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Asphyxia and Birth Trauma Case

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Posted: May 10, 2016

To summarize briefly, Mrs. AC was a 24 year old, g1 p0 edc on 6/23/04. Her antepartum course appears to be uncomplicated. She appears to have had excessive weight gain of around 36 to 41 lbs. She was admitted for induction of labor on 6/17/04. There appears to be no medical indication for the Induction Of Labor(IOL). No indication was on the order sheet for the IOL.

Her cervix was unfavorable and a foley was placed in her cervix on 6/16/04 in the office. The foley fell out and the IOL was continued. Eventually Pitocin was started at 07:33 hrs. The patient progressed and had variable and late decelerations starting around 15:40 hrs. These decelerations were noted by the RN’s and are evident on the EFM. She was fully dilated at 18:30 hrs. Because of the decelerations, the physician performed a manual rotation from the OP to the OA position. There is a question as to whether it was purely a manual rotation. The MD note states that the head was rotated from the OP to the OA position and then an outlet forceps was applied. This does not correlate with other notes in the chart where the last pelvic exam was at +2, the forceps were placed at 20:07, off at 20:09, on at 20:10 and the head was brought down, and off at 20:11. This is a description of a mid-forceps rotation, which is associated with a much higher incidence of trauma.

The patient was delivered of a live male infant at 20:12 hrs.,  6lbs, 10 oz., Apgars 4 and 7 at one and five minutes. She was GBS negative and I did not see any cord gases. Pediatrics was present and there were resuscitative efforts. Initially no issues were noted, but eventually the baby appeared to have seizures, was worked up, placed on antibiotics and phenobarbital, and transferred. I have no subsequent medical records for the baby so I cannot clearly state the etiology of the seizures but they may be asphyxia related and/or birth trauma related.There are a number of issues in this case. There is no indication as to why the patient had an IOL. I did not see any evidence of a medical or obstetrical indication, any notation of a medical indication, or any evidence of a discussion with the patient as to the alternatives, risk, or benefits of continuing to wait for natural labor vs. an IOL. It is well recognized that an IOL carries increased risks and these should be discussed with the patient.

As to the technique of the IOL, they were all standard of care. Foley balloons, Cervidil, Cytotec, and low dose or high dose Pitocin in succession or combination are all recognized methods. The key is to avoid hypertonic contractions, which are more than 5 uterine contractions in 10 minutes, or abnormal fetal heart rate patterns, both of which were present in this case. The nurses notes clearly state the uterine contractions were present every 1 ½ to 2 ½ minutes. Looking at the EFM, there were many periods of time in which there were more than 5 contractions in 10 minutes, which is contraindicated and a departure from good and accepted standards of medical care.

In addition, there were clearly variable and late decelerations starting around 15:30 hrs. which continue until the baby is delivered. The Apgar score of 4 is moderately depressed and the Apgar score of 7 is normal. I did not see any cord blood gases to determine if there was any chemical evidence of hypoxia or acidosis. The tracing is very suspicious and birth asphyxia is a possibility.

In addition, there appears to be a discrepancy in the MD vs. the RN description of the forceps. Outlet forceps are usually when the head is already crowning and that is usually at +4 or more. The last recorded station was +2 which would be a mid-forceps. The station also depends on which criteria the physician is using, some at +4, 5 and possibly others. However, at +2 cm is a mid-forceps and going form OP to an OA is a rotation. The MD note says it was a manual rotation but the forceps were applied twice and the head was “brought down” which describes mid-forceps rotations. If it’s a mid-forceps rotation, this would increase the likelihood of birth trauma. There is no evidence that a discussion as to the risks and benefits of a manual rotation, mid-forceps, outlet forceps, vs. a cesarean section was conducted with the patient.

Failure to discuss alternatives, risk and benefits with the patient is a departure from good and accepted standards of medical care. Failure to recognize a mid-forceps rotation and characterize it as an outlet forceps is a departure from good and accepted standards of medical care.

Whether this was a traumatic delivery, I cannot say with certainty since I don’t have any subsequent records from the baby showing things like CAT scans or MRI’s, which could show evidence of birth trauma, such as fractures or intracranial bleeds. There could easily be a combination of hypoxia and trauma.

My opinions are to a reasonable degree of medical certainty. I reserve the right to change my opinion as more evidence becomes available.