posted by admin on Mar 10
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1 A. Well, of course. We all do. But I’m
2 saying that I don’t think it plays a role in etiology
3 here or — or in management to the extent that it would
4 be — it would prevent a problem. I think we do it
5 because it makes some common sense. We might raise the
6 fetal PO2 one or two points. But we’re not going to
7 take a sick fetus and make it well by giving the mother
8 oxygen.
9 Q. It sounds like what you’re saying, sir, in
10 panel 13666, the standard of care for a reasonably
11 prudent nurse didn’t even require her to give the
12 patient oxygen or put her on her side; correct?
13 A. Well, I think at 13666 for the first time
14 we have reduced variability. And I think it’s a good
15 thing for the nurse to put the patient on her side,
16 promote blood flow, and give oxygen, just in case there
17 is some diminished oxygenation of the fetus at that
18 time.
19 But as far as strict standard of care, no,
20 she’s not in labor. Her cervix hadn’t changed. The
21 heart rate really hasn’t demonstrated any significant
22 patterns. There’s no bradycardia that we know of. So
23 I think by standard of care she probably didn’t have to
24 do that, but I think it was a good idea. I just don’t
25 think it makes the difference between a baby that is
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1 gonna be born healthy and a baby that’s gonna be born
2 sick.
3 Q. That’s fine. We’re just sticking, though,
4 to standard of care now.
5 A. Right.
6 Q. What about that panel, sir, in 13666, do
7 you think made it a good idea, although it wasn’t a
8 standard of care?
9 A. Well, they were having trouble once again
10 establishing heart rate. There was an area where it
11 looked like the heart rate might have been going down.
12 Q. Where is that?
13 A. If you look at pattern — if you look at
14 panel 13665 –
15 Q. Yes, sir.
16 A. – do you see how it looks as if the heart
17 rate is just starting to go down? There’s a little
18 gap, and then it’s down around 70?
19 Q. Okay.
20 A. I think that’s what promoted the nurses to
21 do what they did.
22 Q. Now, sir, is that different than any of the
23 places between midnight and 12:30 which looks similar
24 to that, where the heart rate is up at 180 and then
25 it’s down after a gap?
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1 A. Well, there’s nothing that looks as if it
2 is heading downward as you have in the case I just
3 described. What you have is a monitor that looks like
4 it’s searching for the heart rate. So in that sense
5 it’s different.
6 Q. Is this the type of thing between twelve
7 midnight and 12:30 that it’s not a standard of care to
8 put the patient on their side or give them oxygen but
9 it would be a good thing to do?
10 A. Well, if they go to the side, they may have
11 more trouble getting the heart rate. It couldn’t hurt.
12 Oxygen could have been given at midnight. I just don’t
13 think it plays a role in anything here, whether it’s
14 linked to the problem or standard-of-care principles.
15 I mean, I look at this case as a 34-weeker
16 who came in with premature labor, attempts were made to
17 stop. Around midnight the heart rate, which had been
18 relatively easy to follow, was becoming more
19 problematic. And within — within less than two hours
20 the patient had been delivered by a very rapid cesarean
21 section, based on the fact that the nurses were having
22 trouble and because of the concern that it was more and
23 more difficult to monitor the fetal heart rate.
24 I know we have a bad outcome here. I know
25 this child died. Obviously, the birth had significant
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1 oxygen problems at the time of birth, considering the
2 outcome. But I still don’t believe that any departure
3 from the standard of care occurred by the nurses taking
4 care of Ms. K..
5 Q. Sir, do you know what the pH was at birth
6 of the baby or the cord pH or –
7 A. No, I don’t. I know the first pH, but they
8 did not obtain a cord pH.
9 Q. Do you know what hypothetically a cord pH
10 would have been had it been obtained?
11 A. Hypothetically?
12 Q. Yes, with a reasonable degree of medical
13 probability.
14 A. Well, it couldn’t have been good. I mean,
15 the first gas was 6.7. It’s not gonna be much better
16 than that.
17 So I would think it’s gonna have severe
18 acidosis at birth. That’s about all I could say.
19 Q. Do you have an opinion, sir, that you hold
20 to a reasonable degree of medical probability as to
21 when would be the last time before birth that a gas, if
22 hypothetically taken, such as a scalp pH, would have
23 been normal?
24 A. (Pause)
25 Hold on. I’m just trying to put the fetal
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1 monitoring tracing in order, and I’ve — I haven’t.
2 Q. Okay.
3 A. One second.
4 Q. Okay.
5 A. I got it.
6 On a more-likely-than-not basis, I think
7 that objectively the last time that I would feel
8 comfortable with a normal pH having been possibly
9 obtained at delivery occurred — because I don’t think
10 you could do scalp sampling here — would have been at
11 the 95169 area, which is about twelve — somewhere
12 around 12:57, somewhere in there. Because you’ve got a
13 rate of 120. The variability looks moderate to me, and
14 that’s right as it’s starting to go downward. You
15 might have had a normal pH later, but I think here,
16 more likely than not, the pH would have been normal.
