Case Study: Multiple Failures in Care Result in a Neurologically Impaired Infant

Labor and Delivery

A 30-year-old female, gravida 4, para 3, was admitted for induction of labor at 42 weeks gestation. The pregnancy was essentially unremarkable. Following the artificial rupture of membranes at 7:30 a.m., a Pitocin drip was started, and the dosage was gradually increased by protocol. At 12:05 p.m., a nurse first noted bleeding. At 12:10 p.m., the obstetrician placed an internal lead after performing a vaginal examination. An episode of bradycardia lasting 11 minutes was noted before recovery to baseline. During that time, the fetal heart rate fell below 100 bpm.

At 12:30 p.m., the obstetrician ordered an epidural anesthesia and left the unit. As the anesthesiologist attempted to place the epidural catheter, the patient developed a leg cramp. Therefore, the epidural needle was removed. Placement was finally achieved at approximately 12:55 p.m., at which time the anesthesiologist also left the unit. The length of time that it took to place the epidural catheter was felt in no way to contribute to the fetal difficulties that subsequently ensued. Decelerations were noted during the 25 minutes that it took to complete the placement of the epidural catheter. This was followed by a prolonged deceleration with a decrease in beat-to-beat variability and a slow return to baseline.

At 1:05 p.m., maternal blood pressure decreased to 81/50 following the epidural. The nurse’s note reflects that the obstetrician was called and advised of those changes. At 1:10 p.m., the maternal blood pressure was 88/49 and the fetal heart rate was 150 to 160. At 1:15 p.m., the maternal blood pressure was 99/52, but the fetal heart rate was now below 90 bpm. Late decelerations were noted, and the obstetrician was again notified.

The obstetrician arrived at 1:23 p.m. At that time, the maternal blood pressure was 103/63 and the fetal heart rate was below 80 bpm. There were late decelerations with slow recovery and decreased variability on the EFM strips. A vaginal examination revealed the cervix to be 3-4 cm dilated, with bleeding again present. At 1:30 p.m., the fetal monitor showed minimal variability. At 1:35 p.m., the maternal blood pressure was 85/50, and the fetal heart rate was between 70 and 110 bpm. At this time, the nurses noted bright red bleeding. At 1:38 p.m., the obstetrician called for a cesarean section. The anesthesiologist responded and “topped off” the epidural at 1:52 p.m. The patient arrived in the operating room at 1:59 p.m. The fetal heart rate was now below 60 bpm. The first incision was made at approximately 2:12 p.m. and the infant was delivered at 2:15 p.m.

Post-Delivery Observations

The baby boy weighed 8 pounds 9 ounces. He was extremely floppy at birth, with Apgars of 1, 4 and 7 at 10 minutes. Free blood and clots were seen in the uterus at the time of the delivery, which strongly suggested a placental abruption. At two to three minutes of life, the baby was intubated by the anesthesiologist. The pediatrician arrived at 2:24 p.m. He documented chest compressions with a heart rate of 60. He also documented that the baby was still limp and blue and had a poor response to the resuscitative efforts. He suggested that the tube was misplaced, so the anesthesiologist reintubated the baby. The baby’s heart rate and color then improved. The anesthesiologist went back to care for the mother until 3 p.m.

At 3:10 p.m., a chest x-ray of the infant revealed that the tip of the tube was directed toward the right mainstem bronchus. The radiologist’s impression was that the tube was “malpositioned.” Nothing documented in the medical record reflects that the tube was subsequently raised. However, a second chest x-ray was taken later, showing that the tube tip was now above the carina. The child was maintained on mechanical ventilation, suffered seizures and was transferred to a tertiary medical center. An MRI there showed encephalomalacia changes representing hypoxic-ischemic encephalopathy. The child suffered from cerebral palsy, with spastic quadriparesis and profound cognitive/communication impairment. He required 24-hour home or institutional care. The baby had no genetic defects upon testing.

Lawsuit and Expert Reviews

The plaintiff’s parents commenced a lawsuit against the hospital on the child’s behalf. They sued the pediatrician, a non-MLMIC insured, the obstetrician and his partner, both MLMIC insureds, their professional corporation, and the anesthesiologist, who was also a MLMIC insured. The complaint alleged mismanagement of the plaintiff’s labor and delivery.

