The patient was pregnant with her fourth child. She had carried three other pregnancies to full term, but each of them had been delivered by cesarean. She came to the emergency room believing she was in labor, but was reassured she was not. Six days later she came back in the morning to the same hospital’s emergency room believing she was in labor, and was again reassured. The same afternoon she came back to the emergency room, was examined this time and was again reassured she was not in labor.

   When the patient got home she began to experience vaginal bleeding. She phoned the women’s care center at another hospital and spoke with a nurse. The nurse, before giving any specific advice, spoke with her nursing supervisor. The nurse and her supervisor agreed it was not necessary for the patient to return to the emergency room. They told the patient to stay home and wait for the bleeding to stop.

   The patient phoned her physician and got the same advice. Later that day, however, the patient went to the emergency room anyway. It was found during cesarean delivery of her child that her uterus had ruptured along an old incision line from a previous cesarean. The child had already experienced serious brain damage from lack of oxygen.