The 25-year-old mother of a three-year-old was scheduled for induction to deliver twin boys at her community hospital. Her pregnancy was uncomplicated, except that the non-presenting twin was in a breech presentation. In planning the delivery, the obstetrician requested portable ultrasound equipment and asked Anesthesia to be on hand.
Following induction via Pitocin, the first twin was delivered vaginally, without difficulty. When the obstetrician encountered problems delivering the second fetus, he re-confirmed that it was still a breech presentation. During an attempt to turn the baby via internal cephalic version, the obstetrician intentionally ruptured the membranes. The umbilical cord was wrapped around the baby’s feet and lower body. As the obstetrician further attempted to re-position the baby head-first for a vaginal delivery, the cervix contracted on his hand. The anesthesiologist, who had been called away, was called back to administer nitrous oxide to relax the uterus for further attempts to reposition the baby.
No ultrasound equipment was present in the delivery room, so the nurse monitored the fetal heart rate with a hand held device. At one point, while the obstetrician was attempting to reposition the second twin, the fetal heart rate dropped to 43 BPM. After eight minutes and no success at turning the fetus, the obstetrician called for a C-section.
The baby was born with very low Apgars, no gag reflex, and an EEG demonstrated severe brain damage. He was diagnosed with spastic quadriplegia, was blind, and died five months after birth.