A Tocolysis Crisis

THE FACTS

At approximately 9:55 p.m. on April 28, 2005, at 23 weeks' gestation, the patient presented to Hospital B's Emergency Department via ambulance with a complaint of vaginal bleeding. At 10:15 p.m., she was transferred to the Labor and Delivery (L&D) Unit and examined by Dr. B. He recorded the gestational age, ensured that the patient's vital signs were taken, and ordered laboratory tests, a non-stress test, and 4 doses of dexamethasone (1 dose every 12 hours) to promote lung maturity and decrease risk of intraventricular hemorrhage in the advent of early delivery. Ampicillin was begun for prophylaxis against Group B beta-streptococcus. Dr. B also ordered an immediate intravenous (IV) loading dose of 4 g magnesium sulfate in an attempt to delay preterm delivery and admitted the plaintiff to the L&D Unit. Cervical examination performed between 10:35 p.m. and 10:45 p.m. revealed 2- to 3-cm dilation and the patient was transferred to a birthing room.

Dr. B saw the patient again at 2 a.m. and 4 a.m. and performed the next cervical examination at 7 a.m., at which time the woman was fully dilated and experiencing irregular contractions. Throughout the course of the evening, she refused to consent to the possibility of cesarean delivery, despite the small size of the fetuses, the breech position of "Twin A," and the likelihood that the fetuses would not survive a vaginal delivery.

The second dose of dexamethasone was administered at approximately noon on April 29, 2005. Throughout the day and up to the time the patient was taken into the operating room, a fetal heart rate (FHR) monitor indicated no sign of fetal distress. At noon and 3:30 p.m., U/S were taken that showed normal sonographic appearance, concordant growth, and malpresentation of Twin A. At 8:10 p.m., the patient's magnesium levels were noted to be elevated (7.6) and nonparty Obstetrician C ordered temporary discontinuance of magnesium sulfate.

By 10:05 p.m., the patient had a bloody show, with fetal membranes bulging into her vagina. At that time, the decision was made to deliver the fetuses. The patient's membranes spontaneously ruptured at 11:21 p.m., and at 11:22 and 11:23 p.m. After speaking with the head of perinatology at the hospital between 11:30 p.m. and 12:15 a.m., the patient consented to cesarean section and delivered 2 live twins. Infant A weighed 1 lb, 3 oz; Infant B died hours after his birth of pulmonary hemorrhage.