Legally Speaking: A case of spontaneous Erb's Palsy

• THE FACTS

The patient, a then 24-year-old female weighing over 300 lb, with a history of manic depression, presented for prenatal care on February 20. She was already estimated to be at 38 weeks gestation, and was complaining of decreased fetal movement. The fetal heart was heard in the lower right quadrant, and the most significant lab study performed revealed a glucose challenge test at 151 mg/dL. There was a plan for GTT, but this did not occur prior to delivery.

OBSTETRICAL ULTRASOUND WAS ORDERED for anatomical survey, biophysical profile (BPP), and decreased fetal movement and was done on February 22. A detailed evaluation of fetal anatomy was not possible due to advanced gestational age, maternal obesity, and fetal position, but sonographic measurements were consistent with menstrual dates. The BPP score was 8/8. She was given an EDC of March 5 and returned to the prenatal clinic on March 7, with repeated complaints of decreased fetal movement. The decision was made to send her to labor and delivery for evaluation.

At 6:49 AM, an epidural catheter was placed, and vaginal examination shortly thereafter revealed no change. Oxytocin infusion was started at 1 mU/min, and raised at 1 mU intervals every 15 minutes thereafter until 9:30 AM, at which time it was at 9 mU/mL. A 9:20 AM note reveals that the FHR was reassuring, the cervix was 3 cm, and spontaneous vaginal delivery was ultimately anticipated. By 10:15 AM, oxytocin had been raised to 15 mU/ml, and at 10:25 AM, the FHR decreased to 90 bpm for 10 seconds, and to 80 bpm for 20 seconds, with good return to baseline of 120-130 bpm. A resident's note indicates "decels to 90 x 4 minutes," with dilatation to 4 cm, effacement to 80%, and a vertex at –2. Oxytocin was discontinued at this time, and the patient placed in the left lateral position, with oxygen administered. Artificial rupture of membranes was performed, and the fluid was described as moderately meconium stained. A fetal scalp electrode was placed, and Pediatrics was notified to be available for delivery. The plan was to closely onitor the patient and anticipate vaginal delivery.

At 11:30 AM, oxytocin was restarted at 8 mU/mL and by 12:15 PM was 11 mU/mL. The FHR was at 140 bpm, but decelerations occurred to the 130s after contractions, with minimal variability and occasional nonrepetitive late decelerations. The oxytocin was then stopped, the patient placed in a left lateral position, and oxygen administered. Her cervix was dilated to 4-5 cm, 90% effaced, and the fetus at –1 station. At 2:00 PM, the oyxtocin was restarted at 8 mU/mL, and increased to 12 mU/mL at 2:40 PM. At 3:00 PM, the cervix was 7 cm. dilated, 90% effaced, and the fetus at –1 station. By 4:40 PM, nurses described the FHR as tachycardic at 170-180 bpm, with a quick return to baseline. At that time, the patient was fully dilated and 100% effaced, and told to push.