17 Q. Okay.
18 A. After that we really don’t have anything
19 very objective other than that last couple of minutes
20 before taking the patient to the delivery room — or
21 the operating room. And I just can’t really say much
22 about that.
23 Q. Now, does that normal pH that you told me
24 about, the one o’clock or 12:57, indicate also that the
25 fetus is without hypoxemia?
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1 A. No. Hypoxemia is not a — is not a very
2 pejorative term. You know, you and I can hold our
3 breath and become hypoxemic. It’s tissue hypoxia would
4 be a better way for me to answer the question.
5 Q. Okay. Same question with the word “tissue
6 hypoxia.”
7 A. Yeah, I don’t think there’s any tissue
8 hypoxia going on at that particular point. That’s why
9 I was able to look at the variability and make that
10 statement.
11 After that, I’m not as sure or certain and
12 I don’t know if I could say within medical reasonable
13 probability. And certainly after that is when
14 everything starts to happen and everybody starts to
15 make moves to delivery, which does occur by her coming
16 off the monitor some 28 minutes later and delivered by
17 some 46 minutes later.
18 Q. So just so I’m clear, you will not have an
19 opinion, with a reasonable degree of medical
20 probability, when between approximately one o’clock and
21 the time of birth the child first became — or had
22 tissue hypoxia?
23 A. That’s correct.
24 Q. Would you agree with me, sir, that once a
25 nonreassuring fetal heart tracing is noticed by a nurse
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1 it’s necessary to find a reassuring element of fetal
2 well-being in order to allow labor to continue?
3 A. No, I really don’t. Because it’s the level
4 of nonreassuring. And that’s why I’ve never liked the
5 term; because it puts mild tachycardia with normal
6 variability in the same category as repetitive lates
7 with minimal variability. It’s just not a term I like.
8 I know that the American College of OB/GYN
9 have used it and are pushing it. This is one of these
10 areas where some of us — and I’m obviously one of
11 those included — that disagrees with using that term.
12 So there is plenty of nonreassuring fetal
13 heart tracing that the nurse does not have to alter and
14 find some reassurance — unless she’s gonna use
15 something like variability and to say despite the
16 nonreassuring pattern, as far as tachycardia or
17 repetitive decelerations, that the variability is so
18 reassuring that I’m gonna call this a normal tracing.
19 So it’s a matter of semantics moreso than
20 anything else.
21 Q. Okay. Well, I’m just asking the way you
22 would state it.
23 Do you have an opinion, with a reasonable
24 degree of medical probability, why they had problems
25 with the transducer, in your opinion, between the
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1 twelve and 12:30 time or later?
2 A. I really don’t know. Usually it’s a fetus
3 that’s very active, moving around, and, therefore, the
4 beam under which its heart is being continuously
5 exposed to the ultrasound detectors is no longer able
6 to ascertain a steady heart rate. That could be one of
7 the possibilities.
8 The other is that the heart rate did have
9 some significant decelerations and by the time it came
10 back up periodically, it was difficult for the nurse
11 once again to find it.
12 Q. Prospectively can she know which of the
13 possibilities it is?
14 A. Not really. I mean, that’s the whole point
15 in searching for the heart rate, which began somewhere
16 around midnight.
17 Q. I asked you about what protocol for nurses
18 should state. I don’t know if I asked if you believe a
19 protocol should state when the nurses should call the
20 physician. In other words, in what situations?
21 A. Well, that’s relatively easy to answer.
22 The physician should be called, as a rule, when the
23 nurses believe there has been a change in status such
24 that physician input to either make a decision of
25 status quo and continue the course or to make an
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1 alteration and plan of action should occur.
2 So it’s really when the nurse feels that
3 there is a change in the situation that the doctor
4 needs to be involved in so as to make a decision as to
5 whether to continue what’s going on or to take a change
6 in course of action.
7 Q. So in your definition, if a nurse doesn’t
8 know any better or doesn’t have enough education to
9 know any better and she believes everything is
10 beautiful, the standard of care would not require her
11 to call the doctor; correct?
12 A. No, that’s not true at all. It’s what is
13 actually happening. If the nurse is making a mistake
14 because of her lack of training and education and
15 background, the violation of the standard of care
16 starts when she should have made the right decision but
17 didn’t. It’s the same thing for a physician. If a
18 physician doesn’t make the decision to do a cesarean
19 section until late in the game when everyone can look
20 at the monitor strip and say it should have been made
21 30 minutes earlier, then that doctor, despite the fact
22 that he made his decision 30 minutes later, is still in
23 violation because he should have made it 30 minutes
24 earlier. It’s the same — the same parameters are at
25 work here.
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