This was a 31-year-old woman’s first pregnancy. Due to difficulties getting pregnant, she was seen by Dr. A with respect to In vitro fertilization (IVF) treatment. IVF is a complex series of procedures used to help with fertility and assist with the conception of a child. During IVF, mature eggs are collected (retrieved) from ovaries and fertilized by sperm in a lab.
Once she became pregnant, she was transferred to Dr. B in Oakville. At 32 weeks gestation, an ultrasound demonstrated a very large fetus, with an estimated fetal weight of 2525g. However, Dr. B took no action despite the fact that she was obese and gained significant weight during the pregnancy. The standard of care required Dr. B to arrange a follow up ultrasound to assess fetal weight and growth at 36 weeks, and to closely monitor fetal size going forward. This was not done.
In October and November of 1991, she began to have weekly Non-stress Tests (NST) done. A Non-stress Test is a common prenatal test used to check on a baby’s health. During such a test, the baby’s heart rate is monitored to see how it responds to the baby’s movements. The term “non-stress” refers to the fact that nothing is done to place stress on the baby during the test. She attended at the defendant hospital on several occasions and underwent a series of six NSTs.
In this case, the standard of care was breached with respect to the mismanagement of the NSTs performed in late November and early December.
In late November, the features of the NST produced a non-reactive result (indicating a lack of sufficient fetal heart rate accelerations over 40 minutes). Further, there were subsequent reports of decreased fetal movement, which is consistent with fetal stress and incipient hypoxia (shortage of oxygen). At this point, Dr. B, who interpreted the NST, should have recognized the urgency of the situation and arranged for delivery that day. This was not done.
5 days later, in early December, the woman began experiencing regular contractions and elevated blood pressure, and attended at the defendant hospital. Another NST was performed by Nurse A, which again produced a non-reactive result. The fetal heart rate also exhibited a concerning combination of abnormally reduced variability and late decelerations. These worrying signs all pointed to a need for immediate delivery, and should have prompted Nurse A to quickly notify the most responsible physician, Dr. C. This was not done. In fact, Nurse A waited 55 minutes after the abnormal NST was interpreted before she called Dr. C.
When Dr. C finally arrived, an artificial rupture of the membranes (ARM) was performed (an ARM is a procedure where the membranes are punctured with a crochet-like long-handled hook during a vaginal examination, releasing the amniotic fluid). The ARM revealed thick green meconium (earliest stool of an infant) and a decision was made to deliver the baby by C-section. An argument between Dr. C and the anesthetist ensued in the Operating Room regarding the mode of anesthesia, causing further delay. Dr. C wanted an epidural, while the anesthetist felt that general anesthesia was more appropriate. Ultimately, it was decided to proceed to a C-section with an epidural.
Almost 3 hours after the woman presented at the defendant hospital, the baby was delivered via C-section. She was very large at birth, weighing almost 12 lbs.; her colour was purple, she required immediate resuscitation, and was intubated. The baby required manual ventilation for almost an entire day as the defendant hospital did not have a ventilator, so the staff had to wait until the equipment was brought from another hospital.
The baby had extreme metabolic acidosis at birth. Fetal acidosis results in a high amounts of acid levels in an unborn baby’s blood, typically occurring when a fetus is deprived of oxygen for an extended period of time during or prior to birth.
The baby was diagnosed with Intrapartum Hypoxic-Ischemic Encephalopathy (HIE), a brain injury that occurs when a baby’s brain does not receive enough oxygen during birth. At 7 weeks of life, a diagnosis of cerebral palsy was made (a movement disorder – cerebral means having to do with the brain, while palsy means weakness or problems with using the muscles).
Due to the above factors, and the ensuing 5-day interval up to the presentation in labour, the fetal reserve and the baby’s ability to withstand the stress of labour was severely depleted. Had the baby been delivered prior to the onset of labour, the damage would have been avoided. In this respect, the further delay of almost 3 hours between presentation to the defendant hospital and delivery sealed the baby’s fate.