OR WAIT 15 SECS
The Facts On February 2, 2000, the patient presented to an obstetric clinic where she gave a last menstrual period (LMP) of December 4. When she presented to a hospital clinic on February 9, she gave conflicting dates for her LMP of November 1 and November 15. An examination the next day reflected a gestational age by LMP of 12 weeks, 4 days, but the estimated gestational age (EGA) by ultrasound was 131/2 weeks which would yield an estimated date of delivery (EDD) of 8/13/2000. On March 7, the woman presented to a prenatal clinic, where she gave a history of two prior cesareans, both the result of cephalopelvic disproportion. In the estimated date of conception section of her prenatal record, the patient indicated that her LMP was "definitely" November 15, 1999, giving her an initial EDD of August 22, 2000.
At the next prenatal visit, on March 28, the patient's fundal height was 23 cm and on May 18, the EGA was 26 weeks, 2 days, with a fundal height of 30 cm. A May 16 U/S reflected a gestational age closer to 28 weeks, 4 days, while her assumed dates were 25 5/7 weeks, and the EDD was revised to August 2, 2000.
The patient's care was then transferred to the defendant ob/gyn. At that point, the woman requested a bilateral tubal ligation, refused a trial of labor, and wanted a repeat cesarean delivery. On June 26, the defendant's plan was to get a glucose challenge test and another official U/S. He also wanted the patient to return in 2 weeks and scheduled a repeat cesarean delivery and bilateral tubal ligation at 38 weeks. On July 6, the woman had another obstetric U/S, which revealed a breech with a placental grade of 0 and estimated a gestational age at of 36.5.1 weeks for an EDD of July 30, 2000. Therefore, the defendant kept the EDD at August 2, 2000.
On arrival shortly before 6 PM on July 17, the woman complained of mild contractions and had a fetal heart rate in the 120s with positive accelerations. With the fetus in a transverse lie and a reassuring FHR tracing, the patient was admitted to Labor & Delivery for monitoring and IV hydration. An 8:30 PM note indicates the patient had an "uncertain" LMP of "10/15 vs. 11/15," but was now in early labor and refusing a trial of labor. An untimed attending note indicates she had been complaining of uterine contractions for 2 days with a reactive FHR tracing, and U/S revealed an unstable lie, transverse to oblique.
At 9:49 PM, a 6 lb, 13 oz infant in breech presentation was delivered alive by C/S and had Apgars of 2/7. According to the operative note, manual extraction of the placenta was attempted but not possible because the posterior lower segment was adhering to the uterine wall. Because the slow bleeding could not be stopped and the patient wanted sterilization anyway, a hysterectomy was discussed again with the patient and her husband and performed.
The neonatal intensive care unit (NICU) admitting note indicates a "difficult extraction" with a 1-minute Apgar score of 2, but 5- and 10-minute Apgar scores of 7 and 8, respectively. The baby had poor cry and respiratory effort and bradycardia and required bag/mask and positive pressure ventilation. But she made a quick transition to normal oxygen saturation and blood gases, had well-inflated lungs with mild haziness on chest x-ray, and was mildly anemic, which was thought to account for her initial episode of respiratory distress. Neonatology and pediatrics assessed the child, found her neurologically intact, and estimated her gestational age at approximately 37 weeks.