Legally Speaking: Was this forceps delivery appropriate?
A patient charges that her infant’s injuries could have been avoided.
The patient first presented to defendant ob/gyn PC for prenatal care on June 6, 2008, at age 23. Her estimated date of delivery was January 24, 2009. After the woman’s third visit, the certified nurse midwives (CNMs) in the group followed her, on numerous occasions, between September 5, 2008 and February 4, 2009. By November 21, uterine size discrepancy was noted. The woman’s lab test results and blood pressure remained within normal limits; there was never any edema. On January 26, an ultrasound and biophysical profile (BPP) were done. The BPP was scored 8/8 and estimated fetal weight (EFW) was 3800 g (8 lb 6 oz) (±555 g, at the 75.3 percentile). On January 30 defendant CNM A noted that the patient was post-term; a non-stress test was reassuring. On February 2 the mother was 0 cm dilated, -3 station, and she weighed 204 lb. On February 4, 2009 CNM A noted 0 cm dilated, 0% effaced, and -2 station and 202 lb at 41.4 weeks. BPP was 8/8 with EFW 9 lb or 4087 g (±613).
The woman was instructed to present to the hospital that evening for induction and did so at 8:18 p.m. She was counseled about mode of delivery and requested a trial of labor. She was 0 cm, 30% effaced; presentation was cephalic, at -2 station, and clinical pelvimetry was adequate. EFW was 4087 g. Fetal monitoring revealed the absence of contractions initially, with a slow onset thereafter, and a fetal heart rate (FHR) 122–140 bpm with mild to moderate variability, accelerations and no decelerations. Membranes remained intact. An 8:46 note by CNM A documented delivery route counseling for macrosomia and shoulder dystocia given; the patient was thoroughly informed of the nature of macrosomia and shoulder dystocia and the risks and benefits of vaginal delivery versus cesarean delivery, as well as available alternatives. The risks and benefits to both her and her fetus and reasonable expected outcome to each alternative were discussed and the patient requested trial of labor. Dinoprostonel was placed and the mother was transferred from the OB suite to a room at 9:40. FHR monitoring was continued, externally, with acceptable FHR.
By 3:00 a.m. the patient was noted to have regular contractions. A pelvic exam performed 25 minutes later revealed 1 cm/ 90% / -2 station, and membranes intact. At 5:00, when the patient refused further pelvic exam and requested an epidural for pain management, she was transferred to an L&D room. An epidural was placed by 6:20 a.m. At 6:59, pelvic exam revealed that the mother was 4 cm dilated with 100% effacement without fetal descent. At 8:18 when she was 6 cm dilated, CNM B ruptured the woman’s membranes, and a Foley was placed. At 8:21 Dr C was noted to be attending to the patient. The patient remained 6 cm dilated, 100% effaced, and at -2 station. External fetal monitoring remained ongoing; the FHR was in the 150s with moderate variability, reactive, no decelerations. At 10:00, variability was minimal.
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