Cesarean causes problems for mother and baby

December 1, 2016

Following a cesarean delivery, a mother wonders why she hasn't become pregnant again and the neonate ends up in the NICU with skull fractures.

Facts

The plaintiff was first seen by the defendant ob/gyn for a prenatal visit on July 14, 2009, at 7 weeks’ gestation and she continued to receive treatment from him during her prenatal course, which was fairly uneventful. The woman’s weeks by size were consistent with her weeks by ultrasound up until February 9, 2010, at which time she continued to remain at 36 weeks in size. The plaintiff was seen in labor and delivery that day. An ultrasound showed fetal movement. At a February 19, 2010 visit, the patient reported experiencing good fetal movement since February 9. She was at -2 station with 70% effacement. When the woman was seen by the defendant ob/gyn on February 23, she was 1 cm dilated and fully effaced. Her urine was positive for protein at a February 24 visit and she was 90% effaced and still at -2 station.

On February 26, the patient was admitted to the defendant hospital by the defendant ob/gyn with a complaint of painful contractions. An external fetal monitor was applied and the fetal heart rate (FHR) was noted to be 130, with moderate variability, positive accelerations, and a deceleration in triage, with spontaneous baseline return. Vaginal examination was performed by a PGY-3 ob/gyn, and the patient was noted to be 3 cm dilated, 90% effaced, -2 station. The PGY-3 ordered that the patient be admitted to labor and delivery and made an entry at 8:36 pm indicating that she was called to evaluate the patient for a deceleration shortly after an epidural was placed. The PGY-3 indicated that the patient’s baseline was 135, with moderate variability and accelerations. In addition, she noted a deceleration to 60, with return to baseline after 7 minutes. It was noted that the patient was having a tetanic contraction. Terbutaline 0.25 mg was administered, and the FHR returned to baseline. Importantly, the PGY-3 noted “[Defendant ob/gyn] is in house and managing.”

At 8:35 pm, a nursing entry indicates that the defendant ob/gyn reviewed the FHR tracing and performed a vaginal examination. The patient had progressed to 5 cm dilation and 100% effacement and the fetus remained at -2 station. The defendant ob/gyn performed artificial rupture of membranes and noted “thin mec [meconium].” At 10:32 pm, the defendant ob/gyn noted that the patient had a spontaneous deceleration for 4 to 5 minutes, which was not associated with hyperstimulation and resolved after maternal resuscitative maneuvers.

On February 27 at 12:06 am, the defendant ob/gyn documented another spontaneous deceleration lasting 5 minutes, which was associated with a tetanic contraction. Terbutaline was administered with good results. The defendant ob/gyn noted that the FHR tracing was reassuring before and after this deceleration. The resident documented the deceleration as dropping from a baseline of 130 bpm to 70 bpm and lasting for 7 minutes. She noted that the patient was turned to the left side and onto all fours, with oxygen administered and intravenous fluids running. At that time, 0.25 mg of terbutaline was given.

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At 1:18 am, the defendant ob/gyn documented another 5-minute deceleration associated with a tetanic contraction. As before, terbutaline was administered with good results. Furthermore, he indicated: “fetal heart rate tracing reassuring before and after this decel.” The resident also noted that the deceleration dropped from a baseline of 130 bpm to 70 bpm and lasted 4 or 5 minutes. She also indicated that the fetus was at 0 station.

The defendant ob/gyn noted that at 2:51 am, the patient was fully dilated, the fetus was at -1 station and the mother was feeling rectal pressure. He described the FHR tracing as reassuring and noted that the patient was unable to push due to a substantial epidural. His plan was to delay any attempt at pushing until the patient had more sensation and strength. While waiting for that to occur, the defendant ob/gyn noted that the plaintiff had another prolonged deceleration in response to a tetanic contraction at about 3:27 am and terbutaline was given with good results.

A nurse noted at 3:30 am that the defendant ob/gyn was having the patient push with contractions. It also indicated that a deceleration down to 80 bpm occurred, the patient was placed on all fours, and the FHR returned to a baseline of 150 bpm. In his note at 3:48 am the defendant ob/gyn wrote:

“I anticipate we’ll have to push for greater than an hour and with these repeated decels and meconium this baby is not tolerating labor adequately. I’ve recommended to pt. and husband that we proceed with cesarean section for non-reassuring fetal heart rate tracing….”

The record reflects that the patient was in the operating room (OR) at 3:52 am and a cesarean section was performed by the defendant ob/gyn and the PGY-3. Upon admission to the OR, the FHR was 155 bpm. The female infant had Apgar scores of 1 and 8. She weighed 2895 g.

