Legally Speaking: The ME's million dollar mistake

January 1, 2006



Mrs. M, a 40-year-old morbidly obese (311 lb) gravida 4, para 4, class B diabetic, was admitted to Labor and Delivery on July 8, 1994 for induction of what was anticipated to be a normal, spontaneous, vaginal delivery of her third child. The patient was well known at this particular hospital, because her previous deliveries-both spontaneous vaginal with birthweights of about 7½ lb- had occurred there.

Mrs. M's surgical history was significant for gastric bypass, draining of a pancreatic abscess, and gallbladder removal. Given her history of diabetes, the current pregnancy was considered high risk and Mrs. M was treated at the hospital's Special High Risk Clinic. During the prenatal period, she was closely monitored with a series of sonograms, biophysical profiles (BPPs), and non-stress tests (NSTs), all of which were uneventful and none of which suggested or warranted anticipation of any difficulty with the delivery. Mrs. M's estimated date of confinement was July 12, 1994.

At 9:45 PM, Mrs. M was given 0.5 mg of dinoprostone intracervically for cervical ripening. Second and third doses were administered at 5:45 AM and 1:15 PM, respectively, the next day. Because the cervix was not dilated and remained 1 cm, long and soft on examination, oxytocin was started at 10 p.m. on July 9, at a dose of 1 mU/min. The dosage was increased sequentially until approximately 4 AM on July 10, when it had reached 7 mU/min. An FHR tracing at that time reflected no signs of fetal intolerance or tachysystole. Mrs. M's only complaint on July 9 was of a migraine headache at 1:05 PM, but her medical records reflect a history of migraine, starting at age 14. A note made at 10:45 PM on July 9 indicates that the patient thought her membranes had ruptured, but examination showed they were intact.

Nursing notes made at 3 AM on July 10 reflect that the patient was having uterine contractions 2 to 3 minutes apart and had been given meperidine and promethazine for her complaints of pain and pressure. A 4:15 AM a note indicates that her contractions were still 2 to 3 minutes apart and she was given another 50 mg of meperidine and 25 mg of promethazine. At 5 AM a nursing note reflects contractions 2 to 3 minutes apart and a fingerstick blood sugar of 120 mg/dL, and the patient was noted to be more comfortable with contractions. A 5:15 AM a note reflects spontaneous rupture of membranes with moderate meconium-stained amniotic fluid, to which the chief resident was alerted by 5:28 AM.

At 5:30 AM, the patient was clutching the side rails of the bed and had become unresponsive and incontinent to both stool and urine. A code was subsequently called. The FHR was in the 150- to 160-bpm range and Mrs. M's blood sugar was 100 mg/dL by fingerstick. Before the patient experienced cardiac arrest, her blood pressure was 128/72, with a pulse rate of 74 bpm. At 6:12 AM, while attempts were being made to resuscitate the mother, an attending obstetrician who was not a party to the subsequent lawsuit decided to perform an emergency cesarean delivery to rule out uterine rupture or unnoticed abruption and help resuscitate Mrs. M. A depressed female infant was delivered and handed to the pediatricians, but she did not survive. The patient's uterus and abdomen were closed and packed but resuscitation was recorded as unsuccessful at 6:45 AM.

At autopsy, the medical examiner attributed the patient's death to a "therapeutic complication of cardiac arrest during Pitocin-induced labor, with hypotension and cardiac arrest."