Bad Outcome or Negligence? Evaluating OB Malpractice Cases Without Hindsight Bias

By Maliha Sayla, MD (Guest Blog)

Everything looked routine – until it wasn’t.

A patient presents in active labor with slow but steady progress.  The room hums with anticipation as she begins to push and the baby crowns. Then, the head delivers, but the shoulders do not. The call rings out: “Shoulder dystocia.” Within seconds, the delivery room transforms into what looks like organized chaos—nurses moving into position, legs lifted, the obstetrician calling for maneuvers. Moments later, the baby is born limp, not crying, and one arm still.

In the aftermath, families and attorneys understandably ask: What went wrong? Why didn’t they do something to prevent it? Who is to blame?

For experts reviewing such cases, one cognitive trap looms large: hindsight bias—the tendency to believe, after an event has occurred, that the outcome was predictable all along. In medicine, this bias can distort fair review by conflating a bad outcome with bad care. The legal question, however, is not whether harm occurred, but whether the care provided was within the applicable standard of care based on contemporaneous information.

Let’s explore two common obstetric scenarios often at the heart of malpractice claims through this lens.

1. Shoulder Dystocia: An Unpredictable Emergency

Shoulder dystocia is one of the most feared events in labor and delivery. It occurs when the fetal head delivers, but the shoulders become impacted behind the maternal pubic bone. When this emergency arises, clinicians have mere minutes to resolve it using a series of evidence-based maneuvers. The neonate is at risk for brachial plexus or hypoxic-ischemic injury.

While risk factors such as prior shoulder dystocia, fetal macrosomia (large fetal size), gestational diabetes, or prolonged second stage of labor may increase risk, most cases occur without warning. The only reliable way to prevent a shoulder dystocia is elective cesarean delivery, which is neither practical nor evidence-based for all at-risk patients.

Contemporaneous information (what was known then)
Were risk factors documented and discussed? Was there an estimated fetal weight and appropriate counseling regarding management options? Was the labor course normal? If not, was there clear documentation of sound reasoning to continue labor rather than perform a cesarean delivery? If these steps were performed and the patient managed within the applicable standard of care, then risk mitigation was reasonable.

Recognition & team communication (time-stamped)
Was the dystocia recognized promptly and declared clearly to the team? Shoulder dystocia is typically identified by the presence of a “turtle sign” after delivery of the fetal head, or when the anterior shoulder does not easily deliver with gentle downward traction. Once recognized, a structured team-based response must be initiated immediately to facilitate rapid and safe delivery.

Interventions & sequence (documented response)
Evidence-based maneuvers include McRoberts positioning, suprapubic pressure, delivery of posterior arm, and rotational techniques. These maneuvers must be applied rapidly and sequentially. There is no single “correct” maneuver or required sequence, and even when expertly performed, neonatal injury may still occur. Appropriate documentation of timing, team activation, interventions, and the head-to-body delivery interval is necessary.

Key takeaway:
The presence of shoulder dystocia and subsequent neonatal injury does not imply negligence. The medicolegal question is: Did the clinician recognize, communicate, and respond in a timely and appropriate manner consistent with the standard of care?

It is tempting, in retrospect, to look back at a shoulder dystocia case with a 9.5-pound baby and a prolonged labor and conclude that it “should have been predicted.” But prediction and prevention are not the same as negligence. A fair review demands we evaluate the case through the lens of contemporaneous information, recognition of the emergency, and the appropriateness of the swift interventions undertaken in the moment.

2. Hypoxic-Ischemic Encephalopathy (HIE) and the Category II Fetal Heart Tracing: The Gray Zone

Hypoxic-ischemic encephalopathy (HIE) is a form of neonatal brain injury caused by inadequate oxygen or blood flow to the baby’s brain around the time of birth.  One of the main tools clinicians use to assess fetal well-being during labor is electronic fetal heart rate monitoring (EFM), which is interpreted using a three-tier system.

• Category I: Normal/reassuring
• Category II: Indeterminate (most labors)
• Category III: Abnormal/requiring prompt intervention

HIE most often arises in the setting of Category II tracings—neither clearly normal nor abnormal—requiring continuous judgment rather than algorithmic decisions. These are the gray zones of obstetrics, where decision-making lives in nuance rather than certainty.

Contemporaneous information

What prenatal risk factors may affect a fetus’s ability to tolerate labor? How has the labor progressed? How has the fetus responded to interventions up to this point?

Recognition and communication

Was the tracing accurately interpreted and discussed with the care team in real time? Did documentation reflect ongoing assessment of variability, decelerations, and the overall clinical picture?

Interventions and sequence

Were appropriate intrauterine resuscitative measures—maternal repositioning, IV fluids, oxygen, reducing or discontinuing oxytocin—applied, and was the fetal response documented? The decision to continue labor or proceed to operative delivery depends on the pattern’s evolution, not on hindsight. Multiple reasonable approaches may exist.

Key takeaway:
Most HIE cases occur in the setting of Category II tracings, but most Category II tracings do not lead to HIE. The critical question is not whether an earlier delivery might have changed the outcome, but whether the clinician’s interpretation and management were reasonable based on contemporaneous information available at the time.

“In obstetrics, perfection isn’t the standard—reasonableness under the circumstances is.”

Medicine in Real Time vs. Medicine in Hindsight

In case review, hindsight bias is the gravitational force pulling every observer toward certainty that was never available in real time. A decision that seems “obvious” now may have been uncertain, ambiguous, or rapidly evolving in the moment.

Obstetricians make high-stakes decisions in dynamic, time-sensitive environments. The standard of care is not perfection; it is reasonableness under the circumstances. Attorneys and experts share the same goal: identifying when care truly fell below this standard and caused harm.

When evaluating an obstetric case, ask:

• What was the contemporaneous information?
• Was there appropriate recognition and communication of that information?
• Were appropriate sequences of interventions applied based on those observations?

If the answer is yes to all these questions, then the bad outcome—however devastating—was a complication, not malpractice.

The goal of expert review is not to rewrite history, but to understand it as it unfolded in real time, through human hands, guided by judgment, not hindsight.

About the Author

Maliha Sayla, MD is an OB/GYN hospitalist at Northwestern Medicine/Delnor Hospital with 10+ years of experience in both hospital and outpatient settings. She specializes in high-risk obstetrics and complex emergencies—including obstetric hemorrhage, ruptured ectopic pregnancy, and dilation & evacuation—and teaches Family Medicine residents at Northwestern University Feinberg School of Medicine. Dr. Sayla is known for translating complex clinical issues into clear, actionable insights for medical and legal audiences.

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect those of High Rock Experts®. This content is for educational and informational purposes only and does not constitute medical or legal advice.