Failure to Recognize Fetal Macrosomia

Filed under Cerebral Palsy, Brain Injuries

The Bissonette Case

Fetal macrosomia is a defined as a fetus that is extremely large, weighing in excess of 4000 grams (also known as “big baby syndrome”). The result of a large fetus is that it can be too large to deliver vaginally and require a C-section delivery. If a timely C-section is not performed and labor is permitted to prolong, the fetus is placed at risk for trauma, death, and/or serious birth injuries such as birth asphyxia, in utero stroke, and shoulder dystocia.

In this case, Autumn Bissonette demonstrated virtually every classic sign of fetal macrosomia. Despite these clear signs, the Defendant, a family practice physician who delivered babies, permitted this pregnancy to extend to 42 weeks (including two failed inductions). Moreover, when Ms. Bissonette finally went into labor, the Defendant permitted the labor to prolong for hours and hours before finally recognizing the need for an emergency C-section. As a result of the prolonged labor, the baby, who had a birth weight of 5490 grams (roughly 12.11 pounds), suffered a brain bleed at the time of birth.

The facts are as follows: Autumn Bissonette began prenatal visits with the Defendant in May 1999. The estimated delivery date of the male fetus was January 1, 2000.

Ms. Bissonette was an uncomplicated teenage pregnancy at the start of her prenatal period. By the 3rd trimester, Ms. Bissonette began to exhibit clear signs of macrosomia by having glucose in her urine and fundal heights greater than dates at each visit. At times, there was a discrepancy of 5 cm, which coincides with a 5 week difference in gestational age or clear macrosomia.

During this prenatal care period, our medical experts opined that the Defendant failed to meet the standard of care because:

  •  He should have obtained an obstetrical consultation.
  •  Given that Ms. Bissonette’s fundal height was greater than it should have been for her gestational age, follow up ultrasounds for fetal growth and estimated fetal weight should have been done.
  •  Given that Ms. Bissonette was spilling glucose in her urine at her December 14, 1999 appointment, follow up testing should have been done.
  •  Had these been done, fetal macrosomia would have been recognized and consideration for primary Cesarean section occurred.
  •  Had these been done, fetal macrosomia would have been recognized and Ms. Bissonette could have been given proper informed consent and the option for primary Cesarean section.

On January 9th, since Ms. Bissonette was past her due date, an induction was attempted and failed. Again, the standard of care required the Defendant to obtain an obstetrical consult or perform an ultrasound for estimated birth weight. He did neither.

Again on January 12, 2000, an induction was attempted and again failed. Again, the standard of care required the Defendant to obtain an obstetrical consult or perform an ultrasound for estimated birth weight. Again, he did neither.

Despite the failed induction on January 12th, Ms. Bissonette returned to the Hospital a few hours after being discharged with complaints of being in labor. She was subsequently readmitted. Ms. Bissonette weighed 272 pounds.

At approximately 7:00 a.m. on January 13, 2000, an artificial rupture of the membranes was performed and noted to have a scant amount of blood-tinged fluid. By 8:00 a.m., Ms. Bissonette developed an elevated temperature of 38.1 and her cervix was noted to be dilated 8 cms. She was given Pitocin due to labor not progressing. The Defendant allowed labor to continue.

At approximately 10:00 am, the Defendant noted that Ms. Bissonette was having early and late variable decelerations with unfavorable beat to beat variability. She was also noted to have one prolonged deceleration and several inconsistent late decelerations. Still, the Defendant allowed labor to prolong.

By 2:00 pm, the Defendant noted that Ms. Bissonette was completely dilated and pushing with no further late decelerations. The beat to beat variability was noted to be improved at that time. At 3:50 pm, meconium was documented.

Finally, around 4:10 pm, the Defendant called for a cesarean section. An OB/GYN was consulted to perform the C-section. A C-section was performed and the infant was delivered at 5:38 pm. At the time of the C-section, thick meconium was present. The infant was suctioned before delivery of the shoulders with the DeLee and the blue bulb syringe. The Infant was noted to be macrosomic weighing 5490 grams (12.10 pounds). The APGAR scores were 2/6/7.

