Patrick Salvi II · Matthew Williams
Beyond the Records: Exposing Negligence in Complex Labor and Delivery Cases
May 27, 2025 5:30 PM||
F-37 pregnant with twins complicated by advanced maternal age. At about 34 weeks, mom began to have high blood pressure and headaches, which was diagnosed as preeclampsia with severe features. As a result, she was induced for delivery. She labored a little over 24 hours, during which time both twins were doing very well according to the fetal heart monitor. The babies were doing well throughout the pregnancy, as evidenced by ultrasounds and periodic non-stress tests. Both babies were head down. On February 13, 2018, at 5:35pm, the first baby (Twin A) was born. Twin A had good APGARs and was healthy. After a short period of time monitoring Twin B, during which time her heart rate was reassuring, the obstetrician decided to perform a maneuver called an internal podalic version whereby the baby’s feet would be grabbed to turn the baby to breech presentation, which would then be followed by a breech extraction. This decision was made primarily because the baby’s head was “floating”, meaning the head was not engaged and would float further back into the uterus during the cervical exam when the resident placed her fingers on the baby’s head. The resident OB then began the maneuver but had trouble when the water broke and the limb she was holding, which she believed was a foot, slipped from her grasp. The supervising OB then took over and determined the resident had been grasping a hand, instead of a foot. The OB then performed the maneuver and delivered Twin B at 5:48pm. Twin B was born with the following injuries, some of which were disputed: brachial plexus injury to the left side including 2 avulsions and 2 ruptures, 2 skull fractures (disputed), poor APGARs (blue/limp/low HR/not breathing), and with subsequent significant blood loss, primarily in the intra and extracranial space. Plaintiff claimed that the maneuver itself was negligent, because there was not urgency to delivering Twin B given the good heart rate tracings; that the resident negligently failed to identify the baby’s feet in performing the maneuver; that the supervising OB failed to properly supervise the resident; that the OB team should have provided uterine relaxation; that the OB team used excessive force; and that as a result, the child suffered a severe brachial plexus injury and brain injury. Defendants asserted that the maneuver itself was appropriate due to the floating head; that identifying a hand instead of a foot happens in the absence of negligence; that the uterus was well-relaxed as evidenced by the ease with which the OB was able to deliver upon taking over; that the injuries occurred because the baby had a fetomaternal hemorrhage prior to birth, evidenced by a positive Kleihauer-Betke test and a significant drop in hemoglobin and hematocrit that could not have occurred acutely; that the brachial plexus injury can happen in the absence of negligence; and the Defense asserted that damages were not as significant as claimed, because the child could one day live semi-independently, did not need 24-hour care, and was capable of enjoying life.
Teaching points:
- Proving a medical malpractice case despite the Defendants’ charting the events in a way that would never be negligent;
- Driving a wedge into the inconsistencies between the two doctors primarily responsible for the delivery;
- Deconstructing a causation defense (fetomaternal hemorrhage) – the devil is in the details;
- Handling the experienced Defense expert witness;
- Using medical literature effectively;
- Proving damages for a brain injured 6-year old who can walk and talk.
- Using a newborn’s injury as evidence of negligence
- Barring discussions with patient about risks/complications of a procedure/delivery when informed consent is not raised as an issue at trial
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