Case Studies

Lesson learned

Failed Fetal Monitoring Leads to Neonate with Hypoxic-ischemic Encephalopathy

Case Summary

This 22-year-old gravida 1, para 0 woman received regular prenatal care beginning in August, and she had an uneventful prenatal course. She presented to her OB/GYN's office in late February for a regularly scheduled appointment. On that date, she was 39 weeks, three days gestation, with some bloody mucus discharge noted. She reported having occasional contractions, approximately three every hour, which were moderately uncomfortable. The cervix was closed. A non-stress test was normal, and the OB recommended follow-up on March 2nd.

The woman presented to the local hospital with continuing contractions, pelvic pressure, and bloody discharge early the following morning. She reported regular fetal movement. She was admitted and placed on an electronic fetal monitor (EFM) at 5:45 a.m. The EFM demonstrated a baseline fetal heart rate in the 140s, with good variability and accelerations. An exam at 9:30 a.m. revealed that she was 4-5 cm dilated, with bulging membranes. Membranes were then ruptured, with clear fluid noted.

At approximately 11:00 a.m., she requested an epidural for pain control. The epidural was administered, and the mother had good relief of pain. After this, uterine contractions appeared to space out; therefore, Pitocin augmentation was initiated.

Throughout the second stage of labor, variable decelerations were noted by the OB and the nurses. At 1:00 p.m., the EFM demonstrated fetal heart rate decelerations down to the 70s. At 2:45 p.m., the OB noted the fetal heart tones were not tracing well, and he attempted to place a fetal scalp electrode. The strip was still not tracing well and appeared to document repetitive variable decelerations and likely prolonged decelerations.

The mother was fully dilated at 6:08 p.m. and began pushing at approximately 6:50 p.m. With pushing, the EFM tracings became either abnormal or inadequate to monitor fetal well-being. The OB later admitted that the EFM tracings demonstrated prolonged decelerations into fetal bradycardia, lasting from 7:01 p.m. until 7:20 p.m. In retrospect, much of the final three hours of tracings were thought to show the maternal heart rate.

By 7:45 p.m., the OB believed that he had been seeing deep decelerations in the fetal heart rate for 45 minutes. The EFM tracing was broken in appearance and mostly inadequate for interpretation. However, he took no steps to contact an anesthesiologist or prepare for possible operative delivery. Neither did he call a pediatrician to be present at the birth.

The male child was delivered vaginally at 9:10 p.m. He had a nuchal cord at delivery and was flaccid and blue, with no respiratory effort. His Apgar scores were 2/4/6 at one, five, and ten minutes of life. A pediatrician arrived approximately 15 minutes after the infant's birth. He noted a palsy of the left arm, likely secondary to shoulder dystocia. His arterial blood gas revealed a pH of 7.09 and a base excess of -18.0.

The child was transferred to a tertiary care hospital, where he was diagnosed with hypoxic-ischemic encephalopathy, with neonatal seizures and a left brachial plexus injury. An MRI showed a diffuse cortical brain injury and some basal ganglia injury. Since that time, the child has suffered significant developmental delays, with substantial motor and sensory deficits. He has no speech and little executive function.

The parents of the child brought a malpractice suit against the OB physician. The case settled in the very high range.


The patient was started on Pitocin augmentation after her contractions slowed. The Institute for Safe Medication Practices identifies Pitocin as a high-alert medication and recommends continuous fetal monitoring. For the last several hours of labor, the EFM tracings were inadequate for interpretation, yet the OB did not address the situation. The organization did not appear to have a protocol to follow when EFM tracings were problematic.

While the nurses noted variable decelerations on the EFM tracings, no one spoke up to address the concerning tracings. Organizations should have a process such as a chain of command policy when team members have safety concerns that are not addressed. In this case, although the nurses noted concerning tracings, there is no evidence that they took action to address these concerns.

Despite the abnormal EFM strips, the OB did not contact anesthesia or take steps to prepare for possible operative delivery. The pediatrician was not contacted to be present at the birth. Communication is crucial for the safe delivery of healthcare; criteria should be in place which guide when to prepare for operative delivery and when to call a pediatrician during labor. In this case, the pediatrician should have been notified to be present at the birth.

The infant was born with palsy of the left arm, likely due to shoulder dystocia. However, the mother's medical record did not show appropriate shoulder dystocia protocols.

Risk Management Takeaways

  • Train and educate your perinatal team together (physicians, midwives, and nurses) on:
    • Electronic fetal monitoring and interpretation using National Institute of Child Health and Human Development (NICHD) common language.
    • Require all staff caring for laboring patients to complete EFM education annually.
    • Obstetric emergencies (e.g., mock drills, simulation exercises) such as shoulder dystocia, obstetric hemorrhage, emergency cesarean delivery, newborn resuscitation, and maternal cardiac arrest.
    • Individual communication skills and team collaboration, e.g., SBAR, TeamSTEPPSĀ©, briefs, debriefs from emergency drills handoffs, simulation.
  • Develop criteria that guide when to call in a pediatrician during labor and delivery.
  • Develop a policy on Pitocin augmentation and assure team members are practicing according to the policy.
  • Routinely practice obstetric emergency drills.
  • Include OB case reviews and EFM tracings in quality improvement activities.