law rights & civil resource

posted by admin on Mar 10

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1 fetal stress?

2 A. Well, that’s the — yes. The answer is

3 yes.

4 And I use that term pretty liberally when I

5 have tachycardia. That doesn’t mean that I know that

6 this baby is under some oxygen deprivation. But I

7 categorize it as not normal, since it’s a tachycardia.

8 And for whatever reason, I teach my residents and the

9 nurses to view this as perhaps a mild fetal stress that

10 needs to be looked at and evaluated.

11 Q. So essentially anytime before 9:30 p.m. if

12 we would see fetal tachycardia above 160 for ten

13 minutes or more, you would say that was evidence of

14 fetal stress.

15 A. That’s my definition. I think the American

16 College likes the term “nonreassuring fetal status” for

17 tachycardia. I’ve always thought “fetal stress” was a

18 little more palatable and understandable. But it

19 certainly falls short of fetal distress.

20 But, yes, the answer to your question is

21 yes.

22 Q. Okay. Is a nonreassuring strip the same

23 thing as a strip that contains fetal stress?

24 A. Well, I think — I think so. The American

25 College and I, I think, don’t totally agree on this

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1 issue. They have made pronouncements that they would

2 like the term “fetal distress” removed totally and have

3 never said much about the term “fetal stress” and want

4 physicians to use the term “nonreassuring fetal status”

5 with a description of the fetal monitor strip to

6 determine the urgency of actions taken.

7 I’ve introduced, in my own writings and

8 teachings, the concept of what the College is calling

9 “nonreassuring fetal status” is what we’re teaching

10 here as fetal stress. But I don’t think that’s

11 universally accepted, despite my attempts to convince

12 others of that.

13 Q. Okay. Well, if there was fetal tachycardia

14 before 9:30 p.m. that you would call “fetal stress” and

15 the College is calling “nonreassuring,” when we get to

16 9:30 you told me everything appears fine, do you have

17 an opinion, with a reasonable degree of medical

18 probability, you know, why did things improve at 9:30?

19 A. Well, it could have been that the

20 temperature of the baby dropped somewhat. It’s hard to

21 say. I really don’t know.

22 We have many instances of tachycardia and

23 we don’t understand why. I mean, you have to remember

24 that this is just a heart rate. Admittedly, there are

25 some built-in parameters that give us some guidance –

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1 the variability, for example, the overall rate, the

2 appearance, the presence — rather — of accelerations

3 and decelerations. But it’s just a heart rate. It

4 doesn’t really tell us a lot of the things that I think

5 you and I and other lawyers and people in medical-legal

6 dispute are trying to answer. So we do the best we

7 can. But I don’t think you can make too much of heart

8 rate to determine what’s happening to the fetus unless

9 you have some real extreme cases.

10 Q. Okay. Now, let’s move on from this

11 9:30 p.m. And could you please interpret the strips

12 for me as you see them unfolding. And if you find any

13 accelerations, decelerations, or describe –

14 variability or tachycardia, please feel free to

15 describe them.

16 A. Well, as I look at the tracing from 9:40

17 on, I think the rate is somewhere around 140, and I

18 believe these are accelerations that one sees. The

19 possibility of the rate being 170 with everything else

20 coming down to 140, being representative of

21 decelerations, could be somebody’s interpretation,

22 although at this point it is not mine. I’m trying to

23 look at the entirety of it. And so I still think that

24 the rate is about 140 with moderate variability and

25 accelerations.

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1 I think when you take a look, for example,

2 at 9:55, you see this rate of 140 with a minute and a

3 half of just very reassuring variability. And that

4 just sort of continues through ten o’clock. As we get

5 to 10:20, there is –

6 Q. Before we get there, sir, how can you

7 tell — what’s the basis of your opinion that we’re

8 dealing here with a baseline, as you suggested, with

9 accelerations as opposed to a higher baseline with

10 decelerations?

11 A. Well, I think I mentioned that it’s — that

12 there are people that might interpret this differently.

13 And after a while you just have to come up with, as you

14 used the word, I believe, gestalt.

15 I can’t be sure, so I’m looking at other

16 parameters, in particular the variability when we’re

17 down in those areas I just mentioned. The one, for

18 example, at twelve — at 9:55, if that’s a

19 deceleration, then it’s an innocuous one, because

20 you’ve got a rate that’s still in the 140 range and it

21 has moderate variability.

22 So I can’t always be 100 percent certain,

23 but in looking at and in trying to determine where is

24 my baseline, there is enough areas like, for example,

25 at twelve — excuse me — at 10:20, where you see three

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1 minutes of a rate of 140 with literally no contractions

2 underneath it, which makes me think that this baby’s

3 rate is 140 beats per minute and those other increases

4 are accelerations, not decelerations.

5 Q. How about right before that in time? Why

6 is the rate up around 180 so often?

7 A. Well, it’s actually 170. But there’s a

8 two-minute period there that could be described as a

9 prolonged acceleration. Remember, anything two minutes

10 or more but ten minutes or less above the baseline is a

11 prolonged acceleration. So I would call that a

12 prolonged acceleration. Regardless –

13 Q. What is the –

14 A. Go ahead. I’m sorry.

15 Q. I’m sorry.

16 What is the etiology of prolonged

17 accelerations, sir?

18 A. A well-coordinated brain stem and heart

19 that are well-oxygenated that are responding to its

20 environment. There’s nothing pathologically

21 significant. It’s a physiological event that has

22 really no pejorative attributes but is more of a very

23 positive sign of fetal well-being.

