law rights & civil resource

posted by admin on Mar 10

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1 Many of the policies that I am familiar

2 with simply state that if an abnormality is suspected

3 or noted, that certain things should happen. But I

4 don’t think you have to list all of the objective

5 criteria to determine what is normal and what is

6 abnormal, since so many people don’t agree with that

7 anyway. The ones I’m used to seeing don’t include

8 that. That’s not to say that it doesn’t — that it

9 isn’t included in a number of policies on labor and

10 delivery suites around the country, but I don’t think

11 you have to have it.

12 Q. Okay. Would you think the protocol should

13 state how to interpret findings and what to do with the

14 observations, specifically what nurses and physicians

15 should expect from each other?

16 A. Yes.

17 Q. Would you also agree that this policy or

18 protocol should specify the circumstances under which

19 the nurse should request and expect the physician’s

20 consultation in a prompt manner?

21 A. Yes.

22 Q. Do you know whether the policies or

23 protocols in this particular case describe exactly what

24 I just asked you about?

25 A. No, I don’t.

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1 Q. What is your understanding, sir, of this

2 patient in labor as far as her fetal monitoring was

3 concerned, say, until 10:00 p.m. at night?

4 A. Are you talking about the — on September

5 the 6th from 6:40 p.m. to 10:00 p.m.?

6 Q. The 10:00 p.m. on the night of the 7th. I

7 don’t want to spend the time and go through every strip

8 frame by frame during that time frame. If you can give

9 me your overall gestalt, that’d be great. If you want

10 to, in fact, do it frame by frame, we could do that

11 too. But from 10:00 p.m. on I’m going to take you

12 through frame by frame, so I just thought I’d shorten

13 the process.

14 A. Okay. No, I just didn’t know which date

15 you were talking about. Sure I can give you an

16 overview.

17 From the time of admission to 10:00 p.m. on

18 the 7th, I felt that the tracing was normal in that it

19 had a normal baseline rate. It had moderate

20 variability. It had accelerations.

21 Starting at approximately twelve noon on

22 the 7th, the only difference in characterizing the

23 fetal heart rate monitoring is that there is a mild

24 tachycardia of 170 beats per minute. That is still

25 associated with moderate variability, no significant

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1 decelerations. And that continues with occasional

2 areas of 180 beats per minute, but no higher — usually

3 in the 170. And that continues pretty much — there

4 are some areas of what I would called marked

5 variability noted somewhere around — starting around

6 9:40. But by ten o’clock on the 7th the rate again is

7 at about 140, with evidence of mild cord compression,

8 that is variable decelerations.

9 But up until that point, from 6:40 p.m. on

10 the 6th, through ten o’clock on the 7th, it is a

11 totally normal reactive tracing until ten — until noon

12 on the 7th, where the only difference is there’s a mild

13 tachycardia. And prior to ten o’clock p.m. there’s

14 some areas of marked variability, all of which is –

15 all of these are signs of a baby that is not

16 demonstrating any hypoxia and would be considered a

17 relatively reassuring tracing — certainly up to the

18 point of tachycardia.

19 And even with the tachycardia, I think

20 because of the variability and the lack of

21 decelerations, that it would still be considered a

22 tracing not — not descriptive of a hypoxic baby.

23 Q. When did the tachycardia begin, sir?

24 A. Around 12:10 on the 7th of September.

25 Q. Okay. And did it continue throughout –

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1 until 10:00 p.m. that night?

2 A. It continued until — off and on pretty

3 much that’s the case. It stayed above 160 pretty

4 much — I’m looking here at 8:30, for example — 8:40.

5 At 8:50 it looks like it’s back to 150. But because

6 there are some wider swings, it’s not — you’re not

7 always able to establish a baseline.

8 But I’m looking at 9:10, for example, and I

9 think clearly I have ten minutes of tracing here, which

10 is what you need to see for a baseline rate, and it

11 looks in the 170 range.

12 So I think up until about ten o’clock there

13 is some mild tachycardia, from noon to ten.

14 Q. Within a reasonable degree of medical

15 probability, sir, what was the cause of that

16 tachycardia?

17 A. I’m not sure. I don’t think I have a

18 reasonable answer other than to say that it is one of

19 the signs of an elevated temperature of the baby –

20 remembering that the fetus has a core temperature

21 that’s about a degree higher than the mother’s.

22 I think the most likely explanation is that

23 the mother’s temperature, even though it was not

24 febrile — it was febrile at one point — I take that

25 back. It was febrile to 100.4 at somewhere around

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1 midnight. I would think more than likely this fetal

2 tachycardia is due to a mild elevation of the mother’s

3 temperature, causing a fetal tachycardia because of

4 increased core temperatures in the baby.

5 Q. Okay. I think in the beginning the answer

6 is “I don’t know,” and towards the end I think you had

7 a more-likely-than-not opinion. Let me just ask it

8 again and have it clean for the record.

9 Sir, within a reasonable degree of medical

10 probability, what was the cause of tachycardia at this

11 point in time?

12 A. I think what I tried to do — and obviously

13 not well — was to say I don’t know for sure.

14 But to answer it to a reasonable degree of

15 medical probability, which is greater than 50 percent

16 of the time, so to speak, I think it’s due to a

17 temperature elevation in the baby.

18 Q. Okay. Now, prospectively, sir, would the

19 health care providers know as to the cause of the fetal

20 tachycardia?

21 A. Well, no more than I would in looking at

22 it. Nurses and doctors certainly understand the

23 difficulties in coming up with a specific diagnosis or

24 etiology for tachycardia, but that’s something we

25 teach. And elevated temperatures and infections and

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1 the like are certainly on the list.

