A postpartum patient calls with a severe headache.
Her blood pressure is elevated, but not yet catastrophic. She has not slept. She had an epidural. She is exhausted.
“It’s probably the epidural.”
Another patient is short of breath.
“She just delivered.”
Another has persistent tachycardia.
“She is anxious.”
Another says repeatedly that something is wrong.
“Everything looks reassuring.”
Most of the time, benign explanations really are benign.
The malpractice problem begins when reassurance becomes a substitute for reassessment.
Normal Pregnancy Creates an Abnormal Diagnostic Environment
Obstetrics is unusual because pregnancy itself changes physiology.
Heart rate rises.
Blood volume increases.
Hemoglobin falls.
Edema is common.
Dyspnea can occur.
Headaches are frequent.
Pain, fatigue, nausea, contractions, bleeding, and dizziness may all be part of otherwise uncomplicated pregnancy, labor, or postpartum recovery.
That makes obstetrics particularly vulnerable to normalization.
A symptom that would trigger concern in a nonpregnant patient can easily be attributed to pregnancy.
Sometimes appropriately.
Sometimes disastrously.
Maternal death reviews helped expose this problem years ago. The National Partnership for Maternal Safety developed maternal early warning criteria after case reviews showed repeated delays in recognizing hemorrhage, hypertensive crisis, sepsis, venous thromboembolism, and heart failure. [1]
The problem was not always that nobody measured the vital signs.
Often, the abnormal information was already there.
It had simply not produced the right response.
The Patient Who “Looks Fine”
Imagine a postpartum woman whose heart rate is 124.
She is pale but talking comfortably.
Her blood pressure remains normal.
Her vaginal bleeding does not look dramatic.
It is easy to be reassured.
Now suppose her heart rate is 130 an hour later.
Her abdomen hurts more.
Her hemoglobin begins to fall.
At what point does “probably normal postpartum physiology” become “possible concealed hemorrhage”?
That transition is one of the hardest tasks in clinical medicine.
There is rarely a bell that rings.
Instead, information accumulates.
The malpractice risk is not that clinicians fail to predict the future.
It is that they continue using yesterday’s explanation after today’s facts no longer fit it.
Reassurance Must Have an Expiration Date
This is an important clinical principle.
Every reassuring diagnosis should have an expiration date.
“The headache is probably related to the epidural” may be reasonable at one moment.
But what if the headache changes?
What if the blood pressure rises?
What if visual symptoms develop?
What if neurologic findings appear?
The original explanation must then be reopened.
Good clinical reasoning is not merely choosing the most likely diagnosis.
It is recognizing when the evidence no longer supports it.
Diagnostic Error Is Often Not a Knowledge Failure
We tend to imagine diagnostic malpractice as ignorance.
The physician did not know the diagnosis.
But many diagnostic failures are more subtle.
The correct diagnosis may actually have been considered.
The problem may have been that it was considered and then dismissed too early.
Or the abnormal finding was attributed to something less dangerous.
Or several different clinicians each saw one piece of the puzzle, while nobody assembled the whole picture.
AHRQ has specifically examined diagnostic error as a contributor to severe maternal morbidity and mortality, including failures involving recognition, communication, escalation, and timely treatment. [2]
This distinction matters.
More medical knowledge alone will not solve a failure of clinical attention.
“Common” Does Not Mean “Safe”
There is another trap.
If something is common, clinicians naturally become less alarmed by it.
But frequency and danger are different questions.
Headache is common postpartum.
Preeclampsia is dangerous.
Tachycardia is common during labor.
Hemorrhage and sepsis are dangerous.
Shortness of breath may occur during normal pregnancy.
Pulmonary embolism and cardiomyopathy can kill.
The clinician’s job is not to assume that every symptom represents catastrophe.
That would create overtreatment, unnecessary testing, anxiety, cost, and harm.
The obligation is different:
Do not use the frequency of a benign explanation to erase evidence of a dangerous one.
Early Warning Systems Were Designed for Exactly This Problem
Maternal early warning systems attempt to make deterioration harder to normalize.
Instead of relying entirely on whether someone “looks sick,” certain physiologic abnormalities trigger evaluation.
That is valuable because humans adapt.
The nurse has been watching the patient’s heart rate rise slowly for four hours.
The physician has heard about several elevated pressures.
Everyone becomes accustomed to the abnormality.
A trigger system interrupts that adaptation.
But early warning systems are not magical. Studies show that their sensitivity varies depending on the condition being detected. [3]
The purpose is not to replace clinical judgment.
It is to force clinical judgment to occur.
That is a very different function.
Listen to the Patient
There is also a human source of early warning that cannot be captured completely in a flowsheet.
The patient.
“I don’t feel right.”
“This headache is different.”
“I can’t breathe lying down.”
“I have never felt pain like this.”
“My heart is racing.”
“I think something is wrong.”
These statements are not diagnoses.
But neither are they noise.
The CDC’s maternal safety work specifically emphasizes listening to pregnant and postpartum patients and acting on urgent maternal warning signs. More than 80% of pregnancy-related deaths reviewed through recent maternal mortality review processes were considered preventable, meaning there was at least some chance of avoiding the death through reasonable changes at one or more levels. [4]
That does not mean 80% involved malpractice.
Preventability and negligence are not synonymous.
That distinction is essential.
But it tells us that opportunities for earlier recognition and intervention are real.
The Medicolegal Problem With “Reassuring”
Medical records frequently contain phrases such as:
“Patient reassured.”
“Exam reassuring.”
“Symptoms likely physiologic.”
There is nothing wrong with those conclusions when clinically justified.
The danger comes when the chart does not show what made the situation reassuring.
What was considered?
What dangerous diagnoses were reasonably excluded?
What findings would require reevaluation?
What return precautions were given?
When will the patient be reassessed?
Reassurance should be the conclusion of reasoning, not a replacement for reasoning.
Preventive Ethics Means Planning for Deterioration
Preventive ethics asks clinicians to anticipate foreseeable problems before they become emergencies.
In this context, that means giving patients clear instructions during pregnancy and before discharge:
Which headaches require attention?
How much bleeding is too much?
When is shortness of breath abnormal?
Which blood pressures require action?
When should a patient call the office, go to triage, or call emergency services?
The best time to teach these warning signs is not while the patient is frightened at 2 AM.
It is before she needs them.
The MedMal Room Question
Bad outcomes do not prove that earlier reassurance was negligent.
Medicine requires judgment under uncertainty.
But every reassuring diagnosis creates a responsibility:
What evidence would make me change my mind?
If there is no answer to that question, reassurance has become something more dangerous.
It has become closure.
And in obstetrics, closure can occur long before the disease is finished evolving.
References
Mhyre JM, D’Oria R, Hameed AB, et al. The maternal early warning criteria: a proposal from the National Partnership for Maternal Safety. Obstet Gynecol. 2014;124(4):782-786. doi:10.1097/AOG.0000000000000480.
Agency for Healthcare Research and Quality. The contribution of diagnostic error to maternal mortality and severe maternal morbidity. Rockville, MD: AHRQ; 2021.
Hannola K, Hoppu S, Mennander S, et al. Obstetric early warning system to predict maternal morbidity of pre-eclampsia, postpartum hemorrhage and infection after birth in high-risk women: a prospective cohort study. Midwifery. 2021;99:103015. doi:10.1016/j.midw.2021.103015.
Centers for Disease Control and Prevention. Preventing Pregnancy-Related Deaths. Atlanta, GA: CDC; 2024.