Neonatal Team Absent at Difficult Birth

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Neonatal Team Absent at Difficult Birth
A Virginia woman was referred for an ultrasound by her obstetrician at 20 weeks’ gestation due to a suspicion of omphalocele or gastroschisis. The imaging revealed gastroschisis with a moderate amount of exposed bowel.

The mother presented to the hospital in labor at 38 weeks’ gestation. From the beginning, the electronic monitor tracing of the fetal heart rate exhibited a sinusoidal pattern. At the shift nurse’s request, the fetal monitor strip was reviewed with a physician who found it to be “almost” sinusoidal. When a second nurse started her shift, the fetal heart rate was 60 to 70 beats/min. A physician artificially ruptured the amniotic membranes. No personnel from the pediatric service, nursery, or neonatal ICU had yet been contacted.

Upon rupture of the membranes, thick meconium was found in the amniotic fluid. A fetal scalp electrode was placed, showing a fetal heart rate between 30 and 100 beats/min. A second fetal scalp electrode was placed, and it showed the same fetal heart rate range.

A baby boy delivered precipitously in critical condition, with Apgar scores of 1 at one minute, 2 at five minutes, and 4 at 10 minutes. The newborn was depressed, flaccid, blue, and unresponsive, with thick meconium below the vocal cords, obstructing his breathing at the time of birth.

The neonatal ICU team was called after delivery. When they arrived, the infant was making no respiratory effort and had a heart rate of 60 beats/min. He was suctioned, but the airway box was blocked by meconium. The baby was intubated at four minutes after birth, but ventilation was initially unsuccessful; he was extubated and reintubated at five minutes postdelivery.

Results of an arterial blood sample were consistent with severe metabolic acidosis from hypoxia in utero and during resuscitation. Fetal cooling, which might have ameliorated the infant’s ongoing brain injury, was ruled out by the presence of gastroschisis.

The child experienced hypoxic ischemic encephalopathy from intrapartum asphyxia, which resulted in microcephaly. He requires a feeding tube due to an inability to swallow and will need lifelong care.

OUTCOME
Two suits were filed, one on the infant’s behalf and one on the mother’s. The infant’s case was settled for $1.8 million, and the mother’s case for $1 million.

COMMENT
This fetus was clearly in distress during delivery, and based on the confirmed presence of gastroschisis, the neonatal team should have been at the bedside for delivery. Even assuming that the strip was read as a pseudosinusoidal pattern, the fetus was frankly bradycardic, and the certainty of caring for an infant with exposed bowel contents required the neonatal team’s presence.

Gastroschisis refers to the failure of the developing fetus’s abdominal wall to close, resulting in protrusion of a portion of fetal intestine outside the abdominal cavity. It is relatively rare, with an incidence of 1.4 to 2.5 per 10,000 live births. A sinusoidal fetal heart rate pattern is characterized by a regular, smooth, undulating form typical of a sine wave. It is rare and ominous, and is associated with high fetal morbidity and mortality. By contrast, a pseudosinusoidal pattern is a benign form showing long-term variability. A true sinusoidal pattern lacks the beat-to-beat variability of the more jagged-appearing pseudosinusoidal pattern.

In this case, problems at delivery were foreseeable. A jury would have little trouble understanding gastroschisis and would find it alarming. Given the fetal bradycardia and monitor pattern, most jurors would conclude that the standard of care was breached. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Neonatal Team Absent at Difficult Birth
A Virginia woman was referred for an ultrasound by her obstetrician at 20 weeks’ gestation due to a suspicion of omphalocele or gastroschisis. The imaging revealed gastroschisis with a moderate amount of exposed bowel.

The mother presented to the hospital in labor at 38 weeks’ gestation. From the beginning, the electronic monitor tracing of the fetal heart rate exhibited a sinusoidal pattern. At the shift nurse’s request, the fetal monitor strip was reviewed with a physician who found it to be “almost” sinusoidal. When a second nurse started her shift, the fetal heart rate was 60 to 70 beats/min. A physician artificially ruptured the amniotic membranes. No personnel from the pediatric service, nursery, or neonatal ICU had yet been contacted.

Upon rupture of the membranes, thick meconium was found in the amniotic fluid. A fetal scalp electrode was placed, showing a fetal heart rate between 30 and 100 beats/min. A second fetal scalp electrode was placed, and it showed the same fetal heart rate range.

A baby boy delivered precipitously in critical condition, with Apgar scores of 1 at one minute, 2 at five minutes, and 4 at 10 minutes. The newborn was depressed, flaccid, blue, and unresponsive, with thick meconium below the vocal cords, obstructing his breathing at the time of birth.

The neonatal ICU team was called after delivery. When they arrived, the infant was making no respiratory effort and had a heart rate of 60 beats/min. He was suctioned, but the airway box was blocked by meconium. The baby was intubated at four minutes after birth, but ventilation was initially unsuccessful; he was extubated and reintubated at five minutes postdelivery.

