A 33-year-old woman, G7 P5 with a high BMI of 40.5, a history of asthma, gestational diabetes and chronic hypertension controlled with 50 mg of atenolol, was admitted in active labor at term. The midwife examined her and found her fetus in transverse lie and her cervix dilated to 5cm and 100 percent effaced. The fetal heart rate tracing was reassuring, with a baseline of 130 bpm, moderate variability, some accelerations and no decelerations. The obstetrician on-call performed an ultrasound and confirmed fetal transverse lie, with back down. The obstetrician discussed the option of proceeding with a cesarean delivery versus attempting an external cephalic version followed by a vaginal delivery. The patient agreed to external version, but if not successful to proceed with a cesarean delivery and post partum tubal ligation.
Surgical consent was obtained. An epidural was placed after several attempts, and post-epidural ultrasound showed the fetus was now vertex but not engaged in the pelvis. The fetal heart was bradycardic and controlled artificial rupture of the membranes was performed in the operating room, yielding clear fluid. Fetal bradycardia of 70 bpm was confirmed, lasting about 5 minutes before spontaneous recovery to a rate of 110-120. The cervix was 5-6 centimeters dilated and 80 percent effaced. A fetal scalp electrode was applied after several unsuccessful attempts, and variable decelerations were seen. The fetal heart rate accelerated in response to scalp stimulation but variable decelerations persisted.
The patient was moved from the operating room back to the labor room and within the hour her cervix was 6-7 cm and fetal vertex at -3 station. A cesarean section was called because of fetal bradycardia of 70 bpm, but then cancelled as the fetal heart rate recovered. A fetal scalp ph was attempted, but failed. The patient repeatedly asked the OB if everything was ok and the OB repeatedly said, "he's ok, he'll be fine."
Over the next two hours, minimal variability and recurrent variable decelerations were noted, with the baseline rising to 180 bpm. A cesarean section was called again for fetal bradycardia of 70 bpm but again cancelled as the fetal heart rate recovered. Deep variable decelerations persisted, with a baseline of 180 bpm and absent variability.
The obstetrician involved in this case had less than 5 years post-residency experience and demonstrated indecision and frequent change in the plan of care for managing the patient's labor and delivery. The nurse was initially reluctant to express her concerns to the obstetrician or her charge nurse. After several hours of a non-reassuring fetal heart rate tracing, the nurse notified the charge nurse and the charge nurse spoke to the obstetrician but the clinical discord was not resolved, and no further action was taken.
The patient became fully dilated, and a fetal scalp ph of 6.9 was obtained. She was taken to the operating room and had a spontaneous vaginal delivery of a liveborn male infant with a tight, double nuchal cord. The pediatric team arrived to resuscitate a limp, cyanotic baby. APGARS were 1 at 1min., 3 at 5min. and 5 at 10min., and the initial cord ph was 6.8. The infant was transferred to the intensive care unit and developed disseminated intravascular coagulation, acute renal failure and seizures. Hypoxic-ischemic encephalopathy was diagnosed; life support was withdrawn; and the infant died on day four of life.