Description

Following a difficult vaginal delivery, the parents of a child with cerebral palsy claimed that the certified nurse midwife failed to recognize fetal distress, resulting in hypoxic brain injury.

Key Lessons

• Early recognition of non-reassuring fetal heart rate patterns can facilitate timely intervention that may decrease the likelihood of harm during childbirth.
• Hospital guidelines should clearly address when a certified nurse midwife will consult with and pass full responsibility for the patient’s care to an obstetrician.
• Deleting or amending a note in the medical record incorrectly can increase the chance that changes will be misinterpreted as self-serving, even dishonest.

Clinical Sequence

A 23-year-old woman at 40 weeks gestation, G2P0Ab1, was seen in the office by a certified nurse midwife. She had a history of headaches, pregnancy-induced hypertension (PIH), oligohydramnios, and a low lying placenta confirmed by ultrasound. Her BP was 150/90, and she stated she had persistent headaches not relieved by Tylenol or Fioricet. She was sent to the hospital and admitted for induction of labor. A cervical ripening agent, misoprostel, was placed to help ripen an unfavorable cervix.

At approximately 4:00 the next morning, oxytocin intravenous infusion was started, and she was given pain reliever. Fetal heart rate (FHR) was noted to be reassuring. The midwife and the obstetrician together evaluated the patient at 8:00 a.m., confirming the cervix (cx) to be 1cm dilated / 50% effaced / -2 station. Oxytocin was continued.

At 2:00 p.m., she had spontaneous rupture of membranes notable for thick meconium. Cervical exam at that time was 1.5 cm dilated and 80% effaced. Moderate contractions were occurring every three minutes, lasting 60 seconds, and the baseline FHR was in the 130s. The patient and her spouse were informed of the meconium, and induction of labor continued, oxytocin infusing at 18 mu/min.

The patient was reassessed every 2-3 hours by the midwife, who consistently documented a reassuring FHR. However, a note in the chart at 9:30 p.m. referred to prolonged fetal heart decelerations that responded positively to scalp stimulation. This entry was crossed out as having been done in “error;” however, the change lacked a date and time.

At 11:30 p.m., there was good progress in labor with her cervix at 9cm / 80% / -1, caput noted on the fetal head. Contractions were every two minutes, and baseline FHR was in the 140s with accelerations. During the patient’s labor, the obstetrician periodically monitored her BP and reviewed the FHR tracing, but this activity was not documented in the medical record.

At 12:30 a.m., the FHR tracing was noted to be un-interpretable at times. The patient was fully dilated at 12:50 a.m. At 1:05 a.m., the baseline FHR decreased and was notable for decreased variability and marked decelerations.

At 1:20 a.m., a female infant was delivered vaginally, and she was suctioned immediately for meconium. The baby was limp, and had poor respiratory effort. Meconium was found below the vocal cords. Apgars were 1/5/7. She was taken immediately to the NICU and placed on CPAP. A septic work-up was notable for an elevated WBC = 21.6, negative chest X-ray, and negative blood culture and spinal fluid evaluation. However, she received prophylactic antibiotics.

She began to experience seizures at about four hours of life and was treated with phenobarbital and Ativan. A pediatric neurologist was consulted. An MRI and EEG identified abnormalities consistent with hypoxic ischemic encephalopathy. Pathology of the placenta showed meconium staining, but no abnormalities of the fetal membranes or the umbilical cord were identified.

The infant was hospitalized for eight days and then discharged to home on a regimen of phenobarbital. She was later diagnosed with cerebral palsy. She is now legally blind, has spastic quadriparesis, severe developmental delays, and seizures. She also requires a feeding tube for nutritional support.

Allegation

The patient’s mother sued, alleging that the midwife failed to recognize and treat fetal distress during labor and delivery, resulting in hypoxic brain injury.

Disposition

The case was sent to mediation, settling in the high range.

Analysis

Clinical Perspective

1. This patient had onset of headaches and was known to have PIH and oligohydramnios. She was found to have thick meconium when her membranes ruptured; and later developed an abnormal FHR tracing that at times was deemed un-interpretable, notable for minimal variability and marked decelerations.
   An obstetrical patient with this constellation of signs, symptoms, and diagnoses would be considered high risk for developing maternal-fetal complications during labor and delivery. Such patients should be closely co-managed by a CNM and an obstetrician, or care should explicitly be transferred to the attending obstetrician.
   
   Hospital guidelines need to address when a certified nurse midwife may co-manage or should pass full responsibility for the patient’s care to an obstetrician. When clinicians are unsure or have concerns about a patient, they should be encouraged to seek additional medical assistance or obtain formal obstetrical consultation regarding the situation, especially when dealing with complex and dynamic circumstances. 
2. The midwife continually documented that the FHR tracing was reassuring. However, several experts did not agree with this assessment. During the last 60 minutes of labor, the FHR tracing was at times un-interpretable. Within the last 30 minutes, repetitive, deep decelerations were noted.
   Evaluation and interpretation of FHR tracings is notoriously fraught with challenges. Ongoing continuing education is advisable for all clinicians caring for patients in labor and delivery. The Clinical Guidelines for the Obstetrical Services of the CRICO-insured Institutions advises institutions to develop programs to evaluate and document staff competence in interpretation and management of electronic fetal monitoring. Fetal heart rate tracings that are persistently or markedly abnormal should trigger formal consultation with physician colleagues. Consultation is essential when the experience, expertise, or comfort level of the primary clinician is exceeded. 

Risk Management Perspective

1. The crossed-out note in the medical record regarding “prolonged fetal heart decels …” did not include the date/time or initials of the clinician who made the change or the reason for the deletion except “error.”
    Incorrectly deleting or amending a note in a medical record can facilitate accusations that the clinician was trying to alter or obscure something after the fact. If the record truly requires correction or clarification, then simply place one line through the item to be deleted, your initials and the date and time of the deletion. To add more information to the medical record, write the date and time of this entry, clearly identify it as an addendum, complete the note and include your signature. If this is done in a paper record, do not try to squeeze the note in the margins or immediately under the original entry. Instead, enter the note in the next available space in the patient’s medical record.

Legal Defense Perspective

1. The case could not be tried before a jury after most of the defense experts concluded that earlier detection of deteriorating fetal status and prompt intervention would likely have averted the newborn’s hypoxic-ischemic event and likely have decreased the infant’s chance of developing cerebral palsy.
   Malpractice cases involving neurologically-damaged infants are among the most difficult to win in court. The decision to settle or proceed to trial is a risk for the clinician and the defense team, especially in light of mixed expert reviews. Jurors, mediators, and arbitrators empathize with patients who encounter adverse childbirth outcomes, especially when unanswered questions remain about the clinical decision-making, management of the labor and delivery, the lack of communication between providers caring for the patient, and documentation that is poor or worrisome for dishonesty or fraud.