Attempted Vaginal Breech Delivery Causing Global Brain Damage

The Giancola Case

Brief Description

This was catastrophic birth injury case where the Defendant obstetrician made an extremely dangerous [and contraindicated] decision to attempt a vaginal breech (feet down) delivery when a C-section should have taken place.

As a result, the known risk and exact reason why vaginal breech deliveries do not take place, i.e. the baby’s head could get stuck causing the baby to go without sufficient oxygen, did in fact occur: after the baby’s body delivered, his head became stuck for 18-20 minutes. 

During this time, per the testimony and medical records, the baby turned blue, went limp, and suffered a severe global brain injury from lack of oxygen. This was extremely predictable and absolutely preventable. 

The baby was almost 5-years old at the time the case settled. Tragically, he requires 24-hour care and lives full time at a skilled nursing facility.

Facts

Mom was pregnant and received her prenatal care at a local obstetrical practice group consisting of obstetricians and gynecologists. During Mom’s prenatal care, six ultrasounds found her baby to be in a breech position (feet down). The plan, as documented by three (3) different obstetricians in the group, was to perform a C-section because a breech vaginal delivery attempt is extremely risky because there is a good chance that the baby’s head could get stuck after the feet deliver causing an asphyxial brain injury (from lack of oxygen).

Later in the pregnancy, during the last prenatal ultrasound, the baby was found to be in a vertex position (head down) so the plan switched to a vaginal delivery with Mom being scheduled for an induction on a Monday.

Four days before the induction admission, on Thursday, during a visit to the practice group, an obstetrician, documented, inter alia, that:

• (a) if the baby turned again and was found back in a breech (feet down) or a transverse lie (sideways) during the induction, the plan should revert back to a C-section; and
• (b) a general surgeon would be placed on stand-by for the induction in the event that a C-section is needed - in case any adhesions (from Mom’s prior abdominal surgeries related to Crohn’s Disease) were encountered.

As it turns out, this obstetrician, who was the on-call obstetrician over that proceeding weekend and was not scheduled to handle the induction on Monday, only let the surgeon who was on-call over the weekend know to be on stand-by in the event Mom went into spontaneous labor over the weekend. In other words, the obstetrician was only worried about when he was on-call. The obstetrician never let the on-call surgeon for Monday know of anything.

Conversely, the attending obstetrician in charge of the induction admission on Monday, assumed that her partner had notified Monday’s on-call surgeon about this patient and to be on stand-by on Monday.

As a result of the negligent communication, there was no surgeon on stand-by Monday in case a C-section was needed.

Moving forward, after Mom was admitted for her induction on Monday morning and labored all day, at 10:45 pm, the attending obstetrician found the baby to be in a transverse lie (sideways) (there was no dispute that a transverse lie is undeliverable vaginally and requires a C-section).

After finding the baby in a transverse lie, the attending obstetrician called the surgeon who was supposed to help with the C-section surgery – whom the attending obstetrician thought was on stand-by and aware of this patient (she assumed her partner let the surgeon know).

During this phone call with the surgeon, the attending obstetrician learned that the surgeon was at home sleeping and had no idea that this patient was pregnant. So despite the well-documented plan to perform a C-section if the baby was found breech or transverse, and despite various caregivers testifying that Mom was even asking for a C-section, the attending obstetrician – who had an irrational fear of encountering adhesions and just found out that the surgeon who was supposed to help with any potential adhesions was home sleeping - decided to* try and turn the baby* to avoid a C-section to deliver the baby vaginally.

Therefore, in Mom’s labor room, the attending obstetrician negligently began having Mom push while the attending obstetrician made several attempts to try and turn the baby to a headfirst position.

When that was unsuccessful, Mom was then taken to the operating room where the attending obstetrician planned to again have Mom push while she again would try to turn the baby to avoid a C-section.

