Claim of Malpractice with Multiple Failures and Mismanagement Of Labor and Delivery

Factual Basis of Claim:

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a. Patient AB became pregnant in 2014. Her estimated due date was March 19, 2015. Clinic residents provided prenatal care. On December 3, 2014, AB was noted to have blood in her urine, which continued throughout her pregnancy.

b. The patient presented to the hospital during her prenatal period a total of four times. Her complaints consisted of cramping, abdominal pain, and headache. She was evaluated each time and discharged home.

c. On March 15, 2015 around 1930, AB presented to the hospital for a planned induction of labor due to blood in her urine for the last 4 months. EGA: 393/7 weeks of gestation.

d. At 2002 her contractions were irregular. Cx: 1-2/40-50/-3. Bishop 4.

e. At 2100, baseline fetal heart rate was 135. Reactive with moderate variability. Cytotec (? dose). At 2200 BL was 145.

f. On March 16, 2015 at 0003-0110, BL mod, fhr: 155 with variable decels. Cx: 1-2/50/-3.

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g. 0200 – BL 145; mod variability and reactive. At 0505: Cx: 2.5/50/-3.

h. 0800 – BL 130; one late deceleration noted. (At 0509 a resident discussed starting Pitocin with Dr. DS, who did not want Pit started at that time.) By 0505 AB reported decreased discomfort and pain: 6/10. Fhts: documented Cat 1 tracing.

I. 0930 – Pitocin started at 1mu/min. At 1100, Pitocin was increased to 3mu/min. Pit was increased to 4mu at 1130.

j. 1324 – CLE placed with AROM at 1345; thick meconium noted. VE: 3/60/-3. UCs q 2-3/reported strong. Cat 1 tracing. 1600 – variable decelerations; Cat 1 per resident. Pit at 8mu.

k. 1900 – Pitocin at 13mu. BL 140’s mod var and late decels x 2. 1930 – cx: 4-5/80/-3 per resident. Continue expectant management.

l. 2015 – Cat II variables. 2044 – back to Cat 1. 2044 – Cat II variables, late decels. 2100 – BL 140’s late variable decels. 2229 – Cx: 8.5/90/-3 – caput. Cat 1.

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m. 2315 – 2355 Cat II variables. BL 165(rising) – tachycardia. 0035 – BL 170-180; Sinusoidal pattern. Cat III. 0055 – Patient complete and -2. Pitocin continues. Hypertonus >25mmHg.

n. 0114 – Cat II variables; tachycardia. 0200 – Cat III; late decels. (Over an hour to deliver, at this point. 0210 – Cat III Pt complete and still -2. Variable and Late decelerations. The plan by the attending physician was to continue expectant management.

o. 0230-0250 – replaced FSE. VE: complete and +2 –> caput. Pt pushing. 0259 – Vacuum applied. Back to external monitoring. Lates and variable decelerations.

p. 0307 – Pop-off x1. Vacuum assists x 3 sets. Tachycardia with recurrent late decelerations. Attending present and consent obtained for C-section.

Infant delivered at 0327—no respiratory effort at birth. PPV started. Apgars 2,5, and 8. Infant noted to have severe molding and caput; bruising and scalp lacerations. Baby was transferred to the NICU where he spent 14 days. Brain imaging revealed multiple large areas of infarction consistent with severe hypoxic ischemic encephalopathy.

Breaches in Standards of Practice:

-Failure to diagnose fetal intolerance of labor by 0000 March 16, 2015 and delivery by cesarean section promptly. Failure to function competently as a team. Further: Pitocin mismanagement: never discontinued Pitocin in the midst of: persistent hyperstimulation, tachycardia, decreased variability, sinusoidal pattern, Cat III tracing, and hypertonus => all mismanaged. These providers essentially ignored all the signs of this baby’s fetal distress. Furthermore, imaging shows injury to the posterior skull from pulling the baby, hard, with the vacuum. First and second-year D.O. residents were completely managing this labor and delivery with minimal involvement of the attending until the situation was desperate.

Relevance for Practice

Situation:

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Practicing certified nurse-midwifery in hospital settings with resident training programs should cause you to be very aware of your role if you are involved in a case that is going wrong. In this case, there were no midwives, but the nursing involvement was negligent. Experienced nurses should have been aware that the residents were making dreadful mistakes. It was their duty to inform the attending physician of the patient's condition and the care decisions made by second-year residents. Of course, many CNMs practice in teaching hospitals and support residents with deliveries. Although the physicians are making care decisions, astute midwives would have recognized the malpractice and taken action.

Vulnerability:

If you are involved in a delivery with residents, you can be liable, along with them, if they are mismanaging the situation. You know what to do. You speak up and you contact the attending immediately. The management in this case was flagrant malpractice.

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Expectation and Duty:

In these situations, you owe a duty of care to the patient. You are required to act on the patient’s behalf, especially when there are monitor tracings with Cat II for longer than thirty minutes. If the tracing devolves into Cat III, these residents are done fooling around with the patient. The fact that these residents were wasting time in a dire situation indicates that others present during that labor and delivery were also failing in their duty to be aware of and act upon a deteriorating situation.

Remedies and Protection:

Although it may feel as if it is not your responsibility to consider legal standards in cases like this, mismanagement in your presence should require you to recognize standards of practice and serious negligence that may be taking place before your eyes. Especially in OB care, you need to have some knowledge of legal precedents regarding optimum patient care. As professionals in women’s healthcare, this is not hard to recognize. Legal standard of care requires you to do what any reasonable and prudent nurse or midwife would do in the same or similar situation.

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© 2025 Martha Merrill-Hall JD MS CNM