Legal Briefs: Failure to Diagnose Spontaneous Intestinal Perforation

Abstract

A 26-3/7-weeks’ gestation, 800-g female infant was born to a 28-year-old woman whose prenatal course was complicated by an incompetent cervix and marginal placenta previa. The mother received tocolytics and antenatal corticosteroids when contractions started. Use of tocolytics was discontinued, and labor was allowed to progress when chorioamnionitis was suspected. The loss of fetal heart tones necessitated an emergency cesarean section. At delivery, the infant was in the breech position. Arterial cord blood gas analysis revealed pH 7.21. Apgar scores were 2 and 7 at 1 and 5 minutes, respectively. The infant was intubated in the delivery room and given surfactant replacement therapy. The physical examination findings were normal except for bruising and immaturity. The complete blood cell (CBC) count was normal except for a minimally low hematocrit of 39% (0.39), a finding explained by the bruising. The infant did not receive any further surfactant replacement therapy and continued to receive ventilatory support on low ventilator settings. The physician ordered antibiotics and low-dose indomethacin for intraventricular hemorrhage (IVH) prophylaxis. On day 1, the physician ordered phototherapy because of a bilirubin level of 4.5 mg/dL (77.0 μmol/L) and increased fluids to 150 mL/kg daily. By day 2, the weight was down 9% from birth weight. Antibiotic use was discontinued. On day 4, umbilical catheters were removed. On day 5, the weight was 23% lower than birth weight. Feeds of 1 mL every 8 hours were initiated. Cranial ultrasonography revealed bilateral grade 2 IVHs. On day 8, the feeds were increased to 2 mL every 8 hours, and the weight was down 30%. On day 9, the weight was down 32%, and feeds were increased to 2 mL every 4 hours. On day 10, the feeds were increased to 2 mL every 3 hours. On day 11, the feeds were increased to …