Re: Gel, Pit, & VBAC tragedy
From: Efrain Ramirez (eramirez@icepr.com)
Wed Feb 28 05:00:32 2001
ACOG's VABC guidelines were issued on October 1998 - fui!!
by what it's written - the obstetrician was not present -right?
At Fri, 23 Feb 2001, Gloria Lemay wrote:
>
>Last Updated: Tuesday 27 February 2001 TOP STORIES
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>Judge finds 'overwhelming evidence of negligence' by RCH nurses
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>Neal Hall Vancouver Sun
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>Royal Columbian Hospital has been ordered to pay $2.8 million in damages
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>for the negligence of four nurses who handled a fetus in distress,
>------------------------------------------------------------------------Mother of brain-damaged child awarded $2.8 million
>resulting in a boy being born with catastrophic brain damage.
>
>B.C. Supreme Court Justice Mary Ellen Boyd, in a judgment released
>Monday, found there was "overwhelming evidence of negligence on the
>defendant nurses' part."
>
>The birth mother, Lydie Guerineau, sued the hospital on behalf of her
>son Jesse, who is almost three. While waiting to give birth, the
>mother's uterus ruptured, pushing the fetus into the mother's abdominal
>cavity on March 16, 1998.
>
>The problem wasn't detected for almost an hour, the judge found, because
>of inexperience and failure to call the on-call obstetrician at the New
>Westminster hospital.
>
>The child was born clinically dead but was resuscitated. He has no
>bladder or bowel control, has to be fed by a tube and cannot
>communicate, although he smiles and laughs when tickled. He is expected
>to live until age 20.
>
>"It's going to make a huge difference to the quality of life of the
>parents," lawyer Nathan Smith said of the award to his client. "The
>parents are having to work different shifts so someone could be there to
>look after Jesse."
>
>Lydie Guerineau works as an accounting clerk and her husband is a
>forklift operator. The couple also have an eight-year-old daughter. They
>declined to be interviewed.
>
>The incident began with the mother complaining loudly about vaginal pain
>beginning at 1:10 a.m. but the on-call obstetrician, Dr. Sara Pedersen,
>wasn't called until 2:54 a.m.
>
>Pedersen arrived at 3 a.m., immediately checked the patient and ordered
>a caesarean section. The baby was delivered 23 minutes later.
>
>Both the obstetrician and the family physician, Dr. Mark Seger,
>testified they would have attended if they had been called sooner or
>alerted to any concerns about the fetal heart rate. The expert nursing
>evidence was also highly critical of the nurses' actions.
>
>The judge found that Jean Skidmore, the nurse assigned to the birth, was
>a neophyte in terms of her clinical experience with delivering babies --
>she had only worked 12 shifts in that area, although she had been a
>nurse since 1978.
>
>Another nurse, Heather McKay, who relieved Skidmore during a 30-minute
>break at 2 a.m., was even more junior, having worked only four shifts in
>delivery nursing.
>
>The other nurses found to be negligent were the charge nurse, Miranda
>Ha, who assigned Skidmore as the primary care nurse, and Betty Luk, who
>eventually called a doctor for help.
>
>In a 58-page judgment, the judge found Luk compounded the problem by
>first calling the on-call general practitioner, rather than Pedersen, at
>2:30 a.m.
>
>The judge noted that the mother was already at risk for problems because
>she had previously had a C-section birth and wanted to have a vaginal
>birth.
>
>When the mother attended at hospital about 11 a.m. March 15, she was
>about 10 days overdue, so labour was induced. Induced labour also
>increases the risk involved in a VBAC delivery (vaginal birth after
>caesarean), the judge noted.
>
>The nurses were found negligent in discontinuing a fetal heart
>monitoring strip, which had been improperly interpreted -- a nurse felt
>the drop in the baby's heart rate was simply caused by the mother
>shifting in bed while in pain, causing umbilical cord compression.
>
>Skidmore had consulted with the charge nurse, Ha, and both felt the
>mother's vaginal pain was caused by the earlier insertion of gel to
>induce labour. Ha also made an erroneous assumption that the patient had
>a full bladder, so the patient was instructed to void. The patient spent
>from 1:25 to 2 a.m. in the bathroom, returning to bed at 2:10.
>
>The baby was in an emergency situation by 2:10 and valuable time was
>lost by failing to call the on-call obstetrician, the judge noted.
>
>"In this case, each minute counts," the judge noted. "Even if Dr.
>Pedersen was not called until 2:30, when nurse Luk instead called Dr.
>Seger, the injury could still have been prevented or at least
>minimized."
>
>Helen Carknier of the Simon Fraser Health Region, which operates Royal
>Columbian Hospital, said insurance coverage by the B.C. Health Risk
>Society covers such awards.
--
"Life is neither the notes nor the silence between the notes, but the music that
arises out of sound and silence felt as a living whole. Stop choosing...between
chaos and order, and live at the boundary between them, where rest and action
move together..." David Whyte
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