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Could this brachial plexus injury have been avoided?


Dr. A began managing an obese woman’s pregnancy in October 2006. He had previously managed the second of her 2 previous pregnancies, both of which were normal spontaneous vaginal deliveries (NSVDs). The second was an 8 lb 2 oz healthy baby that Dr. A delivered in April 2006. Notably, before her second pregnancy, the woman developed type 2 diabetes. A perinatal group assisted Dr. A with management of that gestation and there were no complications associated with it.

The estimated date of delivery for the woman’s third pregnancy was June 21, 2007. A November 2006 ultrasound (U/S) revealed a 7-week intrauterine gestation. Regular checkups in December and January were unremarkable. On February 12, Dr. A again examined the woman, who at 21 weeks was noncompliant with glucose monitoring. He referred her to a perinatal group for a Level II U/S and fetal echocardiogram, which were performed on February 16. The results of both were within normal limits for gestational age. The perinatal group agreed to assist in managing the patient’s pregnancy.

On March 27, the patient saw Dr. B, a perinatologist at the perinatal group. He documented that the patient had not been doing home glucose monitoring and that her postprandial blood glucose had been elevated. He recommended weekly nonstress tests (NSTs) and biophysical profiles (BPPs), increasing to twice weekly at 34 weeks. The NSTs and BPPs were to be done at Dr. A’s office. On April 4, at
29 weeks, the patient’s NST was nonreactive and her BPP normal.

On April 7, the patient returned to the perinatal group. She had started glyburide the week before, and in general her blood sugar levels had improved; her fasting blood glucose was between 70 and 90. Nonetheless, her postprandial glucose level still spiked to 250 because she had not changed her diet. At that point, the physicians were holding off prescribing insulin to avoid hypoglycemia. On April 11, the patient returned to Dr. A for prenatal care. Her NST was nonreactive and her BPP normal. Some sugar was present in her urine. She did not do a fasting glucose test.

On April 16, she returned to the perinatal group for a Level II U/S and fetal anatomic survey. The interpretation was that the fetus was large for gestational age (LGA). The pregnancy was at 30 weeks and 4 days, but the fetus was 33 weeks and 2 days by U/S, placing it at the 90th percentile. The perinatologist recommended that thereafter Dr. A perform weekly NSTs and BPPs and that the perinatal group repeat the U/S in 3 weeks.

The patient returned to Dr. A on April 18 at 31 weeks. Documentation from this appointment showed a positive fetal heart rate and fetal movement, but neither a NST nor a BPP was recorded. On April 21 the patient saw perinatologist Dr. C, who noted that she was having mild occasional elevations in her blood glucose during the day, with good control. She was, however, having significant postprandial elevations. He again discussed the possibility of using insulin and asked the patient to return in 1 week to discuss this. He also documented that follow-up with NSTs and BPPs should continue, and that the patient should return to the perinatal group for another U/S in
2 weeks.

On April 26, the patient had a reactive NST and a normal BPP at Dr. A’s office. She did not bring her blood sugar chart, and Dr. A again discussed the risks of intrauterine demise if her glucose level was significantly elevated. She was told to return in 2 weeks for a NST and BPP (despite the earlier recommendation that at this stage she should be returning every week).

On April 28, the patient saw Dr. B at the perinatal group, who described the patient as an “uncontrolled” Class B diabetic. He documented that she should be receiving NSTs and BPPs twice a week at this stage and reiterated the need for a monthly fetal growth assessment U/S and maternal fetal medicine (MFM) consult in 2 weeks.

That consult took place with Dr. C on May 8. He documented consistently increased postprandial glucose levels and added another dose of glyburide following lunch daily. He supported weekly NSTs and “ultimately” wanted a repeat growth scan to check for macrosomia.

The last entry in the perinatal group records was on May 19 by Dr. B. The patient looked well and had been getting her weekly BPPs and NSTs. She was to return on June 5 for a MFM consult and an amniocentesis for fetal lung maturity. The perinatal group, however, documented that the patient did not keep that appointment.

Dr. A saw the patient for her final prenatal visit on June 6. The note has no mention of either the recommended repeat U/S that was never performed or the “missed” appointment with the perinatal group the day before. His prenatal flow sheet reflected that during the last trimester the patient’s fundal heights consistently exceeded gestational age with no documented recognition of this anomaly by Dr. A.

The patient began having contractions at approximately 3:30 AM on June 11, and arrived at the hospital at approximately 5 AM. Dr. A’s admission note estimated the fetal weight at 9 lb based on a manual exam rather than U/S. No episiotomy was performed, and the mother sustained a second-degree laceration during delivery. The labor itself was fairly quick, with artificial rupture of membranes at 5:25 AM and delivery at 5:46 AM. Dr. A’s delivery note reads as follows:

“Patient FO/VTX/O at 5:40 AM. Increased discomfort with contractions. Delivery viable female left occipital transverse at 5:46 AM, naso-oropharynx suctioned. McRoberts position used. Attempt to deliver anterior shoulder with suprapubic pressure unsuccessful. Baby rotated posterior shoulder delivered followed by anterior shoulder. No unusual force, traction used for delivery. Neonatologist present. 2nd degree laceration midline repaired with
3-0 chromic suture.”

The infant weighed 10 lb 13 oz at birth. Apgar scores were 8 and 9, but the records indicate that she was lightly meconium stained and not crying or spontaneously breathing at birth. The infant’s initial arterial blood gas was 7.15. Oxygen was given using a bag valve mask and the baby subsequently cried. Right arm weakness in the infant was fairly quickly appreciated. This was later documented as “Erb’s Palsy right arm.”

After delivery, the child received care primarily from pediatrics and pediatric neurology, but also from a state early intervention program and private physical therapy. Use of her right arm consistently improved, with the pediatrician noting “great improvement” by August. However her pediatric neurologist described “contracture deformity” and “significant residual weakness and decreased range of motion.”

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