Allegation:
The negligent diagnosis and management of a patient's labor resulted in a prolonged period of fetal distress and delayed delivery that subsequently led to irreversible injuries and damage to the child.
The Case:
The patient, a 19 YOF (5’5”, 250 lbs., primigravida), presented to the hospital at 5:21 p.m. for induction of labor. At 6:00 p.m. in the labor and delivery unit, the defendant ob-gyn assessed the patient and noted the cervix was not dilated and that membranes were not ruptured. The defendant ordered induction per Cytotec® protocol. The nursing assessment noted the patient was alert, oriented, and had no complaints. The fetus was noted to be a -2 station. Cytotec was administered at 6:44 p.m. The fetal heart rate was baseline at approximately 160. There were no accelerations or decelerations noted. The patient experienced one contraction of mild intensity about every 15 minutes, lasting about 54 seconds. Cervical dilation was 0-1 cm. At 9:40 p.m., Cytotec was administered again.
At 7:30 a.m. the following day, the defendant ob-gyn was at the bedside and ruptured the patient’s membranes. The cervix was 1-2 cm dilated and a spontaneous vaginal delivery was expected. At about 10:00 a.m., the strips showed an erratic heartbeat. The nurse documented a normal sounding heartbeat, so the erratic heartbeat was considered artifact. The defendant recalled receiving a call at 10:20 a.m. from the nurse to inform her the patient’s cervix was dilated 4.5 cm and was 90% effaced. The defendant ob-gyn told the nurse to reposition, give oxygen, and call if the pattern became non-reassuring.
At 11:05 a.m., accelerations and late decelerations were documented. Moderate variability between 6 and 25 BPM was documented. The nurse started Pitocin® at 11:13 a.m. without dose documentation. The nurse reported she turned off the Pitocin within 5-10 minutes because of continued late decelerations. However, the documentation reflects Pitocin was discontinued after delivery. The nurse stated she called the defendant ob-gyn at 11:40 a.m. to advise she needed to come to the hospital and review the strips showing late decelerations. This call was not documented in the record. The defendant physician disputes she was told about decelerations.
At 4:00 a.m. the following morning, the patient experienced contractions every two minutes, lasting 60 seconds. By 4:30 a.m., the patient’s contractions were every 1-2 minutes and the defendant ob-gyn was notified. At 6:00 a.m., the patient was having persistent late decelerations. She was administered 10L per minute of oxygen and repositioned on her left side. At 6:30 a.m., decelerations were intermittent late with moderate variability between 6 and 25 BPM. The defendant ob-gyn was not notified.
The defendant ob-gyn recalled receiving a call around 11:30 a.m. to inform her there was decreased variability, but stated she was not told anything about decelerations or problems with the fetus. The nurse testified she did not advise the defendant of minimal or absent variability but likely told her there was moderate variability. She did not believe the tracing suggested the need for immediate delivery. The defendant ob-gyn instructed the nurse to attempt to reduce the cervix and have the patient begin pushing.
Late decelerations were seen at 11:39 a.m., 11:47 a.m., 11:54 a.m., 11:57 a.m., and 12:03 p.m. The nurse called the defendant physician at 12:10 p.m. and reported the cervix was rimming at 9 cm dilation, 100% effaced, and was soft and stretchy. Fetal position was anterior at -1 station and the patient was ready to push. The nurse did not advise the defendant ob-gyn of the continued decelerations or poor variability seen on the strips. The patient started pushing at 12:15 p.m. At 1:15 p.m., the defendant ob-gyn was called and told the patient was ready to deliver. At 1:32 p.m., the ob-gyn delivered the infant.
The infant was unresponsive upon delivery. The Apgars were 0 at one and five minutes. The neonatal team was not present. A code was called, the infant was resuscitated and transferred to the nursery. At 4:00 p.m. the infant was transferred to a higher level of care and had no suck or gag reflex, a skull fracture, subdural hematoma, infarctions in the basal ganglia, and spinal cord damage. The infant was subsequently transferred to the hospital’s children’s rehabilitation services with diagnosis of severe cerebral palsy. Today, he is quadriplegic with severe and chronic developmental delays.
The plaintiff’s expert testified the defendant ob-gyn did not proactively seek vital information regarding the fetus’ condition. The expert further stated the ob-gyn should have performed more thorough reviews of fetal heart monitoring strips, and prevented the administration of Pitocin.
The defense expert stated he did not believe the defendant ob-gyn was properly informed regarding late decelerations. He further stated by the time the physician was called to deliver the baby, there was no way to reverse the effects of the severe fetal distress the infant underwent hours before.
The Verdict:
The initial case resulted in a hung jury of 9-3 in favor of the physician. As a result, case was retried the following year and resulted in a defense verdict.
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.