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Cruz v. Paso Del Norte Health3/29/2001
are healthy has very small differences in time between each of our heart beats. We don't just beat like automaton. There is also an aspect of fetal heart rate called long term variability, which over a minute or two in time is reflected in the amplitude or how high and low the heart rate varies, anywhere from five to 15 beats per minute of variance in the heart rate.
Whenever a fetal monitor shows warning signs and nonreassuring patterns, Providence's protocol requires the repositioning of the patient, hydration, administration of oxygen at the rate of eight to ten liters per minute, vaginal examination, and placement of a scalp electrode if the membrane has been ruptured. These signs also require consultation with a physician.
Presentment 2:58 a.m. - 3:55 a.m.
During the early morning hours of September 24, 1994, Cruz arrived at the Providence emergency room in labor. At 2:58 a.m., she was admitted to the hospital. Providence considered Cruz a "no-doctor patient" because she had received prenatal care at R.E. Thomason General Hospital and she came to Providence's emergency room without her medical records. Consequently, the Providence nurses and doctors were unfamiliar with her medical history, including information that she had complained of increased fetal activity on several occasions during the previous three weeks. Within two or three minutes of admission to the Labor and Delivery Department, Nurse Charlotte Graham attached an external fetal heart monitor and took Cruz's vital signs as well as a medical history. Graham also performed a vaginal exam and then, at 3:08 a.m., changed Cruz's position onto her left side so that the fetus would have better blood flow.
According to Graham, the fetal heart rate monitor should be run for fifteen to twenty minutes in order to establish the baseline. Initially, Sergio's fetal heart rate registered in the 140s and 150s and for about the next ten minutes settled into a baseline in the 150s and 160s. Sometime between 3:18 and 3:23 a.m., the baseline heart rate became tachycardic and then at 3:35 it began to rise above 160 to 170 beats per minute. Consequently, at 3:36 a.m., Graham again changed Cruz's position and administered oxygen. Rather than giving oxygen at the rate of eight to ten liters per minute as required by the protocol, Graham administered only four liters per minute due to her unfamiliarity with Cruz's cardiac and pulmonary history. Graham explained that if Cruz had cardiac or pulmonary difficulties, she could have experienced respiratory complications from the higher amount of oxygen, presenting a danger to both mother and baby. The fetal heart rate baseline then elevated to 180 beats per minute. At 3:47 a.m., Graham gave Cruz an intravenous (IV) bolus of lactated Ringers pursuant to the protocol, and a few minutes later she again changed Cruz's position and administered additional oxygen. She performed another vaginal exam at 3:54 a.m. in order to determine whether any progress had been made, and then immediately called an obstetrician, Dr. Rodolfo Tomasino. Graham reported Cruz's status to Dr. Tomasino, including the baseline, tachycardia, variability, and decelerations recorded by the fetal heart monitor, and she told him of all the steps she had taken thus far. Dr. Tomasino approved Graham's actions up to that point, including the administration of oxygen at the lower level of four liters per minute and the IV fluids, and he told her to continue with the same procedures. Following this call, Graham administered another bolus of lactated Ringers.
Between the First and Second Calls to Dr. Tomasino 3:55 a.m. -4:55 a.m.
At 4:10 a.m., the fetal heart rate monitor strip showed what one
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