Postpartum high blood pressure missed, mother suffers brain damage … and more

Postpartum high BP; mother suffers brain damage

HOSPITALIZED TWICE FOR HYPERTENSION in the month before her child was born, a 41-year-old woman gave birth to a healthy baby by cesarean delivery. The mother was discharged 2 days later with a blood pressure (BP) of 130/90 mm Hg.

Three days later, she went to her ObGyn’s office because she was not feeling well and had extreme swelling. Her BP, taken twice by a nurse, read 170/88 mm Hg, and 168/90 mm Hg, but she was not examined by the ObGyn.

That evening, the patient had difficulty breathing and was taken to the emergency department (ED), where she was intubated. She went into cardiac arrest and suffered permanent brain damage after being without a pulse for 15 minutes. She was in a coma for 45 days. She is unable to walk without assistance, is legally blind, and her hands are so contorted that she cannot feed herself. She suffers from short-term memory loss and has difficulty speaking.

PATIENT’S CLAIM The ObGyn should have examined her when she was at the office. Her hypertension would have been properly treated and injuries avoided. She had classic signs of postpartum cardiomyopathy.

PHYSICIAN’S DEFENSE The patient had not come to the office because she was feeling ill, but to show off her baby and have her BP checked. If he had been advised of the BP readings, he would have examined her.

VERDICT A $5 million Georgia verdict was returned.

Cervical biopsy results improperly reported

A 44-YEAR-OLD WOMAN UNDERWENT a cervical biopsy in July 2007 performed by a pathologist. A few days later, the pathologist contacted the patient and reported that the biopsy revealed invasive cervical cancer that required immediate surgery. Several procedures were performed without any cancer ever being found.

A second opinion was sought, and it was determined that the cancer diagnosis was incorrect; another patient’s pathology had been reported as the patient’s.

PATIENT’S CLAIM The pathologist and hospital were negligent in reporting incorrect results of the cervical biopsy, which resulted in the patient’s physical and emotional injuries, including unnecessary surgical procedures and depression and anxiety.

DEFENDANTS’ DEFENSE The defendants did not oppose the patient’s motion for summary judgment on liability; the issue of damages was contested.

VERDICT The patient received summary judgment on liability. She then discontinued claims against the pathologist, and the matter proceeded on damages against the hospital. A $46,000 New York verdict was returned. Stipulated medical expenses were added to the verdict for a total recovery of $60,979.

Brachial plexus injury: child has significant functional disability

AT 38 6/7 WEEKS’ GESTATION, a 23-year-old woman went to the ED with contractions. She had pregestational diabetes mellitus. Her admitting glucose level was 143 mg/dL, and she had gained 25 lb during pregnancy. Her fundal height was 40 cm, and estimated fetal weight was 4000 g (8 lb 13 oz). A pelvic examination determined that she was 3 to 4 cm dilated, 100% effaced, and at minus-1 station. She was given oxytocin to aid labor. The ObGyn noted that overall fetal heart-rate tracings were reassuring, and that a pediatrician would be present for delivery due to suspected macrosomia. Shoulder dystocia occurred during delivery, but it was resolved in 40 seconds. The mother sustained a second-degree perineal laceration.

At birth, the baby’s left arm was limp. Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Her birth weight was 10 lb 2 oz. A brachial plexus injury was diagnosed, and she underwent surgery in October 2008. Despite successful nerve grafts at C5 and C6, the child has significant functional disability in the left arm.

PARENTS’ CLAIM A cesarean delivery should have been scheduled when a macrosomic fetus was suspected.

PHYSICIAN’S DEFENSE The case was settled during trial.

VERDICT A $1,475,000 Maryland settlement was reached.

Breech position and umbilical cord prolapse: Was everything done that could be done?

DURING A MOTHER’S 38-WEEK PRENATAL VISIT, ultrasonography showed the baby was in breech position. The midwife offered two options: to schedule an external cephalic version procedure at 38 weeks or a cesarean delivery at 39 weeks. The parents agreed to schedule a cesarean delivery for 8 days later. The day before the scheduled birth, the mother awoke to find the umbilical cord between her legs. An emergency cesarean delivery was performed. The newborn required resuscitation and mechanical ventilation and suffered permanent brain damage attributed to hypoxia from umbilical cord prolapse.

