Allegation:
Plaintiffs Allege Ob-Gyn Physician Failed to Appropriately Manage and Treat the Patient's Labor.
The Case:
The patient, a 28 YOF (5’1”, 158 lbs., G2P0) with medical history of Group B strep, presented to the hospital at 08:44 with spontaneous rupture of membranes. Around 09:50, the defendant ob-gyn’s exam revealed 2 cm dilation, 70% effacement, and -3 station. Fetal heart rate monitoring was reactive with baseline of 145 beats per minute. At 10:12, the patient received penicillin 5 mg.
The defendant ob-gyn left the hospital at 11:00. At 12:39, the nurse notified the defendant ob-gyn that the patient was shivering but afebrile; fetal strips revealed tachycardia with a heart rate of 170 with decreased variability. The defendant ob-gyn ordered Ancef® 1 gm IV which was given at 12:44. At 12:53, Pitocin® 1 mU was started per low dose Pitocin induction orders. At 13:27, the patient was febrile.
The defendant ob-gyn was notified; at that point, the defendant ordered Tylenol® 975 mg and requested to be kept updated. At 14:08, Pitocin dose was 2 mU. At 14:30, fetal monitoring revealed adequate variability and reactivity with fetal heart rate of 160. At 15:23, nurse examination revealed 3 cm dilation, 70% effacement, and -2 station. Pitocin was stopped at 15:40. At 15:50, fetal monitoring revealed subtle early decelerations. At 16:08, the fetal heart rate was 110 lasting 45 seconds with good recovery.
The patient received an epidural over the next 20 minutes and was off the monitor during that time. At 16:36, after being placed back on the monitor, the fetal heart rate was 90, dropping into the 50s. The patient received ephedrine and Neo-Synephrine® IV. The defendant ob-gyn was notified and arrived at the hospital at 16:55.
At 17:02, a male infant weighing 7.3 lbs. was delivered via emergency C-section. Apgars were 0, 0, and 2. The infant had no tone, poor color, and was intubated at 1 minute 30 seconds of age. The infant was transferred to a children’s hospital with a diagnosis of acute renal injury, oliguria, suspected sepsis, perinatal hypoxia-ischemic encephalopathy (HIE), and respiratory distress.
Head cooling was performed at the children’s hospital. An MRI of the brain at 5 days of age revealed diffuse supratentorial and midbrain restricted diffusion, and elevated lactate consistent with ischemia. Placental pathology indicated a 3-vessel cord with acute funisitis, and moderate acute chorioamnionitis of the fetal membrane. Microbiology of the placenta showed Group B strep of the maternal and fetal slides.
The infant died at 11 days of age. The autopsy revealed severe diffuse alveolar damage (acute respiratory distress syndrome), and severe HIE with diffuse acute anoxic-ischemic alterations involving the cortex, basal ganglia, hippocampi, and dentate nuclei of cerebellum. The autopsy further noted the maternal chorioamnionitis was the initiator of the series of events that led to the infant’s demise.
A lawsuit was filed alleging that the ob-gyn failed to appropriately manage and treat the patient’s labor and failed to timely perform a C-section, resulting in the infant’s death.
Plaintiff’s expert witnesses testified the defendant ob-gyn should have been suspicious of chorioamnionitis at 12:39 when the nurse reported the patient was shivering and ordered penicillin. One witness testified the infections alone did not cause the neurologic damage but that the damage was exacerbated by hypoxia. Other witnesses testified the hypoxic injury occurred during the 30 minutes the patient was off the monitor for the epidural. Additionally, witnesses stated the infant became septic at or near the time of the epidural, and would have survived the Group B strep infection had he not suffered a hypoxic injury.
Multiple defense expert witnesses included professionals in ob-gyn, maternal-fetal medicine, anatomic pathology, pediatric neurology, and pediatric neuroradiology. The expert witnesses testified the injuries were caused by Group B sepsis and fetal inflammatory response syndrome in spite of receiving appropriate in utero antibiotics. The experts agreed the nurses contacted the defendant ob-gyn at appropriate times when the patient’s condition changed.
Additionally, the experts testified the fetus was infected at least two days before the birth and became septic around 6-12 hours before birth. All experts testified there was no indication for delivery until the fetal bradycardia developed around 16:58, at which time the infant was promptly delivered. The presence of necrotizing funisitis indicates the infection was present long enough or aggressive enough to penetrate below the placental membrane. There was also evidence of hemorrhagic endovasculitis (HEV), and few infants with HEV are born alive. None of the experts believed an earlier delivery would have made any difference in the outcome. The jury returned a verdict in favor of the defense.
Verdict:
Despite a bad outcome, the proper communication and documentation in the medical record supported the defendant ob-gyn.
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.
