Death of Baby Following Mismanagement of Neonatal Hypoglycemia
The Frances Case
Following delivery, an Obstetrician, Pediatrician, and nursing staff negligently managed a baby’s neonatal hypoglycemia causing the baby’s death 22-hours after delivery.
The Medicine
Shoulder Dystocia: Shoulder dystocia is when, after vaginal delivery of the head, the baby’s anterior shoulder gets caught above the mother’s pubic bone and the baby gets stuck. Shoulder dystocia is an obstetric emergency and a pediatrician must be called immediately upon encountering it because the baby could suffer a hypoxic injury while being stuck, could suffer an injury to brachial plexus nerves to the shoulder, etc.
Diabetes: A condition in which the body can’t make enough insulin, or can’t use insulin normally. Insulin is a hormone that helps sugar (glucose) in the blood get into cells of the body to be used as fuel. Diabetes in a pregnant woman is known to cause very low blood glucose levels which often transfers to the baby causing neonatal hypoglycemia.
Neonatal hypoglycemia: A condition in which a baby’s blood sugar (glucose) level is lower than normal. It is the most common metabolic problem in newborns. It is a very treatable condition – simply by giving the infant glucose. Though it is correctable, it is fatal if not timely recognized and/or if there is a delay in giving the baby glucose.
Summary
This was a case where doctors and nurses mishandled the care of a baby who was born with neonatal hypoglycemia, miscommunicated with each other, and misunderstood the emergent nature of the baby’s condition. As a result, no one was in charge of the baby’s hypoglycemia which went untreated until it was too late with the baby tragically dying 22 hours after delivery.
With regard to liability, the Defendants were pointing fingers at each other. With regard to causation, the Defendants came up with a bizarre theory that the baby died of some coincidental other cause other than hypoglycemia (which contradicts the pathologist who performed the autopsy who opined that the baby died of cardiac arrest from complications brought on by the neonatal hypoglycemia).
As discussed below, there were irreconcilable differences between the Defendants that could not be explained away:
- Obstetrician v. Nurses
- Nurse v. Pediatrician
- Obstetrician v. Pediatrician
- Pediatrician v. Hospital Policy
- Defense experts v. Autopsy Report
The Delivery
Mom presented to Uniontown Hospital at 35 weeks gestation (5 weeks premature) reporting a spontaneous rupture of membranes (water breaking). Mom had a history of insulin-dependent diabetes throughout her pregnancy. The Defendant Obstetrician was on staff in the labor and delivery department. The Obstetrician admitted Mom to labor and delivery and noted “prepare for increased risk of shoulder dystocia” because women with gestational diabetes are known to have large babies. Therefore, prior to the baby’s delivery, the Obstetrician knew:
- The infant’s gestational age was 35 weeks – 5 weeks premature with underdeveloped lungs;
- Mom was an insulin-dependent diabetic which could result in the baby having neonatal hypoglycemia; and
- The delivery had an increased risk of shoulder dystocia.
Accordingly, it was known that this baby would likely have medical needs at delivery which would require the care of a pediatrician (a physician specially trained to treat newborns who require medical care following delivery). Despite the same, the Obstetrician failed to contact the on-call pediatrician to ensure her availability to be present to care for the baby as was likely going to be necessary.
Moving forward, Mom labored throughout the day. At approximately 4:00 p.m., she started pushing. At 4:53 p.m., the baby’s head delivered. The Obstetrician then encountered a shoulder dystocia - as he anticipated – with the baby’s shoulder stuck on the pelvic bone. There was a dispute whether the Obstetrician ordered a nurse to notify the Pediatrician - which was required by the standard of care (more on that below). The Obstetrician then attempted a series of maneuvers to deliver the baby’s body. Two minutes later, at 4:55 p.m., the baby was fully delivered. She had no respiratory effort, no muscle tone and poor color. The nurses attempted resuscitation, documented Apgar scores of 2, 7, and 7, and then transferred the baby girl to the nursery without the direction or care of a pediatrician.
With regard to notifying the Pediatrician, in his deposition, the Obstetrician testified that he told the nurses in the delivery room at 4:53 p.m. (when he first encountered the shoulder dystocia) to call the Pediatrician immediately. The three nurses in the room all testified that they did not recall the Obstetrician ever giving a verbal order to call the Pediatrician and did not recall whether they did. Further, the nurses testified that had they been given the order to call the Pediatrician, that they certainly would have carried out the order. What we did find out was - based on medical and phone records - the Pediatrician was not called until 5:30 p.m. (35 minutes after delivery and 37 minutes after the Obstetrician claims he ordered the nurses to do so).
