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.