Per the deposition testimony, Mom was taken to the operating room only in the event that the attending obstetrician’s attempts at turning the baby were unsuccessful (with the back-up plan being to perform a C-section as the surgeon was making her way into the hospital). In the operating room, the attending obstetrician again negligently had Mom push as she again negligently attempted to rotate the baby.

The problem was all of the attending obstetrician’s monkeying around to try and avoid a C-section ended up with her** turning the baby the wrong way to breech** (feet first).

To compound her negligence, instead of simply waiting for the surgeon and performing a C-section, the attending obstetrician, in a reckless display of hubris (or panic depending on you look at it), then made the risky decision to try and pull the baby out feet first (a vaginal breech delivery attempt). In other words, the attending obstetrician made a gamble with this baby’s life.

While the attending obstetrician was able deliver the feet, legs, abdomen, chest and one arm, low and behold, the exact risk documented in Mom’s chart happened: the baby’s head and one arm got stuck.

During the next 18-20 minutes, the attending obstetrician then split her time from initially trying to pull the baby’s head and arm out and then trying to push the baby back up the vaginal canal to perform a C-section.

During this time, the baby turned blue, went limp, and suffered a severe global brain injury from lack of oxygen.

At different points during the time the baby was stuck, the attending obstetrician asked a nurse and the surgeon (who arrived in the middle of this) to try and push the baby up (they had never done that before), the attending obstetrician asked the surgeon to perform the C-section incision and the surgeon refused, etc.

Eventually the attending obstetrician’s partner, who was originally called and asked to come in to assist in what he thought would be a routine C-section (he took his time to get there), arrived. Per his testimony, within 15 seconds, he was able to push the baby up the vaginal canal to be delivered via C-section.

Notably, no adhesions were ever encountered. Moreover, testimony from both on-call surgeons revealed that there should never have been a concern over potential adhesions from Mom’s prior surgeries to begin with (as it relates to where the C-section incision is made). Testimony from the surgeons also revealed that even if adhesions had been encountered, it would have been no big deal, a routine finding, and easy to deal with.

Now to add insult to injury, national standards require any hospital providing obstetrical services to have the on-call pediatrician be at the hospital within 30-minutes. Here, the “on-call” pediatrician lived 45-minutes away. As a result, when the baby was born, there was no pediatrician present for a period of time. In fact, when the on-call pediatrician was called, he informed hospital personnel that he would not be able to make it for quite some time.

The hospital then called another pediatrician (pediatrician #2) who was not home and was caring for his gravely ill mother-in-law and advised that he could not come in. The hospital went on to call an additional pediatrician (pediatrician #3) who did not answer his phone.

In the meantime, pediatrician #2 apparently called back and said he would come in; but since there was still no pediatrician present when the baby was actually delivered (lifeless), yet another pediatrician (pediatrician #4) was called (he did not answer his phone either).

As a result, an anesthesiologist was left trying to resuscitate a lifeless baby with no pediatrician present until pediatrician #2 arrived 5-7 minutes after delivery (the original on-call pediatrician who was called arrived 1 hour and 15 minutes later).

Making matters even worse was how the caregivers dropped the ball with the cord blood gases. Hospital policy requires that cord blood gases be taken from the umbilical cord when a baby is born depressed. This is in part to help diagnose the baby’s condition and also is well-known in birth injury trials to help time the brain injury. Here, the cord blood was either not taken or thrown out; and neither the hospital nor the attending obstetrician had any explanation for its absence.

In any event, after a few hours, the baby was life-flighted to UPMC Children’s Hospital where he was diagnosed with a global asphyxial brain injury. As a result, the baby, was completely devastated and lives full-time at a facility requiring 24-hour care (he has never lived at home).

There is no dispute that the child’s injuries occurred during the time that he was stuck. First, all prenatal tests revealed a healthy fetus. Second, the fetal heart monitor tracing before the time the baby was stuck was perfect. Third, both pediatricians who arrived at the hospital testified that there was absolutely no reason to believe that anything other than asphyxia during the 18-20 minutes that the baby was stuck caused his injuries.

