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Morrell v. Finke11/3/2005
at to beat) - Is most accurately determined by internal spiral electrode. This aspect of patient monitoring is the most indicative of fetal well-being and response to stressors of labor. Please document as:
Present = 3 bpm or greater
Absent = <3 bpm
Thus, a normal variation of three beats per minute or more in the fetal heart rate is a reassuring sign of fetal well-being, indicating that the baby>s brain is responding to oxygenation. A less than three-beat-per-minute variation in the baby's heart rate documents that beat-to-beat variability is "absent" and constitutes a nonreassuring pattern.
The fetal heart monitor strip will also show "decelerations," (decels) in the baby's heart rate that may be early, variable, or late. Early decels occur with a contraction and indicate a benign pattern. Variable decels, variable in shape rather than uniform in pattern, may also occur during the contraction. Variable decels are generally caused by umbilical cord compression and are indicative of decreased oxygenation to the baby. Late decels document a deceleration of the baby's heart rate beginning at or after the midpoint of a contraction. Late decels are indicative of placental insufficiency, meaning that the baby is not being profused well by the placenta.
Babies have stored oxygen in cells throughout their bodies called "fetal reserves." Severe, prolonged, variable, or late decelerations are "nonreassuring" and are considered "ominous" if they become "repetitive" because every late or variable decel presents the possibility of depleting fetal reserves, depending on the degree of the insult. Experts testified that, over time, chronic or repetitive decels are nonreassuring because they deplete fetal reserves and make the baby less able to tolerate each successive insult. Madeline's fetal heart monitor strip began at approximately 8:45 a.m., tracing her heart rate from the external fetal heart monitor. At approximately 9:40 a.m., Dr. Finke applied a fetal scalp electrode to Madeline's head to monitor her heart rate more accurately. Experts testified that Madeline's fetal heart monitor strip tracings were nonreassuring from the start because she had no heart rate "accelerations" as that term was defined by the hospital fetal heart monitoring policy and, also according to the policy, beat-to-beat variability was "absent."
C. Morning
Because Madeline's fetal heart monitor strip was nonreassuring, nurses began an IV on Donna and turned her onto her left side. Madeline's strip still did not become reassuring. Dr. Finke, the obstetrician on call for the clinic at the hospital that New Year's Eve, first saw Donna at 9:40 a.m. Dr. Finke reviewed the prenatal records, took Donna's medical history, examined the fetal heart monitor strip, performed a cervical examination, and determined the baby's orientation by sonogram. The baby was full-term at an estimated eight pounds and active, the amniotic fluid was clear with no bleeding, and Donna was having irregular contractions.
Dr. Finke confirmed from her examination that Donna's pelvis was adequate for vaginal delivery, and she anticipated a vaginal delivery with the alternative of a cesarean section if maternal or fetal indications were present. At 10:00 a.m., Dr. Finke formulated her plan to administer Pitocin to stimulate uterine contractions if no further cervical dilation occurred within two hours. She wrote orders for lab work, Pitocin, an antacid, and pain and antinausea medication if needed.
Donna's cervix was dilated only one of the ten centimeters necessary for delivery, with the baby in a head-downward position at a minus two station in the birth canal a
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