2 Q. Okay. How does an elevated temperature in

3 the baby lead to fetal tachycardia?

4 A. Increased metabolic rate. It’s like when

5 you have a fever and the flu your heart rate is going

6 to go up. Metabolism is increased. Temperature — the

7 thermostat is set higher, and so you increase your

8 cardiac output to handle the increased load for that

9 temperature.

10 Q. And how about same question with infection

11 in the baby? How will that lead to an increase in

12 heart rate of the baby?

13 A. Well, it’s probably the same answer, just

14 perhaps a little bit more emphatic. Where you have

15 infection, you also have a significant increase in

16 metabolic rates, and so your heart really needs to

17 speed up to get the blood to the — to the organs that

18 are fighting off the infection.

19 Q. Okay. You had mentioned when this mom came

20 to the hospital with her 34-week gestation and

21 contractions she was, by definition, high-risk.

22 A. Yes.

23 Q. Would the fact that she has fetal

24 tachycardia now be an additional risk on top of the

25 preexisting one?

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1 A. Yes, I believe that would probably be a

2 correct way to state that.

3 Q. Okay. Now, I’m looking at the fetal

4 monitoring strip, say, at 9:20 at night. If you could

5 turn to that. I have panel 13598, for example.

6 A. 13598? Is that what you said?

7 Q. Yeah, I think that’s about 9:20 at night.

8 Are you there?

9 A. Yes, I am.

10 Q. Okay. Do you see what appears to me to be

11 breaks in the tracing and where the monitoring is not

12 tracing clearly?

13 A. Yes, right before the 9:20 mark.

14 Q. Sure.

15 A. Yes.

16 Q. About how long was that break, sir?

17 A. About two minutes.

18 Q. Could you tell, with a reasonable degree of

19 medical probability, what the heart rate was doing

20 during that time period?

21 A. Not really.

22 Q. Okay. And after the 9:20 there is, again,

23 a little bit of breaks; is that correct?

24 A. That’s correct. Actually, they’re from

25 9:18 and a half, so to speak, to 9:20 — around 9:24,

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1 it would be difficult for anyone to be absolutely

2 certain what the heart rate was, but starting

3 thereafter, right where you see 13600, just below that,

4 the rate is — is well-delineated for about — one,

5 two, three, four, five — five more minutes.

6 Q. Okay. Now, what is the baseline for the

7 baby during this time period?

8 A. Well, you really need ten minutes to be

9 absolutely certain. So if you take as much of the

10 information that we have in this particular area you’re

11 asking me to look at, it looks like it would be about

12 150.

13 Q. Okay. Is there something that’s called a

14 normal baseline for a baby and an abnormal baseline?

15 A. There is the normal baseline of 110 to 160.

16 Below 110 for ten minutes or more, it’s a bradycardia;

17 and above 160, it’s a baseline tachycardia.

18 Q. Okay. Now, as long as a fetal heart rate

19 maintains itself between the 110 and the 160, will that

20 be called a normal baseline no matter what the numbers

21 are?

22 A. Essentially, that’s correct. Babies change

23 their baseline periodically during labor so that

24 anything between 110 and 160 is considered a normal

25 rate.

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1 Q. Why do babies change their baseline during

2 labor, sir?

3 A. That’s a very good question. Not really

4 sure.

5 It may have something to do with the

6 stresses of labor. It may have to do with gestational

7 age. To my knowledge, in all of my reading I’ve never

8 seen a good answer to exactly why they change their

9 rate — assuming you were talking about the normal rate

10 between 110 and 160. Obviously, we have a list of

11 things that can cause tachycardia and another list of

12 things that can cause bradycardia. But within that 110

13 to 160 –

14 You know, it’s very similar to us adults

15 who, you know, while we’re sleeping the rate will be

16 60, and when we’re walking around and dealing with

17 stresses of depositions and so forth our rate may go up

18 to 90 or 100. So I think it’s adrenaline, it’s

19 vasomotor, it’s vagal, sympathetic. I think all of

20 those things contribute to a change in a normal rate.

21 Q. When you say the stresses of labor can

22 change the baseline heart rate of a fetus, do you mean

23 only increase it, or could the stress of labor also

24 decrease the baseline heart rate of a fetus, again

25 maintaining it between the 110 and 160 range?

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1 A. Well, I know that if you have a certain

2 amount of vagal tone increase, say from cord

3 compression, you might be able to reduce heart rate in

4 particular. But most of the time the stresses of labor

5 increase heart rate.

6 I look at fetal tachycardia, as we have in

7 this case, at worst case scenario to represent some

8 mild fetal stress — stress that the fetus may be

9 handling based on variability patterns and

10 descriptions. But, nonetheless, I’ve always used the

11 term “fetal stress.”

12 Q. Okay. So, with reasonable medical

13 probability, was there fetal stress at this point in

14 time, say 9:30 at night?

15 A. 9:30. Well, I don’t have — let me see.

16 I’m looking at 9:30, and my rate is 150 with moderate

17 variability. There appears to be some acceleration.

18 So I wouldn’t call this a pattern of fetal stress at

19 this point. You know, what tracing I am able to look

20 at appears to have moderate fetal heart rate

21 variability and no tachycardia, so I would still put it

22 in the normal range at this point.

23 Q. Okay. Was there ever a point in time

24 before 9:30 p.m. where, in your opinion, with a

25 reasonable degree of medical probability, there was