Delayed C-Section Alleged in Infant Death

Allegation

Failure to timely and properly perform a C-Section resulting in death of the infant.

Case Details

The patient, a 38 YOF 5’6”, 217 lb., G5P3AB2, presented to the defendant ob-gyn group early in pregnancy. The medical history included bipolar disorder, for which she was being treated, and a blood clot during her last pregnancy, for which she took anticoagulants. Her pregnancy was considered high risk due to a history of pulmonary embolism and advanced maternal age. She was offered a referral to a perinatologist, which she declined. The patient was prescribed enoxaparin and was scheduled for her first prenatal visit with an ob-gyn (OB1) in two weeks.

The patient had 20 office visits before her due date. She had a higher-than-average level of amniotic fluid in the early months of her pregnancy. The patient had good fetal movement throughout her pregnancy, and all her nonstress tests (NST) were reactive. Five weeks prior to delivery and due to the polyhydramnios, the NST frequency was increased to weekly.

The defendant OB (OB2) saw the patient three weeks prior to delivery and found the amniotic fluid index and NST normal. An ultrasound (US) noted cephalic presentation and Grade I placenta. The patient’s medication was changed from enoxaparin to heparin, and induction after 39 weeks was discussed. Although no order was written, the NSTs were discontinued. Subsequent prenatal visits noted positive fetal movement and no patient complaints.

Six days after a prenatal visit at approximately 3:30 a.m., the patient spoke with OB2. The patient reported a decrease in fetal movement since the previous day. OB2 twice advised the patient to proceed to the hospital for an NST, but the patient opted to wait for her appointment at the group later that day. OB2 instructed her to count fetal kicks and go to the hospital if a low kick count was recorded. At her 11:30 a.m. visit, she saw a third OB (OB3). She informed OB3 of decreased fetal movement over the past day. Examination revealed low amniotic fluid, a BPP 4/8, NST non-reactive and no fetal movement noted. The US revealed that the infant was in a transverse position with the back downwards. OB3 instructed the patient to immediately go to the hospital’s labor and delivery department for a C-section. Instead, the patient went home first and was not admitted until 12:45 p.m. when OB2 saw her. After reviewing the fetal monitoring strips, OB2 determined no immediate need for a C-section, but at 2:00 p.m., nursing notes indicated that preparations were made for a C-section.

The patient was taken to the OR at 3:04 p.m., with first incision at 3:11 p.m. A transverse incision was made into the uterus, but when attempts to manipulate the infant were unsuccessful, the doctor made a vertical incision to facilitate delivery. There was a significant amount of bleeding, which the physician believed was due to cutting through the mother’s myometrium rather than from the infant or any other source. A female infant was born at 3:17 p.m. with a birth weight of 6 lbs. 13 oz. Apgar scores were 5, 7, and 5 at one, five, and ten minutes, respectively. The infant exhibited symptoms of apnea, pallor, and limpness.

Positive pressure ventilation was administered, but the infant was subsequently transferred to the Neonatal Intensive Care Unit (NICU) with a provisional diagnosis of respiratory failure, cardiac failure, hypoperfusion, hypotension, hypoxia, metabolic acidosis, anemia at birth, and thrombocytopenia. Approximately 8 hours later, life support was withdrawn, and the infant expired. No autopsy was performed, but placental pathology revealed thrombotic vasculopathy, indicating issues with blood clotting in the placenta.

Expert Testimony

All three plaintiff experts criticized OB1 for failing to conduct an NST two weeks before delivery, despite a history of previous non-stress tests being performed. They stated that the non-stress test should have been conducted regularly until delivery due to the high-risk nature of the pregnancy. Further, they all criticized OB2 for not insisting that the patient go immediately to the hospital during the early morning phone call given the reported decrease in fetal movement. All three experts also criticized the timeliness of the C-section and surgical approach made by OB2.

All but one of the defense experts supported the care provided by the three OBs and submitted an affidavit affirming the meritorious defense, indicating the defensibility of the case. While the plaintiffs’ expert argued for an earlier performance of the C-section, the defense experts observed no apparent deterioration in the infant’s condition despite the urgency. The fetal monitoring strips did not show any concerning patterns. They further asserted that the delay following the early morning phone call was reasonable, considering the clinical picture of the case and the tests conducted. Additionally, the expert emphasized that the decision not to perform a non-stress test met the standard of care, as the risk factors primarily pertained to the mother, including her prior pulmonary embolism and advanced age.

Finally, several defense experts believed that the infant had experienced an in-utero fetal maternal hemorrhage, most likely occurring approximately 2 to 3 days before the baby’s delivery. As a result, the baby experienced flaccidity and anemia.

Resolution

The combination of proper communication, thorough documentation, appropriate clinical decision-making, and supportive expert testimony resulted in a defense verdict in the case, despite the tragic outcome.

Risk Reduction Strategies

From a risk management standpoint, emphasizing documentation, continuity of care, and timely follow-up can improve claim defensibility. This is especially true with patients who present with recognized risk factors. When faced with a high-risk course, consider incorporating the following into your plan:

• Close monitoring and follow-up
• Consultation with a maternal-fetal medicine specialist and other medical specialists, if indicated
• Order frequent ultrasounds and closely monitor fetal evaluation
• Encourage home blood pressure monitoring
• Carefully monitor medications used to manage preexisting conditions
• Consider late-term labor induction or a C-section.

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