A healthy 30-year-old, with no known allergies, entered Labor and Delivery for induction at 40 weeks. This was her fourth pregnancy, including two previous live births. The patient had a McDonald’s cerclage at 14 weeks gestation which was removed by her obstetrician at 36 weeks. Her cervix was notable for the laceration and scarring at the 4 o’clock position. Her obstetrician scheduled an induction of labor (the indication for this was not documented). Examination in Labor and Delivery revealed that her cervix was 1cm dilated. Pitocin was ordered to induce labor, and the obstetrician attempted rupture of amniotic membrane on three separate occasions over six hours without success. The fetal heart rate (FHR) tracing was reactive throughout the day. Pitocin was stopped in the late afternoon because the patient’s cervix did not dilate. She was sent home with plans to return in a few days.
Six days later, the patient returned for a second induction.
9:00 a.m.
Her cervix was 1-2cm and long, and the FHR had mild-moderate variability. with a baseline of 140-150 beats per minute (bpm). Prostin gel was placed to ripen the cervix and Pitocin started “per protocol.”
12:30 p.m.
Her cervix was 2-3cm dilated and the FHR tracing had moderate variability with occasional variable decelerations.
1:30 p.m.
She received an epidural for pain relief, and her cervix was about 4cm dilated. Her amniotic fluid sac ruptured spontaneously and a “small amount, blood-tinged” fluid was noted.
3:00 p.m.
Her cervix was 5cm dilated, the FHR was 140bpm with minimal variability and variable decelerations around the time of contractions.
7:00 p.m.
Her cervix was 8cm dilated and the fetal head at 1+/2+ station. The FHR was 160-170bpm with minimal variability and variable decelerations, some with slow return to baseline. The patient complained of left-sided pain and her epidural was reinforced.
7:30 p.m.
Her cervix was an “anterior lip.” The FHR was 170bpm with persistent variable decelerations.
9:00 p.m.
The FHR baseline was 170bpm with deep decelerations. An intrauterine pressure catheter was used to record contractions. The patient complained of severe pain and a fetal scalp electrode was applied.
9:35 p.m.
No cervical change. The FHR was 170bpm with deep decelerations. The obstetrician decided to deliver by cesarean section.
A female infant was found free-floating in the abdomen, requiring resuscitation. The mother’s uterus and bladder had ruptured. The infant was severely asphyxiated with extensive neurologic injury, and died at three weeks.