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The patient presented to the hospital following the premature rupture of her membranes. She was 35 weeks and 6 days pregnant with twins. The plan was to perform a repeat cesarean section and bilateral tubal ligation. The procedure began at 12:43 p.m. and lasted just over an hour, resulting in the successful delivery of healthy babies.

After the delivery, the OB/GYN left the hospital, presumably to attend to other patients.

Initially following the delivery, the mother appeared to be stable and doing well; however, beginning around 4:00 p.m., she began exhibiting signs of hypovolemic shock (i.e., hypotension, tachycardia, and hypoxia), which did not resolve despite appropriate treatment and intervention by the nursing and hospital staff. The patient continued exhibiting clear signs and symptoms of hypovolemic shock and intraabdominal bleeding that should have precipitated her transfer to the operating room for emergency surgery, yet no such action was taken. Instead, attending OB/GYN remained off-site until ten minutes before 6:00 p.m. Even once he arrived, he continued to delay the emergency surgical intervention until after 8:00 p.m. Unfortunately, by 8:25 p.m. the patient became unresponsive, so chest compressions were started, and she was intubated due to cardiac arrest but never achieved return of spontaneous circulation. CPR was then stopped at 9:10 p.m., and this new mother was pronounced dead. The autopsy report revealed hemoperitoneum (approximately 1500 cc’s of blood and blood clot) due to suture dehiscence and listed the primary cause of death as exsanguination.

This was a straightforward case. The most likely explanation for the symptoms displayed by the patient was bleeding relating to the surgery she had just had, the cesarean section. This should have been readily apparent to the OB/GYN. His failure to move aggressively to take his patient back to surgery was inexplicable. His patient was exhibiting clear signs of intraabdominal bleeding for over four hours, yet he failed to respond.


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