PARENTS’ CLAIM The midwife’s negligence caused the baby’s injuries. Breech presentation put the pregnancy at high-risk. She did not have a physician examine the patient before scheduling a cesarean delivery and did not attempt to rotate the child back to a head-first position. She did not warn the parents about the risks of breech presentation and umbilical cord prolapse.

DEFENDANTS’ DEFENSE The choices given the parents were reasonable. Scheduling a cesarean delivery at 39 weeks was proper. A prolapsed cord is not predictable or preventable.

VERDICT A $12.6 million Pennsylvania verdict was returned against the midwife and the hospital; a confidential high/low agreement was reached.

Extensive adhesions result in bowel injury

A 58-YEAR-OLD WOMAN UNDERWENT exploratory laparotomy in May 2009. There were extensive adhesions, and the gynecologist used blind, blunt dissection to resect a large pelvic mass adhered to the sidewall. He had difficulty removing the specimen because it was too large to fit through the incision. A left salpingo-oophorectomy was also performed.

On the second postoperative day, the patient reported shortness of breath, intermittent chest pain, and had a fever of 103° F. The next day, she was unable to ambulate due to shortness of breath. CT results ruled out deep vein thrombosis or pulmonary embolism but revealed significantly decreased lung volume. She continued to experience shortness of breath and temperature spikes for 3 more days. She was discharged on the seventh postoperative day despite shortness of breath.

Two days later, she experienced severe abdominal pain and shortness of breath at home and returned to the ED by ambulance. A CT scan revealed free pelvic air, ascites, and extensive inflammatory changes, likely due to bowel perforation. She was intubated and airlifted to a regional trauma center. During exploratory surgery, the surgeon aspirated a foul-smelling fluid and identified a perforation at the rectosigmoid junction; a colostomy was created. The patient stayed in intensive care for 5 days, developed renal failure, and was transfused due to acute blood loss. She was hospitalized for 19 days. The colostomy was reversed in October 2009.

PATIENT’S CLAIM The ObGyn was negligent in injuring the bowel during surgery and in not recognizing the bowel injury and treating it in a timely manner.

PHYSICIAN’S DEFENSE The case was settled during the trial.

VERDICT A $600,000 Virginia settlement was reached.

Pregnant woman stabbed: mother and baby die

A 20-YEAR-OLD WOMAN AT 30 WEEKS’ gestation was treated in the ED for a stab wound to the shoulder. The emergency medicine (EM) physician noted internal bleeding and a possible collapsed lung on radiographs, and began efforts to have the woman transferred. One facility declined because of her pregnancy. The patient was in pain and her ability to breathe declined. An airlift was finally arranged, but she suffered cardiac arrest as the helicopter arrived. A cesarean delivery was performed, but both the mother and baby died.

ESTATE’S CLAIM The EM physician was negligent in failing to perform a thoracotomy and arrange for a more timely transfer. The physician didn’t contact a hospital that was only 8 miles away.

DEFENDANTS’ DEFENSE The federal government, which operated the facility, admitted fault.

VERDICT A $7,267,390 Mississippi verdict included $5.45 million in noneconomic damages.

What caused child’s brain damage?

DURING LABOR AND DELIVERY, electronic fetal heart-rate monitoring indicated fetal distress. Meconium-stained fluid was present. The child was born with brain damage. It is unlikely that he will walk independently, talk in full sentences, or be able to perform daily activities independently.

PARENTS’ CLAIM The fetal heart-rate monitor indicated a need for emergency cesarean delivery. The quality and quantity of meconium should have alerted the caregivers to fetal distress and caused them to perform a cesarean delivery.

DEFENDANTS’ DEFENSE Fetal heart-rate strips did not indicate a need for emergency delivery until shortly before the delivery occurred. The underlying cause of the child’s injuries was an infection that spread to the brain and was irreversible.

VERDICT A $1.71 million Massachusetts verdict was returned.

When did bladder injury occur?

AN 84-YEAR-OLD WOMAN suffered recurrent bladder cancer. She underwent a cystoscopy, and then chemotherapy. Several weeks later, she was diagnosed with a bladder perforation became septic, and died.

ESTATE’S CLAIM The bladder was lacerated during cystoscopy; she would have survived if the laceration had been treated in a timely manner.

