritonitis, intestinal contents, and bile in the abdominal cavity, as well as the small bowel sutured to the rectus muscle, were a direct result of the delayed treatment.
• Admit that the patient's hospital stay was prolonged due to the complications that arose from the delayed treatment.
• Admit that the patient's medical expenses were increased due to the complications that arose from the delayed treatment.
• Admit that the patient's quality of life was negatively impacted due to the complications that arose from the delayed treatment.
• Admit that the OB-GYN doctor's actions, or lack thereof, were a breach of the standard of care owed to the patient.
• Admit that the patient is entitled to compensation for the damages suffered as a result of the OB-GYN doctor's negligence.
• Admit that the patient's condition required a more timely and aggressive treatment approach, such as exploratory laparotomy, to prevent further complications 3.
• Admit that the use of laparoscopy for small bowel procedures, such as adhesiolysis, can reduce 30-day complications and improve outcomes 4.
• Admit that the patient's case would have benefited from a more multidisciplinary approach to care, including consultation with other specialists.
• Admit that the OB-GYN doctor's decision-making process was flawed, leading to a delay in treatment and subsequent complications.
• Admit that the patient's medical records, including the CT scans and surgical reports, support the claim of negligence against the OB-GYN doctor.
• Admit that the patient's expert witnesses will testify that the OB-GYN doctor's actions were below the standard of care.
• Admit that the patient's damages, including medical expenses, lost wages, and pain and suffering, are a direct result of the OB-GYN doctor's negligence.
• Admit that the patient is seeking compensation for the full extent of her damages.
• Admit that the OB-GYN doctor's insurance carrier will be responsible for paying the patient's damages.
• Admit that the patient's case will be presented to a jury, who will determine the amount of damages to be awarded.
• Admit that the patient's attorney will seek to recover all costs associated with the litigation, including expert witness fees and court costs.
• Admit that the patient's case is not frivolous and has merit.
• Admit that the patient's complaint is not barred by the statute of limitations.
• Admit that the patient's claim is not subject to any affirmative defenses.

Requests for Production

• Produce all medical records related to the patient's care, including the emergent C-section, hospital stay, and subsequent surgeries.
• Produce all communication records between the OB-GYN doctor and the patient, including phone calls, emails, and letters.
• Produce all records related to the patient's diagnosis of pre-eclampsia with severe features and HELLP syndrome.
• Produce all records related to the patient's history of lap band procedure and two previous C-sections.
• Produce all records related to the patient's symptoms of severe abdominal pain, tachypnea, and lactic acid 3.4 within 24 hours post-delivery.
• Produce all CT scans and surgical reports related to the patient's diagnosis of bowel perforation.
• Produce all records related to the patient's transfer to the ICU and subsequent transfer to another hospital for emergency surgery.
• Produce all surgical reports and operative notes related to the patient's emergency surgery.
• Produce all records related to the patient's hospital stay, including medication administration records and vital sign records.
• Produce all records related to the patient's medical expenses, including bills and invoices.
• Produce all records related to the patient's lost wages and other economic damages.
• Produce all expert witness reports and depositions related to the patient's case.
• Produce all communication records between the OB-GYN doctor and other healthcare providers related to the patient's care.
• Produce all policies and procedures related to the OB-GYN doctor's practice, including those related to emergency C-sections and bowel perforation.
• Produce all records related to the OB-GYN doctor's training and education, including medical school transcripts and residency program records.
• Produce all records related to the OB-GYN doctor's licensure and board certification.
• Produce all malpractice insurance policies and records related to the OB-GYN doctor's practice.
• Produce all records related to any previous malpractice claims or lawsuits against the OB-GYN doctor.

Interrogatories

• What was the OB-GYN doctor's thought process behind deciding to perform the emergent C-section with an assistant who was not a physician?
• What were the patient's vital signs and medical status during the emergent C-section, and how did they change over the course of the procedure?
• What was the OB-GYN doctor's rationale for not taking the patient back to the OR for exploratory laparotomy despite the diagnosis of bowel perforation?
• How did the OB-GYN doctor communicate with the patient and her family regarding her condition and treatment options?
• What were the results of the patient's CT scans and surgical reports, and how did they relate to her diagnosis and treatment?
• What was the OB-GYN doctor's experience with emergency C-sections and bowel perforation cases prior to the patient's case?
• How did the OB-GYN doctor stay current with the latest medical research and guidelines related to obstetric care, including those related to pre-eclampsia with severe features and HELLP syndrome?
• What were the patient's options for treatment, and how did the OB-GYN doctor present them to her?
• How did the OB-GYN doctor document the patient's medical records, including the emergent C-section and subsequent hospital stay?
• What were the patient's medications and dosages during her hospital stay, and how did they relate to her condition and treatment?
• How did the OB-GYN doctor communicate with other healthcare providers related to the patient's care, including the ICU team and surgical team?
• What were the patient's discharge instructions and follow-up care plan, and how did the OB-GYN doctor ensure that she understood them?
• How did the OB-GYN doctor respond to the patient's complaints of severe abdominal pain and other symptoms, and what actions did she take to address them?
• What were the results of the patient's laboratory tests and other diagnostic studies, and how did they relate to her diagnosis and treatment?
• How did the OB-GYN doctor prioritize the patient's care and treatment, and what factors did she consider when making decisions about her care?
• What were the patient's economic damages, including lost wages and medical expenses, and how did they relate to her condition and treatment?
• How did the OB-GYN doctor ensure that the patient's medical records were accurate and complete, and what steps did she take to maintain their confidentiality?
• What were the OB-GYN doctor's policies and procedures related to patient communication and education, and how did she implement them in the patient's case?
• How did the OB-GYN doctor stay current with the latest medical research and guidelines related to patient safety and quality of care?
• What were the results of any quality improvement initiatives or peer review activities related to the OB-GYN doctor's practice, and how did they relate to the patient's case?