24 Q. Okay. If you can continue interpreting,

25 please.

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1 A. After ten –

2 Q. I think we’re at 10:20.

3 A. Yeah. After 10:20 we have a period of

4 about ten minutes where you have what appears to be a

5 number of accelerations that go up to 180 beats per

6 minute. I still think that the rate is probably in the

7 130, 140 range and that these are accelerations. But

8 there are –

9 Q. What is the basis of that opinion?

10 A. Again, it’s that I’m looking at a longer

11 period than just ten minutes. I’ve gone back for the

12 last 30, 40 minutes, and I keep seeing rates of 140

13 beats. For example, you see it at a little after

14 10:30, another long period of a rate of around 140.

15 But regardless, even if I were — even if I

16 was wrong — and there is no way to be certain,

17 regardless of how much expertise one has — I’m looking

18 at the variability, for example, at 10:30, and I’m

19 seeing a baby that is handling whatever is going on

20 quite nicely.

21 This could be increased variability or what

22 is called “marked variability,” this ten-minute

23 interval. Whatever we’re calling it, I don’t think

24 it’s associated with any fetal distress. It’s not a

25 sign of fetal hypoxia. So I don’t think I can

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1 categorize it with a hundred percent accuracy, but that

2 would be my interpretation.

3 Q. What is the etiology of marked variability,

4 sir?

5 A. In most instances it’s another sign of

6 fetal stress. When you — animal data has shown that

7 when you stress babies but not — don’t cut off oxygen

8 totally but just deprive them slowly of oxygen — they

9 do increase their variability. This has been done in

10 sheep, for example. And I think in looking at

11 thousands and thousands of fetal monitor tracings over

12 the years, I think it’s also present in humans that as

13 babies are stressed in utero, they will sometimes go to

14 a marked variability pattern to indicate an early sign

15 of fetal stress — not of distress, but of just some

16 increased stress, perhaps some adrenaline is being

17 pumped into the fetal circulation and now we have a

18 wider swing of sympathetic and parasympathetic pushing

19 and pulling to establish a baseline. And so at the

20 very most, that’s what I would say would be occurring

21 with marked variability.

22 Again, I’m not sure –

23 Q. Is this well known?

24 A. Oh, yes. Oh, that’s very well-known. The

25 experimental models have been done, and it’s old data

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1 on marked variability being a sign of fetal stress.

2 I’m not sure that I could even interpret

3 this particular ten-minute period as marked

4 variability, but it comes close because of the wide

5 swings. It could also be accelerations. The fact is I

6 don’t think anybody knows.

7 Q. Does the standard of care of a reasonably

8 prudent nurse allow her to assume it’s the benign

9 situation of accelerations as opposed to the more

10 non-benign situation of fetal stress when looking at

11 this fetal monitor strip?

12 A. Oh, I expect a nurse looking at this

13 particular strip to not have any clearer idea than I do

14 as to which one it is. What marked variability demands

15 by standard of care is just continuing observation to

16 see if there’s any trends. It doesn’t really help us

17 in changing some kind of treatment plan, but it does

18 demand continued surveillance, which is exactly what

19 these nurses are doing.

20 Q. Does the standard of care applicable during

21 this time period allow them to maintain this

22 surveillance without informing the physician that they

23 are doing such?

24 A. Oh, I think so, yes.

25 Q. How would the physician know that the

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1 nurses are maintaining surveillance of fetal stress if

2 the nurses don’t inform him?

3 A. Well, the nurses do things all the time

4 without informing doctors. That’s the collaborative

5 collegial relationship that nurses and doctors have.

6 I wouldn’t want my nurse to call me at any

7 time just to tell me that they’re seeing some marked

8 variability. I would like to see some more pattern

9 change.

10 And if you take a look at this, assuming

11 that the nurses diagnose this as marked variability,

12 you’ve only got about nine or ten minutes, followed by

13 a normal tracing. And so I don’t think that there’s

14 any alarm that would go on after just a short period of

15 ten minutes that would, by standard-of-care principles,

16 demand that the nurse notify the doctor.

17 Q. So to make this more clear-cut, you do not

18 believe the standard of care requires during this

19 applicable time period a nurse to inform a physician

20 that fetal stress appears on the monitor; correct?

21 A. Well, that’s a diagnosis, and I wouldn’t

22 expect a nurse to do that.

23 I expect a nurse to say there’s fetal

24 tachycardia or there is increased or marked

25 variability. That would be up to the doctor to

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1 determine whether it was fetal stress or distress.

2 But I have no problem with the nurse not

3 calling Dr. D. at this particular point concerning

4 either the tachycardia or the — the possible marked

5 variability, because I don’t think it’s probable; I

6 just think it’s possible.

7 Q. In your answer you just told me you would

8 expect the nurse to call a physician for marked

9 variability or tachycardia. When would you expect her

10 to do such?

11 A. Well, I think that the — that at some

12 point when a tracing becomes obviously increasingly

13 nonreassuring, that’s when a nurse needs to notify the

14 doctor.

15 I’m assuming that these nurses are

16 monitoring, and have been doing so for a long time,

17 this fetus, noticing that the only thing that occurred

18 has been a mild tachycardia. This episode of marked

19 variability, if that’s what it is, is, in my opinion,

20 not a reason for her to call the doctor. Now, at some

21 point, obviously, nurses and doctors need to talk with

22 each other.

23 Q. Well, in your opinion, sir, how long does

24 the standard of care during this applicable time period

25 allow a nurse to watch the monitor for the possibility