The defendant ob/gyn wrote the following in the record:

Standard horizontal uterine incision performed. Attempt by first assistant to extricate [sic] vertex from pelvis [sic] was unsuccessful. I then also attempted the same maneuver without success. My hand could go below the vertex but I was unable to extricate head from maternal pelvis. Chief resident called in and attempted to displace vertex upward [sic] via vaginal route with simultaneous assistance from above – also not successful. I then performed this same maneuver while both chief resident and first assistant assisted from above – this was unsuccessful. I then instructed the anesthesiologist to administer SQ Terbutaline .25 mg in effort to relax the uterus and obtain more upward movement of vertex. Tis also did not allow extrication of vertex. I called for non-party attending ... for assistance. I then T’ed the uterus ... cut vertically anteriorly along the midline with bandage scissors in order to gain maximum room-the horizontal incision was already maximum to the lateral extent possible. Using this technique we were able to extricate the baby….

NEXT: More facts about the case

 

Following the surgery, the patient had increased bleeding. Intrauterine blood and clots were manually removed. She was treated with methergine 0.2 mg and misoprostol 1000 mg. She had an excellent result and the uterus remained well contracted with hemostasis. She was discharged on the fourth postoperative day, with instructions to return to the defendant ob/gyn’s office.

One year later, a nonparty ob/gyn affiliated with the defendant hospital performed a consult on the plaintiff. The patient said that after a week in the NICU her baby was “perfect,” but that since the cesarean section she had not been able to become pregnant. The nonparty ob/gyn wrote “?antibiotics at discharge” and referred the woman for thrombophilia testing. The director of women’s health and an internist with a subspecialty in hematology saw the patient on June 29, 2011. The woman’s workup revealed low titer anticardiolipin antibodies and low protein S at 62%. The physicians opined that these were consistent with thrombophilia and recommended aspirin as well as enoxaparin in pregnancy.

A nonparty ob/gyn affiliated with the defendant hospital saw the plaintiff on October 25, 2011, when the patient indicated that her cycles were irregular since her cesarean. On examination, the woman’s uterus was retroverted. Ultrasound revealed a 3-mm endometrial stripe. Both ovaries were visualized and had a significant number of small antral follicles.

The plaintiff underwent a hysterosalpingogram on October 31, 2011. The radiologist opined that the plaintiff had a small uterine cavity without demonstrated filling of the left fallopian tube. She suspected an unicornuate uterus. The patient had a normal appearing right horn and rudimentary left horn consistent with uterine anomaly. Magnetic resonance imaging evidenced no congenital uterine anomaly. However, there was apparent scarring, adhesions, and synechia of the endometrium corresponding to the findings on hysterosalpingogram with a secondary decrease in endometrial cavitary volume. The plaintiff was diagnosed with severe Asherman’s Syndrome.

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On November 14, 2011, the patient was admitted to the hospital. Left ovarian cystectomy, laparoscopic-guided hysteroscopy, and lyses of “massive intrauterine adhesions” were performed. The postoperative diagnosis was “Asherman’s Syndrome plus severe pelvic adhesions, left functional cyst.” The patient underwent a laparoscopy and hysteroscopy with lysis of intrauterine adhesions, on January 5, 2012. In his operative report for this procedure, the ob/gyn wrote: “Adhesions were carefully lysed from the previous cesarean section. Some lysis of adhesions followed, however, it was noticed that the myometrium was being entered by lysing the adhesions since the two walls of the myometrium were apposed anterior to posterior probably due to sutures.”

He explained that what he saw during the procedure led him to believe that the top and bottom of the uterus had been sewn together during the cesarean section at issue and, as a result, there was extensive scar formation, which essentially blocked the entire left side of the patient’s uterus. He wrote in his operative report:

… noting the thickness of the myometrium and endometrial cavity and the massive distortion that was revealed during the procedure from previous interventions, the decision was made not to leave a Foley balloon and recommend the patient not to pursue any further pregnancies.

The plaintiff had a tubal ligation in December 2012 and subsequently had twins via a surrogate.

NEXT: The infant-plaintiff and verdict

 

The infant-plaintiff

According to the initial admission note written by the defendant neonatology fellow, the cesarean section involved a “difficult extraction” and the infant emerged limp with no respiratory effort. Her heart rate was between 60 and 100 bpm. Positive pressure ventilation was given via bag mask for about 20 seconds. There was no improvement and by 45 seconds the infant was intubated. She began to have some gasp/respiratory effort at 3 1/2 minutes and her color and tone gradually improved.