Tragically, this was all very predictable and very preventable with good medical care.

AREAS OF NEGLIGENCE

There were numerous areas of negligence:

1. The miscommunication related to making sure the on-call surgeon was on stand-by on Monday;
2. The prenatal obstetrical office failed to have policies in place to avoid such a miscommunication;
3. The attending obstetrician having an irrational fear of adhesions;
4. The attending obstetrician having Mom push while trying to rotate the baby multiple times to avoid a C-section;
5. The attending obstetrician – once she turned the baby to breech – deciding to still try a vaginal breech delivery;
6. The nursing staff failing to call the other obstetrician again to tell him of the emergent situation and to hurry (recall he got the baby out within 15 seconds of his arrival);
7. The nursing staff failing to obtain cord blood gases; and
8. Failing to have a pediatrician there to timely resuscitate the baby.

THE EXPERTS

Plaintiffs obtained experts from the following:

1. A Professor of Obstetrics;
2. A Professor of Neonatology;
3. A Pediatric Neuro-Radiologist;
4. A Professor of Physical Medicine and Rehabilitation.
5. A Life Care Planner);
6. A Professor of Economic.

The projected wage loss ranged from $2,421,650 to $4,927,807. The Life Care Plan with medical inflation ranges from $44,831,001 to $244,994,173.

THE DEFENSE NARRATIVE

While Defendants did not have any defense to the majority of the allegations, the attending obstetrician’s narrative, through her lawyer, was: Everyone (all the other nurses and doctors who were present and testified) was just wrong, including the medical records and an email written by a physician describing the events. All wrong! The attending obstetrician claims she never had Mom push nor did she ever try to turn the baby in the labor room or the operating room. The attending obstetrician claimed she was always going to perform a C-section and the baby somehow, on his own, just turned from sideways to breech (this doesn’t happen), then just came flying out, and she did not have much choice in what to do. In fact, the attending obstetrician testified that she has never tried to turn a baby from transverse (sideways) to vertex (feet first) and did not here.

To anyone that knew the minutia of the facts or medicine, the attending obstetrician’s narrative was laughable. Moreover, in addition to deposing the attending obstetrician (whose deposition was taken last), Plaintiffs took the depositions of thirteen other witnesses involved: 4 nurses, 1 nurse anesthetist, 2 surgeons, 1 other obstetrician, 1 anesthesiologist, 2 pediatricians, and Mom. Not one witness provided testimony that supported the attending obstetrician’s narrative in the slightest. Even worse, all of the witnesses provided consistent, credible, and polar opposite versions of the events.

Nonetheless, the lawyer for the doctor and hospital obtained expert reports from physicians that took the attending obstetrician’s narrative as gospel (ignoring the overwhelming evidence, uncontested facts, and contrary testimony from 13 other witnesses). These experts were willing to testify at trial that the care was appropriate and that no one did anything wrong. Moreover, part of the defense was to claim that the kid was so devastated by what happened that he would likely die within a few years so future medical bills (after a few years) should not be considered.

CONCLUSION

This case was a tragic nightmare involving an adorable kid who should be playing T-ball and enjoying all of the beautiful attributes of being a kid. Instead, he is neurologically devastated, has never lived at home, and will require 24-hour care the rest of his life. This never should have happened.

Shortly before trial, both sides agreed to mediate the case before a well-respected neutral mediator. Plaintiffs prepared an extremely lengthy, informative Mediation Statement laying out in excruciating detail how the Defense narrative was blatantly false (citing deposition (multi-million) testimony, the medical records, etc.).

At the mediation, the case settled for eight figures and is believed to be among the highest, if not the highest, birth injury settlements in the history of the county. The settlement proceeds were placed into a court supervised trust which will allow Mom to get her son the proper medical care he will need for the rest of his life.