Excerpt from, “Patients’ Rights and Doctors’ Wrongs® – Secrets to a Safer Pregnancy and Childbirth”
Howard A. Janet, Esquire – CPFN Legal Advisor
and Giles H. Manley, MD, JD – CPFN Medical Advisor
As she is wheeled into the operating room (OR), Michelle braces to the rush of cold air and squints into the harsh glare of the overhead lights. She is familiar with the delivery room. This is her second baby and her second C-section. As the orderlies position and drape her, she glances around at the equipment and staff. The entire obstetrical team is busily preparing for what they expect to be an uncomplicated delivery. Her heart races with excitement.
It is 7:30 p.m. Michelle has been at the hospital since a little after midnight, when she was admitted because of ongoing contractions. She wasn’t officially in labor, and she won’t be until her cervix either begins to dilate or efface.
Michelle is thirty-eight weeks pregnant, far enough along to be considered full-term. Her obstetrician has scheduled a C-section at thirty-eight and one-half weeks, with delivery to be moved up only if Michelle’s contractions produce cervical changes. Meanwhile, the plan is to monitor her baby’s well-being and observe Michelle for signs of labor.
The initial electronic fetal monitoring tracings showed her baby was doing fine. Throughout the day, little Tanya’s heartbeat has remained strong. The labor and delivery staff continued the fetal monitoring until just after 6:00 p.m., about the time Michelle’s obstetrician arrived at the hospital.
Now, after about twenty hours of contractions, Michelle’s cervix has dilated, indicating she is in labor. Three more hours go by without significant change. Her OB diagnoses an arrest of labor and calls for a C-section. Her baby will be born tonight! Bone-tired and in pain, she focuses on her breathing and the thought that the worst of her labor is likely over.
Behind Michelle, the anesthesiologist prepares to administer the epidural in preparation for the C-section. Michelle breathes deeply. I’ve done this before. I know what to expect. In a few minutes the pain will be gone, and my daughter will be in my arms.
At 7:40 p.m., the anesthesiologist administers the epidural injection. Michelle feels pressure as the needle slips between her vertebrae. Almost instantly, she senses the familiar prickling sensation in her toes. A moment later, her abdomen and pelvic area begin to tingle. As the pain eases, she begins to relax.
But Michelle’s serenity is fleeting. Shortly after receiving the injection, a sickening wave of nausea washes over her. Her stomach turns, and her throat fills with bile. Everything and everyone around her begins to spin.
Michelle knows this feeling. It is the same nausea and lightheadedness she experienced when her blood pressure dropped sharply just after she received an epidural for the delivery of her first baby. Her obstetrician and anesthesiologist are aware it happened before, and should be watching for it with this delivery.
Michelle searches the faces in the room for her obstetrician, but he is not there. The only doctor she sees is the anesthesiologist, who confirms her low blood pressure and gives her medication that elevates it within ten to fifteen minutes. “Don’t worry,” he says. “We’re monitoring you closely. We’ve got it under control.”
Minutes crawl by like hours. Finally, Michelle’s obstetrician enters the OR and bends over his patient. “Are you ready, Michelle? Let’s deliver your baby girl.”
Baby Tanya is born at 8:34 p.m. From the moment of birth, it is obvious her appearance and behavior are not normal. She is not crying or moving, and she is terribly pale. Tanya’s heart rate, respiration, muscle tone, skin color, and response to stimuli are all extremely deficient.
Within the first twenty-four hours of life, Tanya develops seizures – a telltale sign she has suffered a brain injury from lack of oxygen shortly before delivery. Over the first year of life, Tanya exhibits concerning signs of developmental delay. It isn’t long before she is formally diagnosed with cerebral palsy.
What Went Wrong and Why
Michelle’s story sheds light on the most common complications that occur when expectant mothers receive regional anesthesia – maternal hypotension (abnormally low blood pressure) and slowing of the fetal heart rate. Mothers experience hypotension in 25 to 40 percent of pregnancies. Babies develop non-reassuring fetal heart rate patterns up to 25 percent of the time, necessitating approximately 2,000 emergency C-sections each year in the United States. When obstetrical and anesthesia personnel exercise the requisite degree of vigilance, permanent injury to baby and mother can be avoided.
This chapter and the one that follows explain what constitutes the proper degree of vigilance. They also point out the kinds of avoidable mistakes to which some mothers and babies can be subjected. The information that follows will empower you to ensure your health care providers take the necessary measures to protect your baby’s well-being and your own.
Two serious complications developed soon after Michelle received epidural anesthesia for her C-section, but the medical providers in the OR recognized and corrected only one – Michelle’s sharp decline in blood pressure. The other complication, a dangerous drop in baby Tanya’s heart rate, went unnoticed and uncorrected until after her birth.
The OR staff did nothing about it because they didn’t know about it. They didn’t know because they didn’t check. In fact, no one monitored the baby’s heart rate for the entire period Michelle was in the operating room – not before the epidural, not after the injection, and not even after her hypotensive episode.
Despite an order given by the obstetrician for continuous electronic fetal heart monitoring, the obstetrical nurses discontinued EFM a full hour and a half before Michelle was moved to the operating room. They never resumed it. Michelle’s obstetrician wasn’t even present in the operating room when her epidural was administered.
Both maternal hypotension and a dangerously low drop in the baby’s heart rate are undesirable side-effects that can occur following the administration of epidural anesthesia for a C-section. The chance of the baby’s heart rate falling to an unsafe level exists even if the mother does not become hypotensive. That risk increases when the mother experiences a hypotensive episode. But in Michelle’s case, even the mother’s hypotensive episode failed to trigger an assessment of baby Tanya’s heart rate.
