Delayed C-Section Leads to Infant Fatality

This case involves a thirty-five-year-old pregnant female who presented to the labor and delivery unit of a hospital complaining of premature contractions. Upon admission, the fetal heart rate monitor showed a heart rate of 160. Approximately one hour later, the monitor showed persistent variable decelerations, which prompted the resident physician to move the patient to her left side. An hour later, the decelerations persisted and the patient was moved to her right side. Two hours later, a cervidil was inserted and monitors were still showing subtle decelerations. Plans for a C-section were discussed with the patient but did not take place for several hours. The baby was delivered via C-section with APGAR scores being one, four, and six. The initial pediatric note indicated that the infant was severely cyanotic with no spontaneous movement evident. The baby developed acute kidney failure with associated protein and blood loss in the urine. A head ultrasound was performed that demonstrated cerebral edema and an MRI indicated a prolonged hypoxic event.

Question(s) For Expert Witness

1. What are the signs that a cesarean section should be performed emergently and could any intervention have been done to prevent this outcome?

Expert Witness Response

A minority of cesarean deliveries are performed for fetal distress, where fetal heart rate tracings are clearly associated with an increased risk of fetal hypoxia and acidosis. Fetal heart rate monitoring has not decreased the overall rate of cerebral palsy; rather, it has decreased the threshold to perform cesarean deliveries for nonreassuring fetal status. Unfortunately, many obstetricians admit that their practice of medicine has become more defensive. Given the fear of inquiry regarding how a particular patient’s labor was managed, many obstetricians may have a lower threshold to perform a cesarean delivery despite the fact that the incidence of neonatal seizures or cerebral palsy has not been affected by increasing cesarean delivery rates. Despite the dramatic rise in the rate of cesarean delivery, the overall rate of cerebral palsy has not decreased. The only perinatal intervention for which strong evidence shows a beneficial effect on both mortality and the risk of cerebral palsy is an antenatal treatment of the mother with glucocorticoids.