What Should We Do With Category II?

AFFIDAVIT OF EXPERT WITNESS - Brain-injured Baby Litigation

My name is John W. Jones, M.D. I am a physician in active practice in the area of Obstetrics and Gynecology. I am qualified as an expert by virtue of my knowledge, skill, experience, education, and training peritnent to the issues raised in this affidavit and I am qualified to give opinions regarding these issues. I have actively practiced in my area of specialty for 31 years and have established an appropriate level of knowledge in diagnosing the condition at issue in this affidavit. Specifically, I have delivered approximately 9,000 infants in my time as an obstetrician/gynecologist. *

The facts in this case, upon which I base my opinions, are of a type reasonably relied upon by experts in the field of Obstetrics. The testimony I have given herein is, in my opinion, based upon sufficient facts or data which should be admissible evidence at any hearing or trial of this matter. The testimony I have given is the product of reliable principles and methods and I have applied those principles and methods reliably to the facts of this case in arriving at the opinions I express herein.

Because of my background, training and experience, I am familiar with the standard of care and skill ordinarily employed by obstetricians and nurses** when treating obstetrical patients such as Ms. X and her unborn son under similar conditions and like circumstances as are contained in the medical records I have reviewed.

*For privacy purposes, the names in the affidavit and factual summary have been changed.

**There is, currently, case law in some juridictions that does not allow a physician, or other licensed care provider, to testify to the scope of practice/standard of care of clinicians outside their own specialty.

Facts of the Case

1. Ms. X, the plaintiff, received prenatal care from Jane B. Doe, M.D., the defendant, at Women's Health of Saturn. Nothing in the prenatal care records suggests that there were any complications but it should be noted that this was Ms. X's first pregnancy. She was of advanced maternal age, had a blood dyscrasia, and was 41 years old when she had IVF to achieve pregnancy.

2. Ms. X presented to Saturn General Hospital on March 3, 20XX at 2200 hours with complaints of contractions and vaginal bleeding. She had attained 38 weeks gestation. She was admitted to the hospital for labor. Electronic fetal monitoring was started at 2235 hrs which showed moderate variability and one late deceleration. Nurse Mars notified Dr.Doe at 2252 hours that Ms. X was in triage and requested that Dr.Doe evaluate the patient in person (unknown whether this actually happened).

Dr. Burgansky 0255 Cat II
Minimal variability
Illustrated Verdict, Inc.

Dr. Clark q007
Excessive Uterine Activity
Illustrated Verdict, Inc.

3. At 2300 hours, Ms. X was dilated to 7 cm, 90% effaced, and at -1 station. At 2315 hrs, the fetal heart rate tracing showed minimal variability, no accelerations, and excessive uterine activity. At this time, the EFM strip was Category 2.

Q153-DrDepp-SCT-MD-Q153-panel2gif
Prolonged Decel : Category II
Illustrated Verdict, Inc.

4. On March 4, 20XX, after midnight, the fetal tracing still showed minimal variability, no accelerations, excessive uterine activity, and new prolonged decelerations. At 0017, Ms. X ruptured membranes. The fluid was determined to be clear. Ms. X was noted to be 9.5 cm, 100% effaced, and at 0 station. At 0030, Dr. Doe was advised by telephone of the decelerations on the fetal monitor.

5. The fetal monitor tracing continued to show prolonged decelerations that were worsening and severe variable decelerations to 60 starting at 0043 hrs. At 0120, Ms. X was 10cm dilated/100% effaced/0 station. The EFM tracing continued to show minimal variability, prolonged decelerations, and excessive uterine activity. At 0143, the doctor wwas notified by phone that Ms. X was complete.

DrGarite-02230section2.gif
Variable Decelerations - Category II
Illustrated Verdict, Inc.

6. At 0210 hrs, the records note "decelerations on the fetal monitor x 2". At 0220 hrs, there was a 2-minute severe variable to the 60's with absent variability. The fetal heart rate tracing is "ominous" from this point forward. Ms. X was positioned differently 3 times between 0221 and 0224 hrs. At 0230, the doctor was notified via phone of "occasional" variables to the 60's lasting 1-2 minutes. Dr. Doe documented that she advised the nursing staff to continue current management and alert her if the fetal tracing becomes "more concerning". At 0250 hrs, Ms. X was coached on pushing.

7. At 0310 hrs, Ms. X was noted to be pushing effectively with contractions. At 0316 hrs, the fetal monitor tracing shows absent variability. The tracing, at this point, was Category 3. At 0320, Ms. X was laboring down (?). Pushing resumed at 0340 hrs with the patient on her left side. At 0342, the monitor tracing shows a deceleration to the 60's. The patient was re-positioned to her right side with pulse-oximeter placement. Oxygen was already being provided. Additional help was summoned and an IV fluid bolus was started. Dr. Doe was called to the bedside for fetal bradycardia.

mod04Case44
Category III
Illustrated Verdict, Inc.

8. At 0346 hrs, Ms. X was placed in hands and knees position. The fetal monitor tracing was noted to be tracing "the maternal heart rate". A FHR Doppler was applied which indicated the fetal heart rate was 60 beats/min. At 0350 hrs Dr. Doe arrived at the bedside. Her note for this time period states that the fetal heart rate is in the "120's" and that the nurse reported the patient had been pushing and making "good descent".

Dr. Doe discussed with the patient and husband the possible need for operative vaginal delivery due to fetal distress. At the time Dr. Doe arrived, the nurse documented that Ms. X was repositioned to supine, a fetal scalp electrode was placed, and the FHR was in the 40's per doppler. At 0356, the records indicate that the fetal electrode is "off" and a resuscitation team had been called to the bedside.

At 0400 hrs, it is noted that Dr. Doe applied a vacuum and the fetal heart rate was in the "30's to 40's". (The fetal position was not checked prior to application of the vacuum.) (In an entry at 0703 hrs, Dr. Doe stated that the vacuum was applied and pulled with 3 pop-offs with no further descent. The 0703 entry also noted that during the vacuum, the fetal heart rate had decelerations that were not recovering spontaneously and the patient was verbally consented for an emergent c-section for a category 3 tracing.) At 0359 hrs, anesthesia was contacted. The vacuum was removed and a c-section called.

9. At 0402 hrs, the medication record noted that 1 mg/ML of terbutaline was due. At 0404 hrs, Ms. X was in the OB operating room. Baby X was delivered at 0411 hrs, with the record noting that the position of the fetal head, when delivered, was in right occiput transverse position (ROT).

10. Baby X's Apgars were 0,3,4, and 4. He required bag and mask ventilation and epinephrine. He remained without respirations and was intubated, "but able to be weaned to room air." Due to questionable seizure activity, phenobarbital was administered. Baby X was transferred to the Children's Hospital for head cooling. While at Children's Hospital, Baby X was noted to have severe hypoxic ischemic encephalopathy.

Among other issues, the vacuum was misplaced and the fetal tracing was tolerated at Cat II for hours and Cat III for over an hour. This case was settled before trial, in the Plaintiffs' favor, for an undisclosed amount.

(Continue Part 2 - on the website: https://www.midwivesontrial.com )

*Please note: EFM strips presented, here, are random stock images illustrating Category II and one Category III EFM tracing. They are not true representations of monitor tracings from the actual case. mmh

http://www.midwivesontrial.com

Electronic Fetal Monitoring: Management and Standard of Care Part 1

Electronic Fetal Monitoring:Management and Standard of Care Part 2

Shoulder Dystocia Maneuvers: The One Medicine Leaves Out