PHYSICIAN’S DEFENSE Bladder perforation during cystoscopy is a known risk of the procedure. However, the bladder was not perforated during cystoscopy; chemotherapy may have caused the perforation.

VERDICT A Michigan defense verdict was returned.

Fetal tracings poor: Why wasn’t an internal lead used?

AT 32 WEEKS’ GESTATION, a woman’s membranes ruptured, and she was admitted. Her ObGyn planned to induce labor at 34 weeks’ gestation. She experienced contractions on the morning of the scheduled induction. Although fetal heart-rate monitoring was reassuring, the fetus was in a compound position, with the chin leading. Labor progressed rapidly to 6-cm dilation. The fetal heart rate began to show recurrent mild variable decelerations that became increasingly deeper. Although the technical quality of the external monitoring was poor, no internal lead was applied.

After 3 hours, the tracing showed severe variable decelerations. The mother was fully dilated and began to push. The tracings were of poor quality, but interpretable portions showed minimal variability and significant decelerations during contractions. The fetal baseline heart rate became tachycardic. The obstetric nurse and resident continued to note abnormalities, but there is no evidence that they called the attending ObGyn. The fetal baseline heart rate reached 190 bpm with ongoing decelerations associated with contractions. Variability remained minimal to absent. After 2 hours of pushing, meconium-stained fluid was noted. The infant was born 1 hour later. The attending ObGyn was present for the last 30 minutes of labor.

The newborn’s Apgar scores were 1, 5, and 7, at 1, 5, and 10 minutes, respectively. His arterial cord pH was significantly low. MRI of the head showed subdural and intraventricular hemorrhage and evolving, profound hypoxic ischemic injury. At 1 year of age, the child suffers from a seizure disorder, cortical blindness, and severe developmental delays.

PARENTS’ CLAIM The nurse and resident failed to respond to fetal heart-rate abnormalities and failed to insert an internal lead to obtain better quality heart-rate tracings. They did not expedite delivery when fetal distress was evident.

DEFENDANTS’ DEFENSE The case was settled during trial.

VERDICT A $4.2 million Massachusetts settlement was reached.

Hypoxic ischemic encephalopathy

DUE TO PREECLAMPSIA, a woman was admitted to the hospital 5 weeks before her due date. Her condition was monitored for 2 weeks when it was decided to induce labor with oxytocin. After 3 hours in labor, the fetal heart-rate tracing began to show significant decelerations. The baby was born at 37 weeks’ gestation with severe hypoxic ischemic encephalopathy. The child died 2 years later from severe brain damage.

PARENTS’ CLAIM The ObGyns failed to respond to signs of fetal distress by performing an emergency cesarean. The brain images would have been different if a stroke-like event had occurred.

DEFENDANTS’ DEFENSE The fetus experienced an embolic process due to a compressed umbilical cord, resulting in a stroke-like vascular event, which led to the hypoxic ischemic encephalopathy.

VERDICT A $450,000 Wisconsin settlement was reached.

Postpartum high BP; mother suffers brain damage

HOSPITALIZED TWICE FOR HYPERTENSION in the month before her child was born, a 41-year-old woman gave birth to a healthy baby by cesarean delivery. The mother was discharged 2 days later with a blood pressure (BP) of 130/90 mm Hg.

Three days later, she went to her ObGyn’s office because she was not feeling well and had extreme swelling. Her BP, taken twice by a nurse, read 170/88 mm Hg, and 168/90 mm Hg, but she was not examined by the ObGyn.

That evening, the patient had difficulty breathing and was taken to the emergency department (ED), where she was intubated. She went into cardiac arrest and suffered permanent brain damage after being without a pulse for 15 minutes. She was in a coma for 45 days. She is unable to walk without assistance, is legally blind, and her hands are so contorted that she cannot feed herself. She suffers from short-term memory loss and has difficulty speaking.

PATIENT’S CLAIM The ObGyn should have examined her when she was at the office. Her hypertension would have been properly treated and injuries avoided. She had classic signs of postpartum cardiomyopathy.

PHYSICIAN’S DEFENSE The patient had not come to the office because she was feeling ill, but to show off her baby and have her BP checked. If he had been advised of the BP readings, he would have examined her.

VERDICT A $5 million Georgia verdict was returned.

