This case arose from a failure to timely intervene by nurses, a nurse midwife and an obstetrician. The mother of the baby went to her OB/Gyn's office after a spontaneous rupture of membranes (her "water broke"). The child's fetal heart was found to be normal, 150 beats per minute, in the doctor's office, and that heart rate had been in the normal range (130s-150s) in the weeks leading up to the onset of labor. The mother was sent to the hospital for management of her labor, but by the time she arrived at the hospital 30 minutes later, the baby's heart rate had dropped to a rate far below normal at approximately 85 beats per minute.
The labor and delivery nurse caring for the mother had been working only a few months; she called for assistance from more experienced nurses. Those nurses immediately began to prepare the mother for an emergency caesarian section and notified the OB's office. However, when the obstetrician arrived with the nurse midwife, the decision was made to continue laboring the mother. Despite interventions to return the baby's heart rate to normal ("intrauterine resuscitation"), the baby's heart rate could only be increased to approximately 110 beats per minute, which was well below this baby's normal heart rate. Despite the fact that baby's heart rate could not be brought back to normal, the mother was given medication to strengthen contractions.
The baby's heart rate never returned to its normal range, and after approximately 90 minutes of labor with the strengthened contractions, the baby's heart rate began to drop even further below normal. The baby's heart rate crashed nearly two hours after the nurses had first prepared the mother for an emergency C-section. The baby boy was delivered by c-section. He had no heart rate, no respirations and his color was blue because he had not been receiving adequate oxygen. Though the baby boy was resuscitated, he was left with permanent brain damage and cerebral palsy. Forty-two experts were designated.