A 17-year-old G1 presented to labor and delivery at 12:30 PM, at 35 weeks 0 days of gestation, with complaints of a gush of blood, nausea, and vomiting, with intermittent and constant abdominal pain. She reported good fetal movement. The patient was clearly uncomfortable on the bed. Contractions were occurring every 2 minutes, lasting 30 to 40 seconds, and were moderate in intensity to palpation. Fetal heart tones (FHTs) were initially in the 120-130 beats per minute (bpm) range, with adequate variability without accelerations. Two subtle decelerations were noted at 12:50 PM and 12:53 PM. The obstetrician’s examination at 1:00 PM revealed a tender uterine fundus, cervix 1- to 2-cm dilated, 50% effacement, and a vertex presentation at a -2 station. At 1:30 PM, the FHTs were in the 140s with decreased variability, and a possible deceleration to 100 bpm. (There was difficulty continuously identifying the fetal heart rate [FHR] on the external monitor.) There was a moderate amount of blood in the vagina. It was elected to admit the patient with the diagnosis of early labor versus placental abruption. Vaginal cultures were obtained prior to starting Group B streptococcus prophylaxis. No tocolytics or steroids were ordered.
Bedside ultrasound revealed a single fetus in a vertex presentation, AFI = 6, with no obvious placental abruption or previa. Following this evaluation, at 2:15 PM, the physician left the hospital with instructions to notify him if the patient’s clinical status worsened. The nurse’s notes documented that the patient remained very uncomfortable. At 2:30 PM an IV was started and the patient remained on continuous monitoring. A nurse’s cervical exam at 2:50 PM revealed that the cervix was 1- to 2-cm dilated, thick and high, with a moderate amount of blood again noted in the vagina. Although the patient’s contractions spaced out slightly, she remained very uncomfortable between contractions. At 4:00 PM, antibiotics were ordered, without accompanying documentation. FHTs at this time were in the 150s with a spontaneous variable deceleration noted in the nursing notes. At 4:20 PM, morphine and promethazine were ordered to help reduce the patient’s pain. At 5:00 PM, the FHTs were in the 170- to 180-bpm range, with poor variability and no accelerations or decelerations. At 5:20 PM, the nurses documented that the physician was notified of the fetal tachycardia, now with late decelerations. The physician arrived at 5:50 PM and ordered a cesarean delivery for non-reassuring fetal heart tracing. The patient was transferred to the operating room shortly thereafter. A spinal block was inserted at 6:00 PM. The FHTs were 87 after the spinal. The baby was delivered at 6:22 PM, with the findings of a Couvelaire uterus. Because there was difficulty delivering the baby, vacuum assistance was required. Apgars were 0 and 0, at 1 and 5 minutes, respectively. The baby could not be resuscitated. There was a 200 cc subchorionic clot identified. Cord gases revealed an arterial pH of 7.06, with a base excess of -13.9. The venous pH was 6.97, with a base excess of -17.1
Autopsy revealed changes consistent with an intrauterine stress episode, with associated changes in the skin, adrenal glands, pulmonary congestion and hemorrhage, acute tubular necrosis of the kidneys, and a small subdural hematoma. The placenta was small, with uteroplacental vasculopathy and villus information. There was extensive decidual necrosis, hemorrhage, and a marginal abruption. A suit was filed for negligence and wrongful death.
Chart review revealed no contemporaneous physician documentation after the initial assessment. Two late entries were documented at 10:00 PM. One timed at 4:20 PM indicated that it was unclear if the pain was due to an abruption or labor. Thus, morphine was ordered. This was confirmed by a nurse’s later entry, which also included the statement that the physician was notified of fetal tachycardia in the 160s, with decreased variability and spontaneous decelerations. A second late note by the physician documented that, upon the decision for cesarean delivery, it was felt that the situation was urgent but not emergent, thus there was time for a spinal block.