Cervical biopsy results improperly reported

A 44-YEAR-OLD WOMAN UNDERWENT a cervical biopsy in July 2007 performed by a pathologist. A few days later, the pathologist contacted the patient and reported that the biopsy revealed invasive cervical cancer that required immediate surgery. Several procedures were performed without any cancer ever being found.

A second opinion was sought, and it was determined that the cancer diagnosis was incorrect; another patient’s pathology had been reported as the patient’s.

PATIENT’S CLAIM The pathologist and hospital were negligent in reporting incorrect results of the cervical biopsy, which resulted in the patient’s physical and emotional injuries, including unnecessary surgical procedures and depression and anxiety.

DEFENDANTS’ DEFENSE The defendants did not oppose the patient’s motion for summary judgment on liability; the issue of damages was contested.

VERDICT The patient received summary judgment on liability. She then discontinued claims against the pathologist, and the matter proceeded on damages against the hospital. A $46,000 New York verdict was returned. Stipulated medical expenses were added to the verdict for a total recovery of $60,979.

Brachial plexus injury: child has significant functional disability

AT 38 6/7 WEEKS’ GESTATION, a 23-year-old woman went to the ED with contractions. She had pregestational diabetes mellitus. Her admitting glucose level was 143 mg/dL, and she had gained 25 lb during pregnancy. Her fundal height was 40 cm, and estimated fetal weight was 4000 g (8 lb 13 oz). A pelvic examination determined that she was 3 to 4 cm dilated, 100% effaced, and at minus-1 station. She was given oxytocin to aid labor. The ObGyn noted that overall fetal heart-rate tracings were reassuring, and that a pediatrician would be present for delivery due to suspected macrosomia. Shoulder dystocia occurred during delivery, but it was resolved in 40 seconds. The mother sustained a second-degree perineal laceration.

At birth, the baby’s left arm was limp. Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Her birth weight was 10 lb 2 oz. A brachial plexus injury was diagnosed, and she underwent surgery in October 2008. Despite successful nerve grafts at C5 and C6, the child has significant functional disability in the left arm.

PARENTS’ CLAIM A cesarean delivery should have been scheduled when a macrosomic fetus was suspected.

PHYSICIAN’S DEFENSE The case was settled during trial.

VERDICT A $1,475,000 Maryland settlement was reached.

Breech position and umbilical cord prolapse: Was everything done that could be done?

DURING A MOTHER’S 38-WEEK PRENATAL VISIT, ultrasonography showed the baby was in breech position. The midwife offered two options: to schedule an external cephalic version procedure at 38 weeks or a cesarean delivery at 39 weeks. The parents agreed to schedule a cesarean delivery for 8 days later. The day before the scheduled birth, the mother awoke to find the umbilical cord between her legs. An emergency cesarean delivery was performed. The newborn required resuscitation and mechanical ventilation and suffered permanent brain damage attributed to hypoxia from umbilical cord prolapse.

PARENTS’ CLAIM The midwife’s negligence caused the baby’s injuries. Breech presentation put the pregnancy at high-risk. She did not have a physician examine the patient before scheduling a cesarean delivery and did not attempt to rotate the child back to a head-first position. She did not warn the parents about the risks of breech presentation and umbilical cord prolapse.

DEFENDANTS’ DEFENSE The choices given the parents were reasonable. Scheduling a cesarean delivery at 39 weeks was proper. A prolapsed cord is not predictable or preventable.

VERDICT A $12.6 million Pennsylvania verdict was returned against the midwife and the hospital; a confidential high/low agreement was reached.

Extensive adhesions result in bowel injury

A 58-YEAR-OLD WOMAN UNDERWENT exploratory laparotomy in May 2009. There were extensive adhesions, and the gynecologist used blind, blunt dissection to resect a large pelvic mass adhered to the sidewall. He had difficulty removing the specimen because it was too large to fit through the incision. A left salpingo-oophorectomy was also performed.

On the second postoperative day, the patient reported shortness of breath, intermittent chest pain, and had a fever of 103° F. The next day, she was unable to ambulate due to shortness of breath. CT results ruled out deep vein thrombosis or pulmonary embolism but revealed significantly decreased lung volume. She continued to experience shortness of breath and temperature spikes for 3 more days. She was discharged on the seventh postoperative day despite shortness of breath.

