OBGYN ultrasounds indicated that child was large fetus (possibly fetal macrosomia), said that she should not wait until 40 weeks to be induced. she also had gestational diabetes. Scheduled for induction on July 21, 2021, at 39 weeks gestation. She was induced, they ruptured her membrane. The mother was pushing for 2 to 3 hours. Son (Esosa Osaze) was coming down to a certain point but was not progressing past it. Son was delivered via emergency C-section on, July 23, 2021. She was pushing for 3 hours. She spiked a fever. membrane had been ruptured for 4 hours before they did c-section. Child was taken to NICU on Saturday. Baby was not crying when delivered, was not breathing properly, and baby was jaundiced. He was experiencing seizures. They did a spinal tap on baby. He was transferred to Childrens Hospital on Sunday morning. Did MRI later that week which identified hypoxic ischemic injury. He has speech delay. By the age of two the child was formally diagnosed with spastic quadriplegic cerebral palsy.
Files:
Q: what was the Umbilical artery and vein blood gas results?
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Q: please characterize the fetal heart tracing
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Do you believe there might have been medical error?
"Medical error” is not a strict legal term, but it is commonly used in both lay and clinical contexts. Legally, the term that matters more is “medical negligence” or “standard of care violation.” Thank you for the detailed case summary. This appears to have been a high-risk pregnancy due to gestational diabetes and suspected macrosomia, for which the planned induction at 39 weeks was appropriate. The prolonged second stage, maternal fever, and delayed decision for cesarean after failed descent may raise concerns regarding intrapartum hypoxia and chorioamnionitis. Given the eventual diagnosis of hypoxic-ischemic encephalopathy and cerebral palsy, a thorough review of the cases and the fetal heart rate tracings is essential to evaluate whether there were signs of evolving fetal distress that warranted earlier intervention. I would appreciate the opportunity to review the complete fetal tracings, especially from the start of induction through the second stage and decision for cesarean, to assess for variability, decelerations, and any non-reassuring patterns.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the available summary, there is a plausible link between the intrapartum course and the child’s hypoxic-ischemic injury. The prolonged second stage of labor, maternal fever (suggestive of intraamniotic infection), and delayed cesarean after failed descent may have contributed to fetal compromise. The clinical signs at birth—poor respiration, seizures, and subsequent MRI findings—are consistent with a hypoxic event. However, a definitive opinion on causation requires a full review of the medical record, including fetal tracings, timing of clinical decisions, and neonatal evaluations.
What makes you a good expert for this case?
As a board-certified Obstetrician and Maternal-Fetal Medicine specialist with decades of experience in managing high-risk pregnancies and interpreting complex labor and delivery cases, I have extensive clinical and academic expertise in this area. I have published widely on obstetric outcomes, standards of care, and ethical decision-making in perinatal medicine. My background enables me to objectively assess whether care aligned with established guidelines and to identify potential deviations that may have impacted maternal or neonatal outcomes.
How often do you encounter cases similar to this one in your practice?
In my clinical practice as a Maternal-Fetal Medicine specialist, I have routinely managed cases involving gestational diabetes, suspected macrosomia, prolonged labor, and concerns about fetal intolerance to labor. Cases requiring assessment of intrapartum management and neonatal outcomes—especially involving potential hypoxic-ischemic injury—are not uncommon. I also regularly review similar cases in my role as a consultant and educator, including for quality assurance, academic review, and medicolegal analysis.
Do you believe there might have been medical error?
The conditions as described are really too vague to elicit much of a confident opinion that there was medical error. In order to render a more definitive opinion that error was made, we need to determine: 1. although the infant has e/o cerebral palsy, this outcome must be directly linked to a problem experienced or noted during her labor. 2. pushing for 2-3hr is NOT prolonged 3. although she had a fever, there must be evidence that the fetus had suffered HIE from inflammation more likely than not from intramniotic infection-there is no such evidence mentioned. Are there path reports of the placenta confirming intramniotic infection with bacterial gram stain? 4. There is no evidence that the fetus had suffered hypoxic insult during labor. What did the FHT show? how was it characterized/
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
1. there is no definitive indication for early induction for suspected macrosomia, thus induction of labor at 39wk is very reasonable, regardless of GDM 2. If her GDM was well controlled with either diet only (A1GDM) or even with insulin (A2), as long as she was well controlled, it is NOT a departure from SOC to wait for delivery until 39wk. 3. although she was pushing for 3hrs, the fact that she did not make progress was a CORRECT indication for cesarean section 4. she only had AROM for 4 hrs before she was sectioned. This is NOT a prolonged period of time that is definitively correlated with intraamniotic infection-usually concern arises when >12-24hrs. To prove causation, you must link the outcome of cerebral palsy with a definitive intrapartum labor issue such as fetal hypoxia/acidosis and/or intramaniotic infection or severe maternal or fetal anemia.