Therefore, the Obstetrician was initially negligent for failing to ensure the availability of the Pediatrician at and/or shortly after delivery to perform appropriate resuscitation efforts. This was negligent because the Obstetrician knew that the baby was a compromised 5-week premature infant with underdeveloped lungs, had an insulin-dependent diabetic mother whose baby was at risk for neonatal hypoglycemia, and he clearly anticipated a potential shoulder dystocia presentation. Even the Pediatrician testified that any one of these risk factors alone should have prompted a call to ensure the availability of a pediatrician at delivery.
The Obstetrician was also negligent for failing to have the nurses call the Pediatrician at 4:53 p.m. Conversely, if the Obstetrician is to be believed - that he told the nurses to call the Pediatrician – the nurses were negligent for failing to call the Pediatrician. Regardless of who was to be believed - the Obstetrician or the nurses - the ball was clearly dropped by somebody – it was simply a matter of determining who was at fault.
Finally, the Obstetrician was also negligent for failing to initiate proper treatment for this baby and/or notifying the Pediatrician of the baby’s deteriorating condition in the period that he remained in charge of the baby’s care following delivery.
The Pediatrician’s Failure to Recognize Severity of Condition and Failure to Follow Hospital Policy
The initial assessment of the baby performed by the nurses revealed several medical issues that needed addressed, including severe hypoglycemia (low blood sugar) of 17 that needed emergently addressed (normal blood sugar for a newborn is 45 to 126). Recall that hypoglycemia is a very treatable condition simply by giving the infant glucose and fatal if not timely addressed. Here, it was not until 5:30 p.m. (35 minutes after delivery) that the glucose level was tested; it was not until 6:15 p.m. (1 hour and 20 minutes after delivery) that glucose was given via UV (umbilical) line. Moreover, over 10 attempts to obtain IV access were unsuccessful which was critical because the only acceptable method to raise a critically low blood sugar level in an infant is through direct access to a vein. Making matters worse, the only person able to perform a UV (umbilical) line on the baby was the Pediatrician who was not contacted until 5:30 p.m. (35 minutes after the baby’s birth) when a nurse called the Pediatrician who did not arrive in the hospital until 6:15 p.m. (1 hour and 20 minuet after delivery).
As it relates to this phone call at 5:30 p.m., a nurse called the Pediatrician. This was the first notification to a pediatrician despite the Obstetrician’s claim that he ordered the nurses to call at 4:53 p.m. The Pediatrician saw the call from the hospital, knew it could be an emergency, and instead chose to ignore it because she was on the other line on a non-emergent phone call. Eight minutes later, at 5:38 p.m., the Pediatrician returned the call to the nursery. The Pediatrician spoke to the nurse and testified that the nurse told her that there was an infant of a diabetic mother in the nursery and that the baby was “very sick.” The Pediatrician testified that she was not given specifics nor did she ask. The Pediatrician gave verbal orders over the phone for blood work and an x-ray of the chest and clavicles. The Pediatrician testified that the nurse never told her about the severe hypoglycemia of 17 during this phone call which is why she never gave an order for glucose to be administered. Notably, a nurse testified to the opposite. The nurse testified that she did in fact advise the Pediatrician about the severely low blood sugar and that she also documented this communication in the chart. In any event, the baby’s critically low blood sugar went unaddressed following this phone call and unaddressed until the Pediatrician arrived at the hospital 45 minutes later.
With regard to the Pediatrician coming to the hospital, the Hospital had a policy entitled Physician Physical Response Time to Hospital for Emergency Physicians. This policy required the Pediatrician to be physically present in the hospital within 30 minutes of being called. The initial phone call to the Pediatrician was at 5:30 p.m. which went unanswered. In her deposition, the Pediatrician testified that she was on the phone with a mother of a very sick child (as it turns out, after we got phone records and called this “mother”, it turned out it was not the mother of a sick child but instead the Pediatrician’s lawyer with whom she was discussing a business deal). In any event, a nurse called the Pediatrician at 6:00 p.m. again to determine where the Pediatrician was, as she was not yet present at the hospital. The Pediatrician advised that she was en route. According to the medical record, the Pediatrician did not arrive in the nursery until 6:15 p.m. – 45 minutes after the initial phone call to her – and 15 minutes after the 30-minute hospital policy requirement. As a result, the baby went without timely receiving glucose to correct the severely low blood sugar until the Pediatrician arrived at the hospital (1 hour and 20 minutes after birth) and placed the UV (umbilical) line. Moreover, the Pediatrician arrived at the hospital 1 hour and 22 minutes after the Obstetrician testified that he told a nurse to call the Pediatrician. In his deposition, the Obstetrician testified that he was “surprised” to learn the Pediatrician had still not arrived 1 hour after the birth.
