As a medical student you get a rotation on Obstetrics. I was no exception. We were a group of 11 students on rotation for deliveries and as it worked out, I seemed to be called only after 10PM. I recall one night I was on the labor floor talking with the nurses about 2AM waiting. At that time we got a call from the ER saying that a patient in labor had arrived and that they were sending her up to Obstetrics. I looked for a resident—none could be found. I looked for an intern—none could be found. Just me and the nurses, who knew much more than I did. Up comes this elevator and with it the woman in labor. When she saw me, I must have looked very pale, and in response she said: “This is my twelfth child—I will tell you what to do.” She did and the baby was delivered without any issue
Most pregnancies, labors and deliveries are like that. Anyone can deliver such a child including the local policeman, fireman or neighbor. Physicians, labor room nurse, midwives are trained to anticipate and be prepared to appropriately manage the exception.
Some exceptions can be anticipated. That is the reason that prenatal care is provided and suggested. Some exceptions arise and cannot be anticipated but can be managed.
It is when the exception occurs and is not properly managed that we, as lawyers become involved as the results can be devastating to the child and the family. The technological advancements available to monitor a labor and delivery have changed remarkedly over the past few years.The actual physical monitoring of the patient by the physician or nurse has been replaced by machines that can listen to the heartbeat and trace the progress of the labor. However, while the machines have improved and our ability to monitor a labor has improved, the information emanating from the machines is valuable only if looked and understood by those present.
That is not always the case.
CASE 1. Patient in labor enters the hospital and is attached to an external fetal monitor. A fetal monitor is a device that listens to and reports and records the fetal heart rate. The fetal heart rate reflects the status of the fetus in utero. By monitoring the fetal heart rate, the staff are able to get a picture into what is going on and whether or not the fetus is suffering any distress regardless of cause.
The fetal heart rate may change if the umbilical cord is around the fetus’ neck. The fetal heart rate may change if the contractions are too long, and the fetus is compressed for too long a period of time.
In this case an external fetal monitor was applied. Absolutely appropriate. The recordings indicated that the heart rate was within normal limits yet at the time the baby was delivered it was blue, indicating a lack of oxygen and had a heart rate below 60. The baby was severely brain damaged.
What went wrong? A review of the data led to a simple conclusion. The monitor was picking up the mother’s heart rate and not that of the fetus. The staff did not realize that they were monitoring the wrong heart rate. The conclusion was that they should have been aware of their error due to a lack of variability of the heart rate for the length of time the heart was being monitored. Had they done so, and had they been aware of the changes an immediate C-section would have been the appropriate treatment. The damage to the child would have been avoided.
CASE 2: The term used above is “immediate C-Section.” The second case for discussion was inexplicable to us. Every Obstetrical department in a major institution is geared to handle the unexpected and Obstetricians know how to perform emergency C-sections. They have to be done carefully, but they are not complicated procedures and time is of the essence.
In our second case, the determination was made that the fetus was experiencing some distress and there was a need to deliver the baby. From the time that decision was made until the time the delivery occurred two hours had passed. Two hours during which the fetus was showing signs of distress. It was as if the staff were functioning in slow motion. No rationale for the behavior was to be found in the chart. There were no external factors, no hurricane, no great blizzard, just a normal Fall day. End result: a brain damaged baby. In order to determine what occurred, the records were obtained, the fetal monitor strips were obtained, and the events plotted out from the time of admission to the time of actual delivery. A slow decline in the functioning of the fetus was noted.
Another avoidable injury.