Legal Briefs: Iatrogenesis: Prolapsed Umbilical Cord After Artificial Rupture of the Membranes and Unskilled Stabilization

Abstract

* Abbreviations: AROM, : artificial rupture of the membrane ETT, : endotracheal tube FP, : family practitioner HR, : heart rate PPHN, : pulmonary hypertension of the newborn PPV, : positive pressure ventilation A 3,530-g term infant was delivered to a 22-year-old G1P0 mother who had an unremarkable prenatal course. She smoked during pregnancy and had a placenta previa that resolved by mid-gestation. A family practitioner (FP) was the treating physician during pregnancy. He decided at 39 1/2 weeks’ gestation to induce because of “uterine irritability.” When asked during the deposition why he induced labor, he said that the mother complained of abdominal discomfort, and she was at high risk because of her smoking. The plaintiff obstetrician was critical of the decision to induce because a valid reason was lacking, in his opinion. The defense obstetrician countered by saying 39 weeks is an acceptable gestation to induce. The plaintiff obstetrician said it was very unlikely that a successful induction would occur because the mother was a prima gravida, the fetus was large, and the cervix was unfavorable. Induction was by dinoprostone, followed by oxytocin (Pitocin®, JHP Pharmaceuticals, LLC, Rochester, MI) augmentation. When the cervix was 70% effaced and 2 cm dilated, and the fetus was at a −2 station, the FP decided to rupture the membranes. A few minutes after artificial rupture of the membranes (AROMs), multiple severe variable decelerations occurred, and 8 minutes after AROMs a prolapsed cord was discovered; the fetal heart rate (HR) became 50 beats per minute. The plaintiff obstetrician was critical of the decision to rupture the membranes because the fetal head was not engaged. The FP defendant said that the head was “well applied” to the cervix. The defense obstetrician said that because the FP said the head was well applied to the cervix, it was within standard of care to perform AROM even if the head was not technically engaged. All agreed that engagement of the head meant that in cephalic presentations …