Accordingly, if the nurse advised the Pediatrician about the low blood sugar, the Pediatrician was negligent by failing to recognize the severity of the baby’s neonatal hypoglycemia. If the nurse did not advise the Pediatrician of the low blood sugar, then the Pediatrician was negligent for failing to question the nurse as to what the blood sugar was when being told of a “very sick” baby from a diabetic mother. Again, regardless of who is to be believed - the Pediatrician or the nurse - the point was the ball was again clearly dropped by somebody – and again was simply a matter of determining who was at fault.
Further, the Pediatrician was negligent for failing to respond within 30 minutes of the initial phone call at 5:30 p.m. when she was the only provider competent to place a UV (umbilical) line for glucose administration. All of the above resulted in the baby not having severe hypoglycemia addressed until it was entirely too late.
The Nurses
The nurses were negligent – if the Obstetrician was to be believed – for not calling the Pediatrician at 4:53 p.m. when the Obstetrician told them to. The nurses were also negligent for failing to check the baby’s blood sugar until 35 minutes after delivery. The nurses were further negligent – if the Pediatrician was to be believed – for not telling the Pediatrician of the 17 blood sugar level and for failing to clearly communicate the specific needs of the baby during the phone call at 5:38 p.m. Lastly, the nurses were negligent for failing to go up the chain of command and/or seeking help from other doctors when the baby was clearly spiraling downward with no pediatrician present following delivery.
The Hospital
The Hospital was vicariously liable for the actions of the Obstetrician, the Pediatrician and the nurses. The hospital was also directly negligent for its failure to ensure that a rapid response team capable of meaningful intervention, such as placing a UV (umbilical) line, was ready when needed.
The Cause of Death
Mom was an insulin-dependent diabetic during her pregnancy. As such, this was another reason to ensure close monitoring of the baby’s blood sugar. Even more reason to ensure close monitoring of her blood sugar was that the baby was a symptomatic hypoglycemic patient from the moment of birth. She had poor respiratory effort (with Apgars of 2, 7, and 7), poor suck/feeding, cyanosis, mottled color, hypotonia, and tachycardia. The first time her blood sugar was checked was at 5:30 p.m. (35 minutes after birth) revealing a severely low blood sugar of 17.
The first time any form of glucose was given to the baby was at 6:04 p.m. (1 hour and 9 minutes after delivery). The Obstetrician ordered Sweet Ease – which is a form of glucose solution given by mouth. Unfortunately, the baby had no suck reflex and as such oral glucose was not an acceptable method of glucose administration for a symptomatic infant with severe neonatal hypoglycemia; it must be given via IV or UV. Once the Pediatrician finally arrived at the hospital, she gave a glucose push into the left arm at the blood draw site at 6:15 p.m. (1 hour and 20 minutes after delivery).
The Pediatrician attempted resuscitation, but by 6:40 p.m., the decision was made to transfer the baby. Support efforts continued, but the baby’s condition worsened, and by time of transfer, it was noted that she had metabolic acidosis, neonatal respiratory failure, birth depression and moderate to severe encephalopathy (disease, malfunction or damage of the brain).
The baby was transferred to Children’s Hospital in Pittsburgh, but unfortunately, with the poor prognosis and severe neurological injury, support was withdrawn and she passed away at 2:56 p.m. (22-hours after delivery). An autopsy was performed and concluded that the combined hypoxic and hypoglycemic damage led to injury to multiple organ systems, most importantly the brain. The extreme delay of giving the baby glucose to correct her severe hypoglycemia caused hypoxic-ischemic encephalopathy (HIE) which lead to her death.
The baby’s neonatal hypoglycemia was mismanaged by all health care providers – the Obstetrician, the Pediatrician, the nurses, and the hospital. The lack of communication and preparedness by all caused the baby’s death. The Obstetrician failed to communicate with the nurses to ensure that a pediatrician was ready and available when needed. The Pediatrician failed to respond appropriately to the urgent phone call from the nursery at 5:30 p.m. The Pediatrician failed to communicate with the nurses to elicit critical information about the baby’s condition. The nurses failed to assess and reassess the baby’s condition and failed to contact the Pediatrician earlier, despite the baby’s deteriorating condition. The Hospital failed to ensure that appropriate health care providers were available to care for this compromised infant.