Two days later, she experienced severe abdominal pain and shortness of breath at home and returned to the ED by ambulance. A CT scan revealed free pelvic air, ascites, and extensive inflammatory changes, likely due to bowel perforation. She was intubated and airlifted to a regional trauma center. During exploratory surgery, the surgeon aspirated a foul-smelling fluid and identified a perforation at the rectosigmoid junction; a colostomy was created. The patient stayed in intensive care for 5 days, developed renal failure, and was transfused due to acute blood loss. She was hospitalized for 19 days. The colostomy was reversed in October 2009.

PATIENT’S CLAIM The ObGyn was negligent in injuring the bowel during surgery and in not recognizing the bowel injury and treating it in a timely manner.

PHYSICIAN’S DEFENSE The case was settled during the trial.

VERDICT A $600,000 Virginia settlement was reached.

Pregnant woman stabbed: mother and baby die

A 20-YEAR-OLD WOMAN AT 30 WEEKS’ gestation was treated in the ED for a stab wound to the shoulder. The emergency medicine (EM) physician noted internal bleeding and a possible collapsed lung on radiographs, and began efforts to have the woman transferred. One facility declined because of her pregnancy. The patient was in pain and her ability to breathe declined. An airlift was finally arranged, but she suffered cardiac arrest as the helicopter arrived. A cesarean delivery was performed, but both the mother and baby died.

ESTATE’S CLAIM The EM physician was negligent in failing to perform a thoracotomy and arrange for a more timely transfer. The physician didn’t contact a hospital that was only 8 miles away.

DEFENDANTS’ DEFENSE The federal government, which operated the facility, admitted fault.

VERDICT A $7,267,390 Mississippi verdict included $5.45 million in noneconomic damages.

What caused child’s brain damage?

DURING LABOR AND DELIVERY, electronic fetal heart-rate monitoring indicated fetal distress. Meconium-stained fluid was present. The child was born with brain damage. It is unlikely that he will walk independently, talk in full sentences, or be able to perform daily activities independently.

PARENTS’ CLAIM The fetal heart-rate monitor indicated a need for emergency cesarean delivery. The quality and quantity of meconium should have alerted the caregivers to fetal distress and caused them to perform a cesarean delivery.

DEFENDANTS’ DEFENSE Fetal heart-rate strips did not indicate a need for emergency delivery until shortly before the delivery occurred. The underlying cause of the child’s injuries was an infection that spread to the brain and was irreversible.

VERDICT A $1.71 million Massachusetts verdict was returned.

When did bladder injury occur?

AN 84-YEAR-OLD WOMAN suffered recurrent bladder cancer. She underwent a cystoscopy, and then chemotherapy. Several weeks later, she was diagnosed with a bladder perforation became septic, and died.

ESTATE’S CLAIM The bladder was lacerated during cystoscopy; she would have survived if the laceration had been treated in a timely manner.

PHYSICIAN’S DEFENSE Bladder perforation during cystoscopy is a known risk of the procedure. However, the bladder was not perforated during cystoscopy; chemotherapy may have caused the perforation.

VERDICT A Michigan defense verdict was returned.

Fetal tracings poor: Why wasn’t an internal lead used?

AT 32 WEEKS’ GESTATION, a woman’s membranes ruptured, and she was admitted. Her ObGyn planned to induce labor at 34 weeks’ gestation. She experienced contractions on the morning of the scheduled induction. Although fetal heart-rate monitoring was reassuring, the fetus was in a compound position, with the chin leading. Labor progressed rapidly to 6-cm dilation. The fetal heart rate began to show recurrent mild variable decelerations that became increasingly deeper. Although the technical quality of the external monitoring was poor, no internal lead was applied.

After 3 hours, the tracing showed severe variable decelerations. The mother was fully dilated and began to push. The tracings were of poor quality, but interpretable portions showed minimal variability and significant decelerations during contractions. The fetal baseline heart rate became tachycardic. The obstetric nurse and resident continued to note abnormalities, but there is no evidence that they called the attending ObGyn. The fetal baseline heart rate reached 190 bpm with ongoing decelerations associated with contractions. Variability remained minimal to absent. After 2 hours of pushing, meconium-stained fluid was noted. The infant was born 1 hour later. The attending ObGyn was present for the last 30 minutes of labor.

