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    Legally Speaking: How long is too long to crown?

     

     

     

    Andrew I. Kaplan, Esq, is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP in New York City, specializing in medical malpractice defense and healthcare litigation. He welcomes feedback to this column via email to [email protected].

    Facts

    A G2Ab1 presented to a hospital in labor at 41 weeks, 3 days’ gestation in the early morning on November 6, 2004. Her prenatal course had been unremarkable. She reported contractions every 3–4 minutes for over a day. The estimated fetal weight by Leopold’s maneuvers was under 4000 g. The pelvic sidewall and arch were satisfactory, and a normal spontaneous vaginal delivery was anticipated.

    A nurse’s note at 3 a.m. indicated the patient was Group B strep (GBS) positive. Ampicillin was given via IV piggyback and discontinued at 8:55 p.m., approximately 25 minutes after delivery.

    The fetal heart rate (FHR) was initially in the 140s, with positive accelerations and no decelerations. At 3:03 a.m., a fourth-year resident performed a cervical examination and found 1-cm dilation, effacement described as “long,” and fetal station at -2. An epidural was given at approximately 6:56 a.m. Pitocin was started at 2 mu at approximately 4:18 a.m. and increased by 2 mu increments to a maximum level of 20 mu by 10:49 a.m.

    From 8 a.m. to approximately 8:30 a.m., the FHR rose to 150 to 160. By 8:45 a.m., it was 160–170 and then increased to 170–180, triggering notification to a second-year resident of tachycardia. Nurses responded by changing the patient’s position and administering oxygen. Around the time of the nursing interventions for tachycardia, Pitocin was increased from 14 mu to 16 mu.

    In addition, at 1:15 p.m., the nursing staff noted early decelerations, addressed them with position change, and notified the second-year resident. She performed a cervical examination, noting 2- to 3-cm dilation, effacement at 80%, and station at -1. Her impression was prolonged latent phase with mild early decelerations, although FHR tracings were reassuring overall. The second-year resident wrote another progress note at 2 p.m., documenting a cervical exam of 3/80%/-1 and “additional rupture of the forewaters,” described as clear, without meconium staining.

    Read: The best and worst states to practice ob/gyn from a professional liability perspective

    Nursing annotations at 4 p.m. described variable decelerations, of which the chief resident was “aware,” as well as position change, intravenous bolus, and oxygen administration. Between 4:30 p.m. and 4:46 p.m. nurses documented decelerations and the second-year resident was informed. The patient was repositioned and oxygen was administered.

     

    Andrew I. Kaplan, Esq
    Mr. Kaplan is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP, specializing in medical malpractice defense and healthcare ...

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