Results of an arterial blood sample were consistent with severe metabolic acidosis from hypoxia in utero and during resuscitation. Fetal cooling, which might have ameliorated the infant’s ongoing brain injury, was ruled out by the presence of gastroschisis.

The child experienced hypoxic ischemic encephalopathy from intrapartum asphyxia, which resulted in microcephaly. He requires a feeding tube due to an inability to swallow and will need lifelong care.

OUTCOME
Two suits were filed, one on the infant’s behalf and one on the mother’s. The infant’s case was settled for $1.8 million, and the mother’s case for $1 million.

COMMENT
This fetus was clearly in distress during delivery, and based on the confirmed presence of gastroschisis, the neonatal team should have been at the bedside for delivery. Even assuming that the strip was read as a pseudosinusoidal pattern, the fetus was frankly bradycardic, and the certainty of caring for an infant with exposed bowel contents required the neonatal team’s presence.

Gastroschisis refers to the failure of the developing fetus’s abdominal wall to close, resulting in protrusion of a portion of fetal intestine outside the abdominal cavity. It is relatively rare, with an incidence of 1.4 to 2.5 per 10,000 live births. A sinusoidal fetal heart rate pattern is characterized by a regular, smooth, undulating form typical of a sine wave. It is rare and ominous, and is associated with high fetal morbidity and mortality. By contrast, a pseudosinusoidal pattern is a benign form showing long-term variability. A true sinusoidal pattern lacks the beat-to-beat variability of the more jagged-appearing pseudosinusoidal pattern.

In this case, problems at delivery were foreseeable. A jury would have little trouble understanding gastroschisis and would find it alarming. Given the fetal bradycardia and monitor pattern, most jurors would conclude that the standard of care was breached. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Neonatal Team Absent at Difficult Birth
A Virginia woman was referred for an ultrasound by her obstetrician at 20 weeks’ gestation due to a suspicion of omphalocele or gastroschisis. The imaging revealed gastroschisis with a moderate amount of exposed bowel.

The mother presented to the hospital in labor at 38 weeks’ gestation. From the beginning, the electronic monitor tracing of the fetal heart rate exhibited a sinusoidal pattern. At the shift nurse’s request, the fetal monitor strip was reviewed with a physician who found it to be “almost” sinusoidal. When a second nurse started her shift, the fetal heart rate was 60 to 70 beats/min. A physician artificially ruptured the amniotic membranes. No personnel from the pediatric service, nursery, or neonatal ICU had yet been contacted.

Upon rupture of the membranes, thick meconium was found in the amniotic fluid. A fetal scalp electrode was placed, showing a fetal heart rate between 30 and 100 beats/min. A second fetal scalp electrode was placed, and it showed the same fetal heart rate range.

A baby boy delivered precipitously in critical condition, with Apgar scores of 1 at one minute, 2 at five minutes, and 4 at 10 minutes. The newborn was depressed, flaccid, blue, and unresponsive, with thick meconium below the vocal cords, obstructing his breathing at the time of birth.

The neonatal ICU team was called after delivery. When they arrived, the infant was making no respiratory effort and had a heart rate of 60 beats/min. He was suctioned, but the airway box was blocked by meconium. The baby was intubated at four minutes after birth, but ventilation was initially unsuccessful; he was extubated and reintubated at five minutes postdelivery.

Results of an arterial blood sample were consistent with severe metabolic acidosis from hypoxia in utero and during resuscitation. Fetal cooling, which might have ameliorated the infant’s ongoing brain injury, was ruled out by the presence of gastroschisis.

The child experienced hypoxic ischemic encephalopathy from intrapartum asphyxia, which resulted in microcephaly. He requires a feeding tube due to an inability to swallow and will need lifelong care.

OUTCOME
Two suits were filed, one on the infant’s behalf and one on the mother’s. The infant’s case was settled for $1.8 million, and the mother’s case for $1 million.

COMMENT
This fetus was clearly in distress during delivery, and based on the confirmed presence of gastroschisis, the neonatal team should have been at the bedside for delivery. Even assuming that the strip was read as a pseudosinusoidal pattern, the fetus was frankly bradycardic, and the certainty of caring for an infant with exposed bowel contents required the neonatal team’s presence.

Gastroschisis refers to the failure of the developing fetus’s abdominal wall to close, resulting in protrusion of a portion of fetal intestine outside the abdominal cavity. It is relatively rare, with an incidence of 1.4 to 2.5 per 10,000 live births. A sinusoidal fetal heart rate pattern is characterized by a regular, smooth, undulating form typical of a sine wave. It is rare and ominous, and is associated with high fetal morbidity and mortality. By contrast, a pseudosinusoidal pattern is a benign form showing long-term variability. A true sinusoidal pattern lacks the beat-to-beat variability of the more jagged-appearing pseudosinusoidal pattern.

In this case, problems at delivery were foreseeable. A jury would have little trouble understanding gastroschisis and would find it alarming. Given the fetal bradycardia and monitor pattern, most jurors would conclude that the standard of care was breached. —DML