Baby’s death in infancy blamed on difficult birth
A woman who was receiving prenatal care from a family medicine practice had a positive 1-hour glucose test, but never took the 3-hour glucose test. She later went into preterm labor and delivered a child vaginally at 34 to 36 weeks’ gestation. Shoulder dystocia occurred during delivery and a nuchal cord was present. An attempt to reduce the cord failed, and it was clamped and divided. Although the child was born depressed, he was resuscitated successfully. He later was diagnosed with hypoxic–ischemic encephalopathy. His neurological status degenerated, and he died at 3 months.
Patient’s claim Negligence occurred in several areas: failure to order a 3-hour glucose test; failure to refer the patient to an OB; failure to order a tocolytic to stop premature labor; and use of too much force to reduce the nuchal cord.
Doctor’s defense An OB consult was not required as this pregnancy was not high-risk; tocolytic treatment was not indicated; and a problem with the cord integrity caused its rupture, not excessive force. Also, a sonogram on the first day of life showed periventricular leukomalacia, indicating that a hypoxic event had occurred in utero and caused the hypoxic–ischemic encephalopathy.
Verdict Illinois defense verdict.
Shoulder dystocia is part of the complexity of birth problems in the first two cases in this installment of Medical Verdicts. Learn how an expert clinician sheds light on this condition in "Shoulder dystocia: Clarifying the care of an old problem"
Did the forces of labor cause Erb’s palsy?
During a delivery marked by shoulder dystocia, the McRoberts maneuver and suprapubic pressure were used. The infant suffered injury to her brachial plexus, resulting in paralysis of the brachial plexus, shoulder, and upper arm on the right side. The child now receives physical therapy for her injury, which has caused her to be left-side dominant.
Patient’s claim The delivering physician used excessive pressure. Shoulder dystocia should have been expected because of the large fetal size.
Doctor’s defense The physician claimed that he had handled the dystocia properly and avoided possible brain damage. He also argued that the shoulder dystocia could not have been predicted. The brachial plexus injury was caused by the natural forces of labor, which were especially pronounced because the mother weighed 350 pounds.
Verdict Pennsylvania defense verdict.
Severe retardation after troubled delivery
A woman pregnant with her third child presented at a hospital in the early stages of labor. Her second child had been delivered by cesarean section. The morning after her admission, a physician noted that the pregnancy was at term and characterized by a failed trial of labor and cephalopelvic disproportion. He recommended that the woman undergo cesarean section due to failure to progress. Fetal heart tracings were within normal limits.
The woman was given general anesthesia and underwent a nonemergency cesarean section, during which uterine dehiscence was found. The child was pale, floppy, and bradycardic, lacked respiration, and had an initial Apgar score of 1.
Patient’s claim A first-year resident not fully trained in obstetrics observed repetitive decelerations on the fetal heart tracings. An emergency cesarean section should have been performed more than 2 hours before the actual delivery because of nonreassuring fetal monitor strips and evidence of uterine rupture. The child suffered hypoxic–ischemic encephalopathy, resulting in brain damage and severe mental retardation.
Doctor’s defense The doctor maintained that he had seen the child’s head during delivery, with no myometrial membranes covering it, and had used a catheter to suction the infant to prevent aspiration of meconium. The child was depressed at birth due to the anesthesia administered to the mother, but recovered and had a normal Apgar of 7 at 5 minutes after meconium was suctioned from the airway.
The physician also argued that the infant had a normal neonatal course and was moved to a regular nursery, where he thrived. He did not suffer hypoxia, multiple organ failure, or seizures during the neonatal period. Febrile seizures at 21 months resulted from a seizure disorder not related to an injury at birth.
Verdict $300,000 Illinois verdict against the physician; $4 million settlement with the hospital.
Did delay in diagnosis alter cancer outcome?
After finding a lump in her breast, a 28-year-old woman went to her ObGyn, who ordered a biopsy but did not obtain the biopsy results or follow up. Four months later, the woman consulted a second physician and was diagnosed with breast cancer. She underwent lumpectomy, chemotherapy, and radiation.
Patient’s claim Her cancer diagnosis was delayed because of the inaction of the first ObGyn, decreasing her chances of survival from 80% to 40%.