The newborn’s Apgar scores were 1, 5, and 7, at 1, 5, and 10 minutes, respectively. His arterial cord pH was significantly low. MRI of the head showed subdural and intraventricular hemorrhage and evolving, profound hypoxic ischemic injury. At 1 year of age, the child suffers from a seizure disorder, cortical blindness, and severe developmental delays.

PARENTS’ CLAIM The nurse and resident failed to respond to fetal heart-rate abnormalities and failed to insert an internal lead to obtain better quality heart-rate tracings. They did not expedite delivery when fetal distress was evident.

DEFENDANTS’ DEFENSE The case was settled during trial.

VERDICT A $4.2 million Massachusetts settlement was reached.

Hypoxic ischemic encephalopathy

DUE TO PREECLAMPSIA, a woman was admitted to the hospital 5 weeks before her due date. Her condition was monitored for 2 weeks when it was decided to induce labor with oxytocin. After 3 hours in labor, the fetal heart-rate tracing began to show significant decelerations. The baby was born at 37 weeks’ gestation with severe hypoxic ischemic encephalopathy. The child died 2 years later from severe brain damage.

PARENTS’ CLAIM The ObGyns failed to respond to signs of fetal distress by performing an emergency cesarean. The brain images would have been different if a stroke-like event had occurred.

DEFENDANTS’ DEFENSE The fetus experienced an embolic process due to a compressed umbilical cord, resulting in a stroke-like vascular event, which led to the hypoxic ischemic encephalopathy.

VERDICT A $450,000 Wisconsin settlement was reached.

Postpartum high BP; mother suffers brain damage

HOSPITALIZED TWICE FOR HYPERTENSION in the month before her child was born, a 41-year-old woman gave birth to a healthy baby by cesarean delivery. The mother was discharged 2 days later with a blood pressure (BP) of 130/90 mm Hg.

Three days later, she went to her ObGyn’s office because she was not feeling well and had extreme swelling. Her BP, taken twice by a nurse, read 170/88 mm Hg, and 168/90 mm Hg, but she was not examined by the ObGyn.

That evening, the patient had difficulty breathing and was taken to the emergency department (ED), where she was intubated. She went into cardiac arrest and suffered permanent brain damage after being without a pulse for 15 minutes. She was in a coma for 45 days. She is unable to walk without assistance, is legally blind, and her hands are so contorted that she cannot feed herself. She suffers from short-term memory loss and has difficulty speaking.

PATIENT’S CLAIM The ObGyn should have examined her when she was at the office. Her hypertension would have been properly treated and injuries avoided. She had classic signs of postpartum cardiomyopathy.

PHYSICIAN’S DEFENSE The patient had not come to the office because she was feeling ill, but to show off her baby and have her BP checked. If he had been advised of the BP readings, he would have examined her.

VERDICT A $5 million Georgia verdict was returned.

Cervical biopsy results improperly reported

A 44-YEAR-OLD WOMAN UNDERWENT a cervical biopsy in July 2007 performed by a pathologist. A few days later, the pathologist contacted the patient and reported that the biopsy revealed invasive cervical cancer that required immediate surgery. Several procedures were performed without any cancer ever being found.

A second opinion was sought, and it was determined that the cancer diagnosis was incorrect; another patient’s pathology had been reported as the patient’s.

PATIENT’S CLAIM The pathologist and hospital were negligent in reporting incorrect results of the cervical biopsy, which resulted in the patient’s physical and emotional injuries, including unnecessary surgical procedures and depression and anxiety.

DEFENDANTS’ DEFENSE The defendants did not oppose the patient’s motion for summary judgment on liability; the issue of damages was contested.

VERDICT The patient received summary judgment on liability. She then discontinued claims against the pathologist, and the matter proceeded on damages against the hospital. A $46,000 New York verdict was returned. Stipulated medical expenses were added to the verdict for a total recovery of $60,979.

Brachial plexus injury: child has significant functional disability

AT 38 6/7 WEEKS’ GESTATION, a 23-year-old woman went to the ED with contractions. She had pregestational diabetes mellitus. Her admitting glucose level was 143 mg/dL, and she had gained 25 lb during pregnancy. Her fundal height was 40 cm, and estimated fetal weight was 4000 g (8 lb 13 oz). A pelvic examination determined that she was 3 to 4 cm dilated, 100% effaced, and at minus-1 station. She was given oxytocin to aid labor. The ObGyn noted that overall fetal heart-rate tracings were reassuring, and that a pediatrician would be present for delivery due to suspected macrosomia. Shoulder dystocia occurred during delivery, but it was resolved in 40 seconds. The mother sustained a second-degree perineal laceration.

