Monday morning quarterbacking

Over a year ago, I happened across a YouTube video that led me to a blog called “untangling knots” which I won’t link to but should be the top search result if you Google it. The video was a montage of pictures of a baby who was stillborn or nearly so; and I searched through the comments until I found the blog that told the rest of the story. You can go read the birth story, then come back. (I’m not linking to it, because I have some questions which may be distressing to the mother, and I don’t want to cause her any pain — she’s been through enough, and reading what I have to say won’t help her, nor bring her daughter back.)

Basically, the woman had an uneventful pregnancy, and went into labor with little contractions at first and then suddenly had strong contractions which sent her to the hospital — still unsure if this was actually real labor, because it didn’t follow the typical “labor pattern” of slow, mild contractions gradually lengthening and strengthening. Apparently, when she was admitted, the baby’s heartbeat was there but they wanted more monitoring because they said it was “tachy”. They didn’t explain this very well to the mom (or she didn’t remember or write it down, which is understandable considering the jumble of events), and she was asking for her epidural and upset that the nurse couldn’t find a vein. There was an OB in the room, but another OB was walking down the hall, and heard the baby’s heartbeat and didn’t like it, so he came in and requested to break her water. I assume that the purpose of breaking the water was either to check for meconium or to place an internal monitor on the baby’s head. The mother consented.

When her water was broken, mec came out, they lost the fetal heartbeat and could only hear maternal; either the internal didn’t show anything or they couldn’t get it properly placed; a quick ultrasound was performed and showed no fetal heartbeat. The mother was raced back for an emergency C-section but it was too late. The baby was kept alive on life support so the mother could wake up from surgery and spend time with her alive, and then the parents had to make the decision to withdraw life support.

The mother credits the passing OB with the fact that her daughter was even born alive.

The post after the birth story has preliminary autopsy results (and I never found more in-depth ones, so will assume that the “working theory” on the baby’s death was confirmed) showed that the baby basically had a weak heart that was unknown and unknowable prior to the onset of labor; that the labor coming on fast and strong was too much for her to handle, causing her to pass meconium; and that all these things together combined to cause her death.

Now for the “Monday morning quarterbacking.” While the mom credits the passing OB with her daughter’s live birth, I wonder if he is not also to blame for her ultimate demise. The baby may have been showing signs of fetal distress prior to her amniotic sac being broken but she had a heartbeat until then.

As the mother said, a baby passing meconium is not a death sentence, nor is the particular heart defect this baby had, nor is having a strong and fast labor (after all, how many women are put on Pitocin in order to make their natural contractions stronger and labor happen faster? and how many stories abound of women barely making it to the hospital in time [or giving birth accidentally out of the hospital] because labor and birth went so fast that they couldn’t make it). But the baby had a heartbeat while her amniotic sac was intact.

If the doctor suspected fetal distress from hearing the baby’s heartbeat, he could have done an ultrasound with the sac intact, and probably seen meconium. Apparently there was an ultrasound machine in the room (perhaps a Doppler — just sound, no picture), since the birth story made it sound like everything took place in that one room.

Had the doctor not intervened, it’s possible the baby would have died anyway — after all, the contractions were so strong or long that the baby was showing signs of distress — although the heartbeat was apparently not so bad that the OB already in the room was concerned. But had he made the call to perform a C-section in the face of fetal distress rather than an amniotomy, the baby might have lived. Monday morning quarterbacking.

It may have just been coincidence that the baby’s heart stopped beating about the same time that her amniotic sac was broken; but perhaps she was able to tolerate contractions (though in distress) with the fluid cushion, and they became intolerable without it. It’s also possible that the baby also suffered a cord prolapse with the ruptured amniotic sac. The first time I read this story, that’s what I thought had likely happened; then on pondering it (I didn’t read anything but the “birth story” post for a very long time), I thought maybe the death was due to vasa previa or velamentous insertion, and that when the doctor had ruptured the amniotic sac, it tore the umbilical cord from the placenta. However, the preliminary autopsy results showed that the placenta was normal. In re-reading the birth story post, I realized that a cord prolapse was more possible than typical with a first-born child. In the lead-up to the “labor” part of her story, she said that she never really “dropped” — that the baby didn’t engage in the pelvis. (It’s possible that the baby was in fact engaged, although the mother never felt any different; but most first-time moms will feel the baby engage a couple or three weeks before birth, although fewer second-time and later moms have their babies engage.) When the baby is still high and “floating” and the amniotic sac ruptures (either spontaneously or artificially, as in this case), it’s possible that the umbilical cord can get swooshed down below the baby’s head as the amniotic fluid rushes out. My sister’s second birth was a planned home-birth which ended in a non-emergency transfer to the hospital, after she was “stuck” at 6 cm dilation for some 8 hours; the midwife didn’t want to break her waterat home because the baby was too high, and she didn’t want to precipitate a cord prolapse, so they went to the hospital. So it may be that losing the baby’s heartbeat when the doctor broke her water was just an unfortunate coincidence. It may be that some trauma or shock of having the amniotic sac be broken and/or the fluid rushing out or losing the fluid cushion was too much for the baby’s delicate heart to handle. Or it may be that the amniotomy precipitated a cord prolapse which sent an already fragile condition into a lethal one. I suppose we’ll never know.

Of course, this is what lawsuits are fought over — one expert witness (which I am not! I’m just a curious thinker) saying, “If I had been in charge, this wouldn’t have happened.” And this is why medical malpractice insurance costs so much — when a baby dies or is injured, a jury of 12 people will almost certainly find fault with something the doctor did, even if it was done with the best intention, and with the best of his knowledge. I don’t think that the doctor intentionally caused harm; and he may have done the best thing. But the thing that gets me is that the baby had a heartbeat (however fast or slow or distressed) until he broke her amniotic sac. That’s the thing that has stayed in my mind for the past year or however long it’s been since I first read the birth story: the heartbeat disappeared when the sac was broken.

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