Once the mother’s blood pressure returns to a normal level, the potential for crisis is not over. There is no guarantee the baby’s heart rate will return to normal, even if the mother’s blood pressure normalizes. To be certain of the baby’s well-being following administration of epidural anesthesia for a C-section, regardless of whether the mother becomes hypotensive, either external fetal monitoring or internal monitoring should be continued virtually up until the moment of birth.
If external fetal monitoring is being used, it should be continued until the mother’s abdomen has been sterilized with antiseptic solution, and delivery should be completed within several minutes thereafter. With internal monitoring – which does not pose the same concerns about contaminating the sterile surgical field as external fetal monitoring – there is no reason to discontinue monitoring until the OB begins the C-section.
While Tanya’s heart pumped at a dangerously slow pace, her brain and other vital organs were being deprived of an adequate flow of oxygen. Because of the extensive amount of time that elapsed from the onset of this complication until the time of delivery, Tanya sustained permanently life-altering brain damage. The C-section should have been started, at the very latest, when her mother’s blood pressure normalized. The procedure would have been completed within several minutes, and Tanya would have escaped any permanent impairment.
Inexcusable oversights by Michelle’s obstetrical and anesthesia teams, poor communication between the two teams, and faulty hospital policy – all were responsible for the tragic turn of events shortly before Tanya’s birth that changed her life forever.
The actions and inactions of Michelle’s delivery team and the hospital were completely contrary to even the most minimal standards expected today.
The Obstetrical Team
The obstetrician bears responsibility for failing to be in the delivery room when the anesthesiologist gave the epidural injection. He checked on Michelle and her baby when he arrived at the hospital just after 6:00 p.m., but never looked in on them again until he was called to perform the C-section. If he had, he would have realized the baby’s status was unknown – an extremely unsafe circumstance. Further, although he knew an epidural takes effect within approximately ten to fifteen minutes, he never investigated why more than double that amount of time passed before he was called to surgery.
Michelle’s obstetrician also failed to ensure both Michelle’s and Tanya’s reactions to the epidural would be monitored.
Finally, when he did arrive in the delivery room, the obstetrician neglected to ask about the condition of either mother or baby. He assumed both of them were being monitored closely and he would be told if there were any complications. In view of his knowledge about the hospital’s policies and practices with respect to staffing the OR for C-sections, he lacked any reasonable basis to make such an assumption.
Hospital Policies and Procedures
Those very staffing policies and practices, which fell well below generally accepted hospital standards, substantially factored into the failure to adequately monitor Tanya’s state of health in the OR. As a matter of policy and practice, the hospital did not require monitoring fetal well-being following administration of an epidural for C-section. Once Michelle was in the operating room, there was no way to monitor her baby’s well-being, as the hospital failed to equip the OR with an EFM or a Doppler/Doptone (a hand-held ultrasound device that gives a digital readout of the FHR).
Consistent with the hospital’s substandard policies and procedures, the nurse in the operating room was concerned only with preparing Michelle for surgery. She was not charged with the responsibility of performing fetal monitoring, and the hospital provided her no means by which to accomplish it. Tanya was unmonitored the entire time she was in the delivery room. And that followed on the heels of the obstetrical nurse’s failure to monitor her for the previous ninety minutes.
The Anesthesia Team
The members of the anesthesia team completely disregarded their second patient, baby Tanya. They recognized Michelle’s hypotensive episode and took appropriate steps to correct it, but they failed to address the potentially dangerous effects it could have on her baby. They turned a blind eye to the baby’s well-being, even though they knew there was no fetal monitoring equipment in the OR.
Michelle’s anesthesiologist and the nurse anesthetist assisting him knew about the hospital’s deficient monitoring policy and observed that no one in the delivery room was monitoring Tanya. They knew the baby could develop adverse side effects from the epidural her mother received. Nevertheless, they accepted those circumstances and subjected Tanya to the associated risk.
Their conduct became even more indefensible once they became aware of Michelle’s hypotension – a clear signal the dangers to Tanya had increased. They did not coordinate fetal monitoring, and they did not immediately summon Michelle’s obstetrician, who was within earshot of the delivery room. After Michelle’s obstetrician finally arrived in the OR, neither the anesthesiologist nor the nurse anesthetist informed him about the drop in Michelle’s blood pressure. Oblivious to Tanya’s condition and the hypotensive episode Michelle had experienced, the obstetrician proceeded with the C-section in a routine manner instead of delivering her emergently, as the circumstances required.
Failure to Inform
Michelle knew the signs and symptoms of hypotension from her previous delivery, but she had no knowledge of its potential effects on her unborn child. Her first baby had been able to tolerate the regional anesthesia and his mother’s hypotension. If Michelle had been adequately informed of the risk regional anesthesia for C-section poses to babies, she would have insisted her baby be adequately monitored and delivered without undue delay. She would have known it wasn’t enough for the OR staff to monitor and care solely for her.
We’re Here to Help
There are two patients in the labor and delivery suite – mother and baby – and the importance of monitoring them both cannot be overstressed. Medical errors of this type, and the resulting permanent injury to a child, occur far too often. If you believe medical mistakes at birth cause your child’s cerebral palsy, contact the Cerebral Palsy Family Lawyers at Janet, Janet & Suggs for a free, no-obligation case review.