Complicated Delivery of Twins Results in Death of Fetus

This case involves a thirty-two-year-old female who was pregnant with twins. The patient went into labor at twenty-four weeks gestation and ultrasound studies suggested that the babies had some bone length discrepancies. The patient was admitted with fetal monitoring ordered at three times per day and ultrasounds were done two times per week. The mother delivered thirteen days later after all attempts were made to prevent the premature labor. The ultrasound on the day of delivery showed no heart rate in the first twin and several complications in the second twin including dicrotic notching, epicord entanglement, and intermittent diastolic flow in the umbilical artery. It was at this point an emergency delivery was initiated. The physician on the service instructed the nurse to only monitor the first twin since the complications were more severe and that any change in one baby will occur in the other. However, the first twin was delivered with some complications and the second died in utero.

Question(s) For Expert Witness

1. What are the proper methods of maternal and fetal surveillance in labor and delivery?

Expert Witness Response E-005925

After an initial period of continuous monitoring of fetal heart rate and uterine contractions, if findings are suggestive of reassuring surveillance, the patient would be a candidate for expectant management. The patient should be placed on the obstetric floor for bed rest. Because bed rest in pregnancy is associated with an increased chance of deep venous thrombosis, prophylaxis to reduce this risk should be instituted. Fetal monitoring should be performed at least once a day. If evidence of frequent cord compression is present as determined by moderate-to-severe variables, continuous monitoring should be reinstituted. Maternal vitals need to be monitored closely. Tachycardia and fever are both suggestive of chorioamnionitis and require careful evaluation to determine the presence of intra-amniotic infections, in which case delivery and initiation of broad-spectrum antibiotics should be promptly facilitated. Ultrasonographic examination for an amniotic fluid index, fetal growth, and well-being should be used liberally to ensure appropriateness of continued expectant management. While oligohydramnios, defined as an amniotic fluid index of less than two centimeters, has been associated with short latency and chorioamnionitis, it alone is not an indication for delivery when other means of surveillance are reassuring. White blood cell count is not predictive of outcome and does not need to be monitored other than to support the clinical suspicion of chorioamnionitis.