Cesarean causes problems for mother and baby
The plaintiff was first seen by the defendant ob/gyn for a prenatal visit on July 14, 2009, at 7 weeks’ gestation and she continued to receive treatment from him during her prenatal course, which was fairly uneventful. The woman’s weeks by size were consistent with her weeks by ultrasound up until February 9, 2010, at which time she continued to remain at 36 weeks in size. The plaintiff was seen in labor and delivery that day. An ultrasound showed fetal movement. At a February 19, 2010 visit, the patient reported experiencing good fetal movement since February 9. She was at -2 station with 70% effacement. When the woman was seen by the defendant ob/gyn on February 23, she was 1 cm dilated and fully effaced. Her urine was positive for protein at a February 24 visit and she was 90% effaced and still at -2 station.
On February 26, the patient was admitted to the defendant hospital by the defendant ob/gyn with a complaint of painful contractions. An external fetal monitor was applied and the fetal heart rate (FHR) was noted to be 130, with moderate variability, positive accelerations, and a deceleration in triage, with spontaneous baseline return. Vaginal examination was performed by a PGY-3 ob/gyn, and the patient was noted to be 3 cm dilated, 90% effaced, -2 station. The PGY-3 ordered that the patient be admitted to labor and delivery and made an entry at 8:36 pm indicating that she was called to evaluate the patient for a deceleration shortly after an epidural was placed. The PGY-3 indicated that the patient’s baseline was 135, with moderate variability and accelerations. In addition, she noted a deceleration to 60, with return to baseline after 7 minutes. It was noted that the patient was having a tetanic contraction. Terbutaline 0.25 mg was administered, and the FHR returned to baseline. Importantly, the PGY-3 noted “[Defendant ob/gyn] is in house and managing.”
At 8:35 pm, a nursing entry indicates that the defendant ob/gyn reviewed the FHR tracing and performed a vaginal examination. The patient had progressed to 5 cm dilation and 100% effacement and the fetus remained at -2 station. The defendant ob/gyn performed artificial rupture of membranes and noted “thin mec [meconium].” At 10:32 pm, the defendant ob/gyn noted that the patient had a spontaneous deceleration for 4 to 5 minutes, which was not associated with hyperstimulation and resolved after maternal resuscitative maneuvers.
On February 27 at 12:06 am, the defendant ob/gyn documented another spontaneous deceleration lasting 5 minutes, which was associated with a tetanic contraction. Terbutaline was administered with good results. The defendant ob/gyn noted that the FHR tracing was reassuring before and after this deceleration. The resident documented the deceleration as dropping from a baseline of 130 bpm to 70 bpm and lasting for 7 minutes. She noted that the patient was turned to the left side and onto all fours, with oxygen administered and intravenous fluids running. At that time, 0.25 mg of terbutaline was given.
At 1:18 am, the defendant ob/gyn documented another 5-minute deceleration associated with a tetanic contraction. As before, terbutaline was administered with good results. Furthermore, he indicated: “fetal heart rate tracing reassuring before and after this decel.” The resident also noted that the deceleration dropped from a baseline of 130 bpm to 70 bpm and lasted 4 or 5 minutes. She also indicated that the fetus was at 0 station.
The defendant ob/gyn noted that at 2:51 am, the patient was fully dilated, the fetus was at -1 station and the mother was feeling rectal pressure. He described the FHR tracing as reassuring and noted that the patient was unable to push due to a substantial epidural. His plan was to delay any attempt at pushing until the patient had more sensation and strength. While waiting for that to occur, the defendant ob/gyn noted that the plaintiff had another prolonged deceleration in response to a tetanic contraction at about 3:27 am and terbutaline was given with good results.
A nurse noted at 3:30 am that the defendant ob/gyn was having the patient push with contractions. It also indicated that a deceleration down to 80 bpm occurred, the patient was placed on all fours, and the FHR returned to a baseline of 150 bpm. In his note at 3:48 am the defendant ob/gyn wrote:
“I anticipate we’ll have to push for greater than an hour and with these repeated decels and meconium this baby is not tolerating labor adequately. I’ve recommended to pt. and husband that we proceed with cesarean section for non-reassuring fetal heart rate tracing….”
The record reflects that the patient was in the operating room (OR) at 3:52 am and a cesarean section was performed by the defendant ob/gyn and the PGY-3. Upon admission to the OR, the FHR was 155 bpm. The female infant had Apgar scores of 1 and 8. She weighed 2895 g.
The defendant ob/gyn wrote the following in the record:
“Standard horizontal uterine incision performed. Attempt by first assistant to extricate [sic] vertex from pelvis [sic] was unsuccessful. I then also attempted the same maneuver without success. My hand could go below the vertex but I was unable to extricate head from maternal pelvis. Chief resident called in and attempted to displace vertex upward [sic] via vaginal route with simultaneous assistance from above – also not successful. I then performed this same maneuver while both chief resident and first assistant assisted from above – this was unsuccessful. I then instructed the anesthesiologist to administer SQ Terbutaline .25 mg in effort to relax the uterus and obtain more upward movement of vertex. Tis also did not allow extrication of vertex. I called for non-party attending ... for assistance. I then T’ed the uterus ... cut vertically anteriorly along the midline with bandage scissors in order to gain maximum room—the horizontal incision was already maximum to the lateral extent possible. Using this technique we were able to extricate the baby….”