Allegation:
Failure to properly interpret FHM strips, an attempted and abandoned forceps delivery that resulted in a skull fracture and subgaleal hemorrhage, and the failure to recognize the need and timely perform an emergency C-section resulted in fetal demise.
The Case:
The patient, a 24 YOF (5’2”, 138 lbs., G1P0), presented to the hospital in labor at 08:00. Upon admission, she was dilated at 3, 80% effaced, and at -2 station. The defendant ob-gyn initially saw the patient around 08:20. At 08:46, anesthesia inserted an epidural. At 09:30, the FHR was baseline 130 with moderate variability, accelerations, and periodic late and variable decels associated with contractions every 2-3 minutes. At 10:00, contractions were every 1-2 minutes. The defendant ob-gyn documented the NST was Category 1 with regular contractions. The infant’s weight was estimated at 6-7 lbs.
From 11:00 to 12:30, the FHM consistently showed baseline rates varying from 135-150 with moderate variability and periodic late and variable decels with contractions. At 12:30, the defendant ob-gyn was at bedside and performed a vaginal exam that revealed the patient was 7 cm dilated, 100% effaced, and at +1 station. The patient was started on oxygen.
At 16:00, the FHM showed a baseline of 140 with moderate variability and 15x15 accelerations. The defendant ob-gyn was at beside and performed a vaginal exam; the patient was dilated to 9 cm. At 17:00, the nurse checked the patient; she was 9 cm dilated, 100% effaced, and at +1 station. The defendant ob-gyn documented the NST was Category 1. At 18:00, the FHM was unchanged and the nurse called the physician. At 18:10, the defendant ob-gyn was at the bedside when the patient started pushing. By 18:23, the patient was complete. The FHR was 150-155, with marked variability, no accelerations, and periodic variable decels with contractions. The patient was pushing with the assistance of the defendant ob-gyn and nurse. At 18:40, the FHR was 170.
Around 19:00, the defendant ob-gyn felt the patient’s pushing was inadequate due to the epidural masking the contractions, so the epidural was turned off. The FHR was varying between 135-160 with minimal variability, no accelerations, and periodic variable decels. As the decels were associated with contractions and becoming longer, the defendant ob-gyn suspected a nuchal cord and discussed with the family a forceps delivery with possible C-section.
At 20:03, a forceps delivery was attempted and abandoned. Staff did not bring the defendant ob-gyn the type of forceps she typically used, so she went to the OR and found the Luikart-Simpson forceps she was more accustomed to using. Once she returned, she requested neonatology be notified of the delivery plan. The defendant ob-gyn was able to place the left forceps easily, but could not guide the right blade. At 20:07, she called for a C-section and again requested neonatology be contacted.
The defendant ob-gyn accompanied the patient to the OR, and requested neonatology be contacted for the third time. Once the uterus was incised, thick meconium was noted. The defendant ob-gyn was able to cup the baby’s head and lift it out of the pelvis; however, she could not get the baby out. She made a vertical scissors incision to extend the uterine incision. At 20:07, she was able to deliver the infant who was floppy, blue, and unconscious. The baby was transferred to the warmer and resuscitative efforts were started. Apgar’s were 0/0/0.
The neonatologist arrived approximately 28 minutes after delivery. The infant was intubated but resuscitation was difficult due to the thick meconium below the cords. The infant was diagnosed with bacterial sepsis, hypotension, hypoglycemia, cephalohematoma, subgaleal hemorrhage, metabolic acidosis, and HIE. Around 03:00 the following morning, the infant was transferred to a different hospital with additional diagnoses of acute kidney injury and DIC. Around 05:39, the family was called and told the infant had coded. He died later that day. Cause of death was perinatal complication of instrumentation (forceps) during delivery.
The plaintiff expert testified the FHR tracings reflected a concerning pattern beginning around 13:13. He further testified the defendant ob-gyn was grossly negligent in deviating from the standard of care by failing to timely perform a C-section when the FHR tracings clearly indicated fetal distress. A peer review concluded the same.
The defense expert stated the fetal heart tracings could have been interpreted as Category 2 or 3 around 13:00, and believed a credible argument could be made that the patient should have been taken for a C-section earlier. Additionally, the medical record documentation reflected the defendant ob-gyn’s difficulty freeing the baby from the pelvis, and refusal of assistance when the nurses offered to help.
Verdict:
The case was settled.
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