The “Defenses”
The Obstetrician’s defense was that he could not have reasonably foreseen the occurrence of neonatal hypoglycemia. This defense was absurd. Hypoglycemia is the most common metabolic issue occurring in the neonatal period. Neonatal hypoglycemia most commonly affects infants of diabetic mothers or large for gestation age infants (of which the baby was both). Further, all of the symptoms present immediately after delivery were all indicative of neonatal hypoglycemia which should have prompted a simple heel stick to test the infant’s blood glucose level immediately. Instead, 35 minutes went by before the baby’s blood sugar was tested revealing a critical low level of 17 – and then, another 45 minutes elapsed before the baby was given glucose. As such, the Obstetrician’s failure to reasonably foresee the occurrence of hypoglycemia was a breach of the standard of care.
The Obstetrician’s defense for failing to call the pediatrician at 4:53 p.m. when he found shoulder dystocia was to blame the nurses by claiming he ordered them to call the Pediatrician.
The nurses’ defense for not calling the Pediatrician was to blame the Obstetrician for not telling them to call the Pediatrician.
With regard to not timely arriving at the hospital, the Pediatrician first claims that no one called her at 4:53 p.m., i.e. she blamed the Obstetrician and nurses. Secondly, the Pediatrician claimed that she appropriately followed the Hospital policy by arriving at the hospital within 30 minutes of notification; however, this was done by fudging the times. The first phone call to the Pediatrician was at 5:30 p.m. After initially ignoring the call because she was on the other line, the Pediatrician returned the call at 5:38 p.m. The nurse again called the Pediatrician at 6:00 p.m. to find out if she was en route. The medical record documents the Pediatrician’s arrival to the nursery at 6:15 p.m. – 45 minutes after the initial 5:30 p.m. phone call. The Pediatrician conveniently chose to begin the 30-minute countdown when she first decided to call the nursery back, not when the nursery first tried calling her. The Pediatrician then conveniently claimed she arrived at the Hospital just under 30 minutes from returning the call even though her claimed arrival time is inconsistent with the medical record documentation of her arrival time. Moreover, the Pediatrician’s arrival time was significant because she was the only medical provider that could place a UV (umbilical) line to administer glucose to the baby; and only after her arrival did the baby receive glucose (roughly 1 hour and 20 minutes after delivery).
With regard to not treating the critically low 17 glucose level that the nurse claimed she told the Pediatrician about during their initial phone call, the Pediatrician claimed the nurse never told her about it (despite the nurse’s testimony to the contrary). In other words, the Pediatrician blamed the nurses. The nurse’s defense to not telling the Pediatrician about the critically low 17 glucose during their phone call was to blame the Pediatrician by claiming she in fact told the Pediatrician about it (despite the Pediatrician’s testimony to the contrary).
Due to the incredible amount of finger pointing, the global defense was to claim that none of the negligence mattered because the baby was going to die anyhow. In other words, the escalating and compounding negligence by all involved was a mere coincidence to this baby dying. To do that, the Defendants claimed that the cause of the baby’s death was not severe hypoglycemia, but instead a splenic rupture - found during the autopsy - that they claim occurred during the shoulder dystocia which caused bleeding which caused the death. However, the autopsy report specifically stated that the splenic rupture was a result of the chest compressions and cardiopulmonary resuscitation. This defense ignored the fact that the untreated neonatal hypoglycemia caused the infant to code in the first place, which then required the medical providers to perform chest compressions (in other words even if their argument is to be believed it was caused by negligence). Further, the autopsy report specifically noted “the splenic laceration was not likely to have significantly altered the patient’s outcome.” Moreover, the autopsy noted “the combined hypoxic and hypoglycemic damage led to injury to multiple organ systems, most notably the brain.” Accordingly, Defendants’ causation defense was not credible and was a clear Hail Mary in reaction to the obvious negligence.
The Outcome
Days before trial, weeks after a failed Court ordered mediation, we settled with the Pediatrician and the Hospital for substantial amounts and were prepared to go to trial against just the Obstetrician. The next day, the Obstetrician’s insurance company tripled its offer and the case was fully settled.