Case Archive

Failure to Diagnose & Manage Prematurely Ruptured Membranes
$37 Million Pennsylvania Verdict

A woman at 23 weeks gestation called her obstetrician's office to report the possibility that her water had broken. A medical assistant took the call and, without checking with a physician, instructed the woman to come in the next day. The OB's exam revealed leaking vaginal fluid which was positive for nitrazine (consistent with ruptured membranes), Fern negative, containing clue cells (consistent with infection), with a pH of 6.0 (elevated and consistent with a mixture of amniotic and vaginal secretions). The exam also revealed that a bacterial vaginal infection, which is associated with an increased risk of ruptured membranes and neonatal morbidity. The OB advised the patient that she did not have ruptured membranes, however, he gave her instructions consistent with ruptured membranes (monitor her temperature four times daily and call if she had a fever or foul?smelling vaginal discharge). He also instructed her to provide a urine sample, which she returned to the office two days later without evaluation by anyone. The next day the patient, who had a history of ulcerative colitis, experienced abdominal cramping and called the office. She asked if she could take the medication for her colitis. Her OB was away for the weekend, and the answering service forwarded the message to the covering OB, who returned the call. The woman informed him she was 23 weeks pregnant, experiencing abdominal cramping, and had a history of ulcerative colitis. She also stated she had seen her OB four days earlier because she thought her water may have broken but her OB did not agree. The covering OB told her she could take her medication for colitis. Later that evening she called the service to report the cramping had returned and that she had noted some bright red bloody discharge. The covering OB again returned the call and, after the woman informed him that she was now spotting, told her not to worry and gave no instructions. The next morning the woman noted that something was hanging out of her vagina. She immediately called the answering service but when no one promptly returned her call she and her husband drove to the hospital. An OB resident performed an exam, which revealed an umbilical cord prolapsed with good pulsation in the cord and a normal fetal heart rate. An ultrasound revealed no presence of amniotic fluid. A code denoting a fetal emergency was called. The hospital's associate director of neonatology was called to come in. Until his arrival, a staff pediatrician went to the delivery room to assist. The hospital's attending OB and the OB resident performed an emergency C-section. A blood gas taken from the umbilical cord immediately after birth was normal, indicating that the baby was born with good oxygenation and normal metabolic status. The male infant did not have spontaneous respirations so the pediatrician intubated him with a 2.0-mm endotracheal tube. According to the Neonatal Resuscitation Program, which was taught at the hospital by the associate director of neonatology and developed by the American Heart Association and the American Academy of Pediatrics, a 2.0-mm tube should never be used because it is too small to permit adequate oxygenation and suctioning of airway secretions. Bicarbonate was administered via the endotracheal tube which, experts testified, is contraindicated due to the caustic effect on the lungs. Additionally, bicarbonate should only be given intravenously. The associate director did not arrive for more than 27 minutes, despite hospital policy that on?call neonatologists must be no more than 20 minutes away. Taking charge of the infant's care, he reintubated with a 2.5-mm endotracheal tube. The baby was transferred to the Neonatal ICU, where an umbilical arterial line was placed. Oxygen saturation, normal at birth, had dropped to 67%. Nursing noted pale and mottled skin, unequal movement, hypotonic tone, lethargy, decreased breath sounds, retracted and labored respiration, and cool and moist skin. Temperature, normal at birth, had dropped to 90.5 degrees. The infant was placed in a warmer that was inappropriately cold (where he remained throughout the remainder of his stay at the hospital). Ten minutes later the baby was placed on a ventilator. Blood gases revealed a severely acidotic infant with a pH of 6.86 due primarily to inadequate ventilation. Instead of increasing the respiratory rate setting, the neonatologist increased the bicarbonate and the pressure to the baby's lungs, exacerbating the metabolic derangement. The neonatologist ordered the first chest X?ray to check the placement of the endotracheal tube. It clearly showed the tube to be located in the esophagus (rather than the airway), which was consistent with the severe respiratory acidosis and the observations of deteriorating clinical status. The neonatologist had failed to recognize the misplacement of the endotracheal tube for approximately 40 minutes until the first X-ray. After another 20 minutes, a second chest X?ray continued to show the misplacement of the endotracheal tube, ventilating only one lung. Hospital records produced initially during discovery failed to include the blood gas results showing deterioration from a normal status to life-threatening acidosis, the reports of the chest X?rays showing the improper placement of the endotracheal tube, and all mentions of endotracheal intubation. Records of these events were ultimately produced only after deposition testimony of hospital staff. The baby did poorly until he was transported to a major medical center, where within the first two weeks he developed a bowel perforation arising from hypoxic/ischemic injury surrounding the birth resuscitation events. He required several colostomy surgeries, as well as multiple surgeries to treat retinopathy of prematurity. He remained ventilator?dependent and required tracheostomy placement. After 8 months he was discharged with the aforementioned in addition to myriad medical monitoring devices and therapies to be administered by his parents and nursing staff at home. Now 6-years-old, the child is retarded, fed through an in-dwelling gastrotomy tube, will always require special schooling, and is not expected to live independently or to be gainfully employed as an adult. A medQuest OB/GYN testified at trial that the defendant OB's deviated from the standard of care. With proper management, many cases of ruptured membranes have a good full-term outcome. The jury returned a verdict of $37 million.

Attorney for the Plaintiff:
James E. Beasley, Esq.
Marsha F. Santangelo, MD, JD
Beasley, Casey & Erbstein
Philadelphia, PA

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