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.