During the intrapartum care period, our medical experts opined that the Defendant failed to meet the standard of care because:

  •  Given that Ms. Bissonette was not progressing during the day of the second induction, an obstetrical consultation should have been obtained.
  •  Given that Ms. Bissonette was not progressing during the day of the second induction and was over 41 weeks gestation, an obstetrical consultation should have been obtained.
  •  Given that Ms. Bissonette was not progressing during the day of the second induction, was over 41 weeks gestation she should not have been discharged to home on 1/12/2000.
  •  Given that Ms. Bissonette progressed very slowly and her failure to progress was evident following her eventual return to the Hospital on the evening of the 12th and throughout the morning and day of the 13th, obstetrical consultation should have been obtained.
  •  Given that during her labor, on the morning and day of the 13th, the fetal monitoring revealed episodes of fetal intolerance to labor, an obstetrical consultation should have been obtained.
  •  Given that there were signs and symptoms of chorioamnionitis on the morning of the 13th, the fetal monitoring demonstrating fetal intolerance to labor and slow progression of labor, an obstetrical consultation should have been obtained.
  •  Had an obstetrical consultation been obtained in a timely fashion, a primary cesarean section would have been performed and the baby would not have sustained the acidosis and subsequent neurologic injury.

Thereafter, within a few hours, the baby was transferred to the NICU at West Penn Hospital in Pittsburgh due to seizures and intracranial hemorrhages.

The baby was noted to have had one gasp after delivery prior to intubation with good spontaneous respirations by four minutes. The arterial cord gas was noted to be 7.01 and venous gas 7.23. The right-sided seizures were noted to begin in the second hour of life. An EEG was documented as abnormal brain activity and a brain CT showed a right frontal infarct, questionable parietal infarct, non-hemorrhagic. Originally it was thought that they were venous infarcts, but a later MRI suggested that they were arterial involving the different vascular territories including the middle cerebral arteries bilaterally. The baby was also diagnosed with HIE (hypoxic ischemic encephalopathy).

Subsequent to discharge, the baby was followed by West Penn Hospital’s Developmental Clinic and he is currently being followed by specialists at Children’s Hospital of Pittsburgh, including Neurology, who most recently diagnosed him with spastic diplegia. He has also been evaluated at the Children’s Institute in Pittsburgh for his developmental delays. More recently, he has been recommended for special education outside of the public school system. Past testing demonstrated his IQ at 66. In addition, he is receiving wrap around services through Family Behavioral Health. He also receives occupational and speech therapy.

In the future, the child’s ability to be employable will be severally challenged due to his cognitive limitations. If he will be employable at all, he will require the assistance of a job developer and a long term job coach that will be able to teach him the job and provide the ongoing behavioral and cognitive support his disability requires.

On behalf of the child, we brought suit against the Defendant and his employer (8-years after the birth).

Our experts (maternal fetal medicine specialist, family medicine specialist, neonatologist, pediatric neurologist, and a pediatric neuroradiologist) were prepared to testify that had the Defendant not been negligent (at any point along the way), the perinatal damage that the fetus sustained at the time of birth would have been averted and the child would not have the long term sequelae and brain damage that he has today. The damages caused to the fetus were a direct result of the repeated negligence of the Defendant.

The Defendants’ experts were prepared to testify that the Defendant physician was not negligent in any fashion and that even had the Defendant been negligent, the in-utero stroke that the fetus suffered was in no way causally related to the negligence. Their experts will also prepared to testify that the child’s injuries were not severe and that he would be able to be gainfully employed (even though the child was in special education classes and had an IQ of 66).

Two weeks prior to trial, the parties agreed to mediate the case before a local mediator. Although the case did not settle during the mediation, the parties reached a substantial settlement one week prior to trial. The settlement proceeds were placed into a special needs trust that our firm helped establish with a local bank.

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Publisher: Harry S. Cohen and Associates, P.C.