At birth, the baby’s left arm was limp. Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Her birth weight was 10 lb 2 oz. A brachial plexus injury was diagnosed, and she underwent surgery in October 2008. Despite successful nerve grafts at C5 and C6, the child has significant functional disability in the left arm.

PARENTS’ CLAIM A cesarean delivery should have been scheduled when a macrosomic fetus was suspected.

PHYSICIAN’S DEFENSE The case was settled during trial.

VERDICT A $1,475,000 Maryland settlement was reached.

Breech position and umbilical cord prolapse: Was everything done that could be done?

DURING A MOTHER’S 38-WEEK PRENATAL VISIT, ultrasonography showed the baby was in breech position. The midwife offered two options: to schedule an external cephalic version procedure at 38 weeks or a cesarean delivery at 39 weeks. The parents agreed to schedule a cesarean delivery for 8 days later. The day before the scheduled birth, the mother awoke to find the umbilical cord between her legs. An emergency cesarean delivery was performed. The newborn required resuscitation and mechanical ventilation and suffered permanent brain damage attributed to hypoxia from umbilical cord prolapse.

PARENTS’ CLAIM The midwife’s negligence caused the baby’s injuries. Breech presentation put the pregnancy at high-risk. She did not have a physician examine the patient before scheduling a cesarean delivery and did not attempt to rotate the child back to a head-first position. She did not warn the parents about the risks of breech presentation and umbilical cord prolapse.

DEFENDANTS’ DEFENSE The choices given the parents were reasonable. Scheduling a cesarean delivery at 39 weeks was proper. A prolapsed cord is not predictable or preventable.

VERDICT A $12.6 million Pennsylvania verdict was returned against the midwife and the hospital; a confidential high/low agreement was reached.

Extensive adhesions result in bowel injury

A 58-YEAR-OLD WOMAN UNDERWENT exploratory laparotomy in May 2009. There were extensive adhesions, and the gynecologist used blind, blunt dissection to resect a large pelvic mass adhered to the sidewall. He had difficulty removing the specimen because it was too large to fit through the incision. A left salpingo-oophorectomy was also performed.

On the second postoperative day, the patient reported shortness of breath, intermittent chest pain, and had a fever of 103° F. The next day, she was unable to ambulate due to shortness of breath. CT results ruled out deep vein thrombosis or pulmonary embolism but revealed significantly decreased lung volume. She continued to experience shortness of breath and temperature spikes for 3 more days. She was discharged on the seventh postoperative day despite shortness of breath.

Two days later, she experienced severe abdominal pain and shortness of breath at home and returned to the ED by ambulance. A CT scan revealed free pelvic air, ascites, and extensive inflammatory changes, likely due to bowel perforation. She was intubated and airlifted to a regional trauma center. During exploratory surgery, the surgeon aspirated a foul-smelling fluid and identified a perforation at the rectosigmoid junction; a colostomy was created. The patient stayed in intensive care for 5 days, developed renal failure, and was transfused due to acute blood loss. She was hospitalized for 19 days. The colostomy was reversed in October 2009.

PATIENT’S CLAIM The ObGyn was negligent in injuring the bowel during surgery and in not recognizing the bowel injury and treating it in a timely manner.

PHYSICIAN’S DEFENSE The case was settled during the trial.

VERDICT A $600,000 Virginia settlement was reached.

Pregnant woman stabbed: mother and baby die

A 20-YEAR-OLD WOMAN AT 30 WEEKS’ gestation was treated in the ED for a stab wound to the shoulder. The emergency medicine (EM) physician noted internal bleeding and a possible collapsed lung on radiographs, and began efforts to have the woman transferred. One facility declined because of her pregnancy. The patient was in pain and her ability to breathe declined. An airlift was finally arranged, but she suffered cardiac arrest as the helicopter arrived. A cesarean delivery was performed, but both the mother and baby died.

ESTATE’S CLAIM The EM physician was negligent in failing to perform a thoracotomy and arrange for a more timely transfer. The physician didn’t contact a hospital that was only 8 miles away.

