When—and why—was this newborn’s brain injured?
A PREGNANT WOMAN at 34 weeks’ gestation, with a family history of hypertension, experienced swelling of her feet and ankles. She called the midwife prenatal clinic where she was receiving care and was advised to elevate her feet. The next day she called again to report decreased fetal movement, severe edema in her feet and ankles, dizziness, and blurred vision. She was sent to the hospital, where her normal blood pressure and urine protein measurement ruled out preeclampsia. A nonstress test was initially nonreactive and then became reactive, and a biophysical profile score was reassuring. After the results were reported to her certified nurse-midwife, the patient was discharged and instructed to perform fetal kick counts to monitor fetal movement. She was also instructed about preeclampsia. Two weeks later, at 36 weeks’ gestation, she reported contractions, low back pain, headache, and swollen feet and ankles. She was sent to the hospital, where her blood pressure was found to be severely elevated, her urine protein was 3+, and fetal heart tones were nonreassuring. The infant was born 1 hour 14 minutes later by emergency cesarean delivery performed by the ObGyn, who had been delayed by another birth. Mild placental abruption was noted; the child had low Apgar scores, decreased respiratory effort, and low cord blood gases. Diagnoses of birth depression and hypoxic–ischemic encephalopathy were given, and periventricular leukomalacia was evident on head imaging. The child has cognitive deficits and cerebral palsy.
PATIENT’S CLAIM She should have been admitted to the hospital for observation and 24-hour urine testing; then her elevated blood pressure and urine protein level would have been discovered in time for delivery before injury to the infant. Also, because of the nonreassuring fetal monitor tracing, delivery should have been performed earlier that day.
PHYSICIAN’S DEFENSE The fetus was injured in utero a month or more before birth, as periventricular leukomalacia usually occurs at 28 to 32 weeks’ gestation. Also, the patient was properly discharged, because there was no evidence of preeclampsia and the fetal status was reassuring.
VERDICT $1.625 million Michigan settlement.
OB: “Don’t blame me” for faulty IUD placement by nurse
A NURSE UNDER THE SUPERVISION of an obstetrician placed an intrauterine device (IUD) in a patient, but at a follow-up visit the nurse could not see the string of the IUD. Ultrasonography showed the IUD was not in the woman’s uterus. It was removed by laparoscopic surgery.
PATIENT’S CLAIM The nurse placed the IUD incorrectly and, as a result, the uterus was perforated. Also, the physician’s supervision of the nurse was inadequate.
PHYSICIAN’S DEFENSE Not reported.
VERDICT $379,906 Arkansas verdict against the nurse only.
Sexually inactive woman delivers 12-lb stillborn
A 28-YEAR-OLD MORBIDLY OBESE WOMAN presented at the emergency room with low-back pain. Dr. A examined her but could not find a cause for the pain. She then went to Dr. B, an ObGyn, and reported pelvic pain. She admitted having infrequent periods and being sexually inactive. Dr. B performed no pregnancy test and, because of her size, could not palpate the uterus. Dr. A examined her again 10 days later. A few days after that, an x-ray showed a deceased fetus in a breech position. A 12-lb stillborn infant was delivered later that day.
PATIENT’S CLAIM Dr. A and Dr. B were negligent for not diagnosing the pregnancy. Despite her denial of sexual activity, they should have ordered a pregnancy test, which would have discovered the fetus and allowed the birth of a healthy baby. Instead, the fetus died 2 days before delivery.
PHYSICIAN’S DEFENSE Given the history and presentation of the mother, Dr. B claimed his care was reasonable. Also, the fetus died before the mother came to him.
VERDICT Kentucky defense verdict for Dr. B. Before a trial, Dr. A settled for an undisclosed amount.