By 5 minutes, the infant’s heart rate was greater than 100 bpm and she was moving all extremities. She was extubated because she fought the tube and made an effort to cry. Following removal of the tube, the infant cried. She was brought to the NICU on room air, with an oxygen saturation of 95%. Her initial arterial blood gas was 7.1/46/45/-15.

Upon physical examination by the defendant neonatology fellow, crepitus was palpated over the right parietal region of the infant’s head. Skull flms demonstrated multiple lucencies throughout the calvarium. There was inferior displacement of the coronal sutures along with displacement of the frontal bones. A computed tomography (CT) scan showed multiple bilateral skull fractures in the frontoparietal regions. There were multi-focal acute subacute hemorrhages in the right cerebral hemisphere and patchy bilateral frontal parietal hypodensity indicative of edema. There was no evidence of acute infarction or hydrocephalus.

A neurosurgery consultation was requested. That physician recorded that the infant had an “elonged head c/w prolonged period in birth canal.” The neurosurgeon wrote:

It is difficult to prove her bradycardia is directly related to the epidural hematoma in the setting of so much other brain injury and possible brain hypoxia/anoxia, but after multiple discussions with NICU director, we agreed that we needed to rule out that her hemodynamic instability is not related to direct mass effect from EDH. We will perform limited craniotomy, evaluate blood, try to find bleeding bone edges and leave subgaleal drain behind . . . .

Intraoperatively, a neurosurgeon found a large subgaleal hematoma, which was evacuated. Thereafter, he noted that there were multiple skull fragments with fractures. Upon removing a small portion of the skull, he encountered an epidural component to the hemorrhage, which was also removed. The neurosurgeon also found a component of subdural hemorrhage under high pressure, which was evacuated.

A CT on February 28, 2010, showed complete resolution of the epidural and subgaleal hematoma. The surgeon wrote: “Neurologically, the baby looks normal, without any focality to exam…” His plan was to defer further management to the NICU team as “it does not appear that cardiac issues are related to brain stem compression as was feared when the epidural was discovered initially.”

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The infant was also seen by a pediatric neurologist. She was noted to be doing well, but the resident wrote: “It was not possible to predict how significant any deficits would/could be. Would follow closely and suggest EIP and other interventions as warranted.”

The infant was discharged home on March 5, 2010. On March 12, 2010, the infant was seen in the department of neurosurgery. She was awake, crying appropriately to stimulation, her eyes were midline, and she was beginning to track. On March 31, the infant was seen in the department of pediatric neurology. It was noted that she was “doing well, no neurological deficit.”

At age 2 years the child exhibited no neurologic abnormalities or developmental delays. She did have a calvarial defect that would eventually require repair. She eventually had a successful cranioplasty at another hospital.

Discovery

The infant’s mother testified that she was very concerned about having a vaginal delivery because she has a very small frame. When the infant was delivered the mother knew that something was wrong because the baby was not crying. At one point, the defendant ob/gyn mentioned that he had to make an inverted “T” to get the baby out as the baby was stuck in the birth canal. The patient recalled a conversation with the defendant ob/gyn that her uterus was contracting during the cesarean section and that it would not release and why she was given a shot. Later, a high-risk doctor told her that the reason for her strong contractions may have been thrombophilia.

The defendant ob/gyn testified that the 6 documented episodes of prolonged decelerations did not warrant taking the woman to the OR for a cesarean section. Rather, it was the defendant ob/gyn’s assessment that she should proceed to a cesarean because it would have taken a long time to achieve delivery. The defendant ob/gyn explained that the difficulty in delivering the fetus was due to the uterus remaining contracted until the T incision was made. The defendant ob/gyn explained that the plaintiff’s uterus was closed by him and that he supervised the entire delivery. The doctor also said that he did not feel that there was an improper stitch placed during closure.

 

The subsequent treating ob/gyn noted in his report that the mother’s inability to have additional pregnancies was due to the uterine repair undertaken by the defendant ob/gyn. At our meeting with him, the subsequent treating ob/gyn explained that the scarring would not have occurred if a “T” incision were not performed. The doctor had little doubt that what he saw was why the left side of the woman’s uterus was “obliterated.” He said that he did not find any sutures in place during the January 5, 2012, procedure. The subsequent treating ob/gyn also said that the scarring he found could also have been due to having to “T” the uterus in order to expedite delivery. Further, the scarring could have also occurred as a consequence of removing the placenta.