immediate, i.e., within 30 minutes, C-section as an "obstetrical emergency."
Plaintiffs' other expert, Dr. David C. Abramson, Board-certified in pediatrics and in peri- and neonatal medicine, was, from 1970 through 1978, Chairman of the Perinatal Medicine Division, Department of Pediatrics, at Georgetown University Medical Center. (He is currently Director of Emergency Medicine at a general hospital in suburban Washington, D.C.) In Dr. Abramson's opinion, Ms. Walker represented a "high risk" case, but not the obstetrical emergency perceived by Dr. Morton. Dr. Abramson believed that a "careful trial of labor" was appropriate (contemplating, of course, effective fetal monitoring). He could not say when, if ever, a C-section actually became necessary, however, because the fetal monitor tracings were not available for examination.
He found the failure to activate an internal fetal monitor, the need for it having been recognized by Dr. Crane, to have been below the standard of obstetrical care as he has observed it from the vantage point of a "member" of the perinatal "team" concerned primarily with fetal health.
Defendant's expert, Brocket Muir, Jr., M.D., has been a practicing obstetrician in the Washington, D.C., metropolitan area for over 17 years. He is Board-certified in obstetrics and gynecology, is a member of the clinical faculty at Georgetown University Medical Center, and delivers, he estimates, some 250-300 babies a year. To Dr. Muir, the findings on admission, namely, the presence of meconium and fetal heart rate decelerations, are of themselves of "little meaning." Decelerations, if corresponding to maternal contractions, are, in fact, "reassuring"; it is the loss of "beat-to-beat variability" in fetal heart rate, or "late" decelerations, i.e., those which follow (rather than coincide with) a contraction, which the profession regards as ominous. Meconium, even "pea soup" meconium, merely raises the "index of suspicion." While it can signify fetal distress, it does not invariably do so, nor is fetal distress always accompanied by meconium staining. All that was professionally required upon Ms. Walker's admission, according to Dr. Muir, was close monitoring, a fact recognized by Dr. Crane. Dr. Muir agreed with Dr. Abramson that, once the need for it was recognized, the failure to insert the internal monitor for an hour was substandard. He disagreed, however, with the suggestion that a caesarean section was indicated at any point in the labor. None of the signs which prompted Dr. Crane to order Ms. Walker to the delivery room and to perform the low forceps delivery were, in his opinion, diagnostic of fetal distress. At most, he said, they reflected a fetus "under stress" from any of the myriad sources accompanying the normal birth process, most likely, in this case, a transient hypoxia secondary to either the rapidity of the labor or the nuchal cord. But the most convincing evidence of record that fetal distress was never present, according to Dr. Muir, is Steven's elevated Apgar scores at birth, his normal postnatal course and (except for the peripheral nerve deficit) his normal neurological status today.
The Court credits the testimony of Dr. Muir to the extent of finding no true fetal distress to have occurred at any time during the course of Mrs. Walker's labor when surgical delivery was an option, and, thus, no indication for a section ever to have been present, even if unperceived. The hospital record, such as it is, supports the finding. Although the fetal monitor tracings are missing, the nursing notes in the hospital record reflect that the external monitor was in operation from 12:30 a.m. forward.
The fetal heart rate, recorded at half-hour intervals (presumably from the external monitor, possibly by fetascope) remained between 144 and 147, well within normal limits. Although fetal tachycardia and late decelerations were detected by Dr. Crane shortly after activation of the internal monitor at 1:30 a.m., upon the mother's arrival in the delivery room at 1:45 a.m. the fetal heart rate had returned to 147. Nineteen minutes later Ms. Walker delivered Steven, weighing five pounds one ounce. His Apgar scores of seven and eight were indicative of a normal, healthy child, which, save for the facial asymmetry, it is undisputed that Steven is today.
Steven's immediate postnatal and current normal neurological status are the most persuasive evidence that the signs Dr. Crane suspected as indicating "fetal distress" -- and, perhaps injudiciously, entered as such on the chart -- were not, in fact, fetal distress at all. They were, most probably, the result of transient episodes of hypoxia related to the rapidity of labor and tension on the nuchal umbilical cord as the infant descended the birth canal, which did not commence until shortly before birth and were not of a duration sufficient to threaten permanent cerebral injury. The Court finds nothing to have occurred while the internal fetal monitor remained unconnected which would have indicated a caesarean section, even were Dr. Crane's failure to place it in operation deemed to have been negligent. Caesarean sections, presenting, as they do, significant risks for the mother, are generally not performed absent indications for them. Thus, the failure to attach the internal fetal monitor cannot be found to be the proximate cause of the failure to have delivered Steven Walker by caesarean section, nor, it necessarily follows, of any injury done to him in the course of the properly-performed low forceps vaginal delivery. The Court concludes that plaintiffs have failed to prove, by a preponderance of the evidence, that defendant's failure to make timely connection of an internal fetal monitor was the proximate cause of such seventh cranial nerve deficit as Steven Walker possesses today, and it is, therefore, this 10th day of January, 1985,
ORDERED, that judgment be entered for defendant.