DEFENDANTS’ DEFENSE The federal government, which operated the facility, admitted fault.

VERDICT A $7,267,390 Mississippi verdict included $5.45 million in noneconomic damages.

What caused child’s brain damage?

DURING LABOR AND DELIVERY, electronic fetal heart-rate monitoring indicated fetal distress. Meconium-stained fluid was present. The child was born with brain damage. It is unlikely that he will walk independently, talk in full sentences, or be able to perform daily activities independently.

PARENTS’ CLAIM The fetal heart-rate monitor indicated a need for emergency cesarean delivery. The quality and quantity of meconium should have alerted the caregivers to fetal distress and caused them to perform a cesarean delivery.

DEFENDANTS’ DEFENSE Fetal heart-rate strips did not indicate a need for emergency delivery until shortly before the delivery occurred. The underlying cause of the child’s injuries was an infection that spread to the brain and was irreversible.

VERDICT A $1.71 million Massachusetts verdict was returned.

When did bladder injury occur?

AN 84-YEAR-OLD WOMAN suffered recurrent bladder cancer. She underwent a cystoscopy, and then chemotherapy. Several weeks later, she was diagnosed with a bladder perforation became septic, and died.

ESTATE’S CLAIM The bladder was lacerated during cystoscopy; she would have survived if the laceration had been treated in a timely manner.

PHYSICIAN’S DEFENSE Bladder perforation during cystoscopy is a known risk of the procedure. However, the bladder was not perforated during cystoscopy; chemotherapy may have caused the perforation.

VERDICT A Michigan defense verdict was returned.

Fetal tracings poor: Why wasn’t an internal lead used?

AT 32 WEEKS’ GESTATION, a woman’s membranes ruptured, and she was admitted. Her ObGyn planned to induce labor at 34 weeks’ gestation. She experienced contractions on the morning of the scheduled induction. Although fetal heart-rate monitoring was reassuring, the fetus was in a compound position, with the chin leading. Labor progressed rapidly to 6-cm dilation. The fetal heart rate began to show recurrent mild variable decelerations that became increasingly deeper. Although the technical quality of the external monitoring was poor, no internal lead was applied.

After 3 hours, the tracing showed severe variable decelerations. The mother was fully dilated and began to push. The tracings were of poor quality, but interpretable portions showed minimal variability and significant decelerations during contractions. The fetal baseline heart rate became tachycardic. The obstetric nurse and resident continued to note abnormalities, but there is no evidence that they called the attending ObGyn. The fetal baseline heart rate reached 190 bpm with ongoing decelerations associated with contractions. Variability remained minimal to absent. After 2 hours of pushing, meconium-stained fluid was noted. The infant was born 1 hour later. The attending ObGyn was present for the last 30 minutes of labor.

The newborn’s Apgar scores were 1, 5, and 7, at 1, 5, and 10 minutes, respectively. His arterial cord pH was significantly low. MRI of the head showed subdural and intraventricular hemorrhage and evolving, profound hypoxic ischemic injury. At 1 year of age, the child suffers from a seizure disorder, cortical blindness, and severe developmental delays.

PARENTS’ CLAIM The nurse and resident failed to respond to fetal heart-rate abnormalities and failed to insert an internal lead to obtain better quality heart-rate tracings. They did not expedite delivery when fetal distress was evident.

DEFENDANTS’ DEFENSE The case was settled during trial.

VERDICT A $4.2 million Massachusetts settlement was reached.

Hypoxic ischemic encephalopathy

DUE TO PREECLAMPSIA, a woman was admitted to the hospital 5 weeks before her due date. Her condition was monitored for 2 weeks when it was decided to induce labor with oxytocin. After 3 hours in labor, the fetal heart-rate tracing began to show significant decelerations. The baby was born at 37 weeks’ gestation with severe hypoxic ischemic encephalopathy. The child died 2 years later from severe brain damage.

PARENTS’ CLAIM The ObGyns failed to respond to signs of fetal distress by performing an emergency cesarean. The brain images would have been different if a stroke-like event had occurred.

DEFENDANTS’ DEFENSE The fetus experienced an embolic process due to a compressed umbilical cord, resulting in a stroke-like vascular event, which led to the hypoxic ischemic encephalopathy.

VERDICT A $450,000 Wisconsin settlement was reached.