What makes you a good expert for this case?
solicited for case review by over 30 different attorneys over the past 15 years. I do not advertise, but work from word of mouth. i have given over estimated 15 depositions and testified twice (once each for defendant and plaintiff). In practice for 25 years (including residency), former dept chair at a state university, current professor rank, and now director of MFM for a large market for a major healthcare system in the US.
How often do you encounter cases similar to this one in your practice?
I am part of the QI/QA system, and help review all cases of potential birth injry/poor outcome
Do you believe there might have been medical error?
The merits of the case depend on a large number of factors, including the precise estimate of the fetal weight at time of delivery, the specific measurements of the fetus (head circumference, abdominal circumference), how well controlled her diabetes was, if she was on medication for her diabetes, and if so what medication. It also involves the way her labor was induced – what steps were taken? Was her labor actively managed or not? How long after she became fully dilated did she start pushing? You mention the baby was “coming down to a certain point but not progressing past it” – what was that “point?” And most importantly – what was the fetal heart rate tracing like throughout her entire labor and specifically while she was pushing? Also, was the mom’s heart rate high? If so, was a pulse-ox and/or fetal scalp electrode used to differentiate between maternal and fetal heart rates? The most common problem that I see coming up in cases of a long second stage which end up with this or a similar fetal/neonatal outcome is that the external doppler for heart rate reads the maternal pulse rate but the team mistakes it for the fetal heart rate. The interpretation is that the heart rate is "reassuring" because it is in the normal fetal heart rate range (and sometimes with accelerations - often times DURING the contractions/pushing), but in reality it is actually the maternal pulse rate they are tracing.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If in fact the heart rate being monitored was the maternal pulse, then there would have been no fetal monitoring for some period of time. Second stage labor with chorioamnionitis should have continuous fetal monitoring because tracings can deteriorate and become an indication for cesarean. If the fetal heart rate was inadvertently not being monitored, then there would not be an opportunity for an accurate clinical assessment of the fetal status. If the mother is tachycardic, pulse ox should be placed to distinguish between maternal and fetal rates.
What makes you a good expert for this case?
I am an MFM (Maternal-Fetal Medicine) attending physician and Associate Director for Perinatal Quality at my hospital. I conduct case reviews regularly including reviewing the chart, reviewing tracings, interviewing doctors, nurses, etc, and determining if the standard of care (SOC) was met. If I suspect SOC is not met or there is opportunity for improvement, I present the case in our Departmental case review meetings and lead discussion re: the merits of the case. I also am of course present and participating discusses of cases presented by other physicians (assigned by our clinical quality specialist to a group of attending physicians - some of whom I personally selected - to review our cases). I also regularly participate in RCA discussions with our hospitals Quality Management office and sometimes involve our hospitals executive leadership (medical director, associate medical director of the hospital). I am involved in various quality performance-improvement projects in our hospital and for our hospital system, including specifically authoring a guideline on how to manage induction of labor which is planned to be adopted across our entire hospital system (10 birthing hospitals, appx 30,000 deliveries per year). I have also published on management of labor and have given numerous (double-digit) invited presentations on evidence-based management of labor and labor-induction including grand rounds at various hospitals, as well as at the national level (Society for Maternal Fetal Medicine, Denver, CO on 1/27/2025), and internationally (Guyana, Taiwan - planned for June, 2025). Can provide CV upon request.
How often do you encounter cases similar to this one in your practice?
Approximately 2-4 per month. We have weekly meetings to review cases in our hospital that were identified, and we encounter HIE several times per month.
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