Medical experts in the fields of obstetrics, anesthesiology and pedi atrics reviewed this case. The obstetrical reviewer expressed concerns that at approximately 12:05 p.m., the electronic fetal monitoring tracing and the nurse’s notes reflected maternal bleeding. The fetal monitor strips showed prolonged, deep variable decelerations and a reduction in beat-to-beat variability. After the epidural was completed at 12:55 p.m., the strips demonstrated a bizarre pattern, with almost complete loss of variability, associated with a baseline of approximately 100 bpm, with multiple short accelerations to 130 bpm. The electronic fetal monitoring strips continued to show ominous signs until approximately 1:40 p.m. when the emergency cesarean section was called. The obstetrical expert opined that the cesarean section should have been called for at around 12:30 p.m., which would have resulted in the delivery of the fetus approximately one hour and 15 minutes sooner.

The anesthesiology reviewers opined that the insured anesthesiologist should have questioned the appropriateness of placing an epidural in a patient with bleeding and a fetus in distress. They also advised that he should have stayed with the mother to observe the effects of the epidural, which caused a decrease in blood pressure. They also were extremely critical of the lack of documentation by both the obstetrician and the anesthesiologist. The anesthesia record indicated that the epidural placement was at 12:30 p.m.  The nurse’s notes reflect that the catheter was initially removed due to a possible injury to the patient. Further, the anesthesiologist entered no notes in the record regarding topping off the epidural at 1:52 p.m.

The most damaging part of the anesthesia record were the vital signs of the mother taken between 12:30 p.m. and 2:00 p.m. The record showed repeated blood pressure entries of 115/55. However, the nurses had recorded blood pressures of 80-90 systolic. It was not clear whether the anesthesiologist was in attendance with the mother from 12:30 p.m. onward, as the cesarean section was called at 1:38 p.m., and the nurse’s notes indicate that the anesthesiologist responded at 1:50 p.m. The anesthesia record also failed to reflect the time of the incision. Additionally, the anesthesiology record was extremely brief regarding the intubation of the infant. However, the nurse’s notes indicate that the initial intubation by the anesthesiologist “failed” and that the infant was not successfully intubated until nine minutes after delivery.

This faulty recordkeeping and poor documentation were very damaging to the credibility of the anesthesiologist. Because his credibility was completely compromised, an expert witness could not support his care.

Settlement

The plaintiff’s initial demand to settle this matter was $11 million. Negotiations ensured for quite some time, and the case was eventually settled on behalf of all the defendants. Interestingly, this settlement occurred prior to the inception of the New York State Medical Indemnity Fund, to which these parents would have been directed to seek money for future medical expenses and devices.

Takeaways

Cases that involve brain-damaged infants are extremely expensive to resolve. This case revealed multiple legal concerns resulting from the care of both the anesthesiologist and obstetrician that made it very high risk to defend and made settlement imperative for both physicians.

The main allegation against the obstetrician was a failure to recognize an abruption of the placenta in a timely manner. He then failed to order an emergency cesarean section, despite seeing and being notified of bleeding during the patient’s labor.

The patient’s blood pressures and the fetal heart rates were seriously depressed, yet the obstetrician left the patient. He failed to return to see her for over an hour despite being called by nurses several times. When he finally appeared, the fetus had already been severely compromised. Therefore, the appearance of a lack of concern for both the patient and fetus, without being able to articulate a rationale for doing so, seriously undermined any possible defense.

The anesthesiologist had even more serious deficits in his care. He failed to have and document an informed consent discussion with this patient regarding the epidural anesthesia she was to undergo. He failed to both have such a conversation and document the procedure itself. Also, he did not document the problems he had starting the epidural.

It was suspected that the anesthesiologist inaccurately reflected his treatment on multiple occasions. There were two conflicting anesthesia records, and he failed to document the two attempts to start the epidural. These inaccuracies and the prior conflicts with the nurses’ notes created suspicion that other aspects of the anesthesia records, such as the blood pressures entered during the emergency surgery, were also inaccurate and/or poorly documented.

Although the anesthesiologist was aware that the patient was bleeding and the fetus was showing significant signs of distress after he started the epidural anesthesia, he, too, left the patient and also failed to contact the obstetrician. While he claimed that he was never notified of continuing problems by the nursing staff until the cesarean section was called, the nurses’ notes clearly contradicted his claims.

Because of all these deficits in his care, and especially the many alterations in his anesthesia record, it would have been impossible to permit this physician to testify under oath to a jury.

In summary, despite the plaintiff’s substantial monetary demands for the care of a severely compromised newborn, settlement of this case by both the obstetrician and the anesthesiologist was necessary to protect them from a judgment that exceeded the limits of all of their policies.

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This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.