Fetal Monitoring Mistakes Verdicts & Settlements

During childbirth, a baby’s heart rate is monitored through a fetal heart monitor to assess the baby’s oxygenation, including oxygenation of the baby’s brain. This is how the baby talks to us and tells us how it is doing.

The fetal monitor produces a strip that must be read and analyzed almost continually during the birthing process to determine whether the baby’s heart rate suggests oxygen deprivation.

A typical variation in the fetal heart rate is a reassuring sign of fetal well-being. So fetal monitor tracing shows fetal well-being (heart rate, heart rate decelerations, heart rate accelerations) or fetal distress (late decelerations with decreased variability).

Categories of Fetal Heart Rate Tracings

The American College of Obstetricians and Gynecologists (ACOG) classifies FHR tracings into three categories: I, II, and III, based on specific characteristics observed in the FHR pattern.

Category I (Normal)

These tracings are considered normal and indicate a well-oxygenated fetus with a low risk of acidemia. They include a baseline rate of 110-160 beats per minute, moderate baseline variability, no late or variable decelerations, and may or may not have early decelerations or accelerations.

Category II (Indeterminate)

This category includes tracings that do not meet the criteria for Categories I or III. They are not necessarily indicative of fetal acidemia. Things are okay, but keeping an eye out is the best way to explain Category II. This category encompasses a wide range of FHR patterns, making it the most common category.

Category III (Abnormal)

The worst-case scenario for the fetus is a Category III tracing.  This is an abnormal tracing in which the baby’s heart rate has a sinusoidal pattern, absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia.  A Category III tracing is the baby telling us that she is in trouble and needs to be delivered immediately. Category III tracings are considered abnormal and are associated with an increased risk of fetal acidemia or neurological injury. The key features of a Category III tracing include any of the following:

• • Absent baseline FHR variability and any of the following:
    • Recurrent late decelerations
    • Recurrent variable decelerations
    • Bradycardia
  • A sinusoidal pattern (a smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5 per minute)

The presence of a Category III tracing typically prompts immediate evaluation and intervention, which may include providing oxygen to the mother, changing her position, discontinuing labor-inducing drugs, treating maternal hypotension if present, and in some cases, expediting delivery (potentially via cesarean section) if the abnormal pattern cannot be quickly resolved. The fetus is deemed to be in jeopardy.

How to Read a Contraction Monitor at the Hospital

Reading a contraction monitor, also known as a fetal monitor, during labor involves understanding two main components: the fetal heart rate and the uterine contractions. Labor and delivery use these monitors to check the baby’s heart rate and the mother’s contractions’ frequency, duration, and intensity. The interplay between the two is also critical.

Here’s a basic guide on how to read the information provided by a contraction monitor:

1. Fetal Heart Rate (FHR)

The fetal heart rate monitor is the best way for the baby to tell us how they are doing.

• Normal Range: The normal FHR is typically between 110 and 160 beats per minute (bpm). The monitor will display the heart rate in beats per minute on one of its graphs or digital displays.
• Patterns to Notice: Look for consistency in the heart rate and note any significant fluctuations. Accelerations (a temporary increase in the FHR) are usually a good sign, indicating that the baby is responding well. Decelerations (a temporary decrease in FHR) may occur during contractions but should return to the baseline afterward. Persistent or severe decelerations can indicate distress, requiring medical attention.
• Variability: This refers to the fluctuations in the FHR from the baseline rate, indicating neurological control of the fetal heart.  People are often surprised to learn that moderate variability is a good sign for babies (and adults).

2. Uterine Contractions

Uterine contractions are a powerful tightening of the womb muscle. During childbirth, they squeeze the baby down the birth canal, becoming stronger and closer together as labor progresses. These contractions can feel like intense cramping or pressure and are essential for a safe delivery.

Here’s what doctors and nurses should be paying attention to during labor and delivery:

• Frequency: This measures how often contractions are happening, from the start of one contraction to the start of the next. It’s usually measured in minutes.
• Duration: This is how long a contraction lasts, measured in seconds from the beginning to the end of a contraction.
• Intensity: Though more challenging to quantify without internal monitoring, some monitors can measure the intensity of contractions. This is the strength of the contraction, which may be indicated by how high the peaks go on the graph. Intense contractors are not evil – they typically demonstrate a labor that is progressing well. But extremely intense and frequent contraction can be associated with fetal distress.  Why?  Because too frequent contractions can reduce the critical oxygen supply for the child.

Understanding the Monitor’s Display

• Graphs and Numbers: The monitor will typically display the FHR on the upper part of the graph, with the heart rate shown in beats per minute. The contractions are displayed on the lower part, showing the frequency and duration. The monitor might also provide digital readouts of these measurements.
• Peaks and Valleys: The FHR graph will show fluctuations with peaks (accelerations) and valleys (decelerations). The contraction graph shows a rise during a contraction (indicating the uterus is contracting) and falls back down when the uterus relaxes.

Interpreting the Data

• Healthy Signs: A steady fetal heart rate that fluctuates within the normal range, along with regular, manageable contractions, typically indicates that labor is progressing normally.
• Possible Concerns: Frequent or severe decelerations in the baby’s heart rate, especially if not recovering well after contractions, might indicate distress. Similarly, if contractions are too close together, too long, or too intense, it could suggest complications like uterine tachysystole.

Labor and delivery professionals are trained to interpret these monitors and will watch for signs of distress or complications during labor.  Deficient or improper fetal heart rate monitoring is a common starting point for a birth injury lawsuit.

Negligent Fetal Monitoring

When properly used and interpreted, EFM devices can effectively warn doctors of dangers in time to prevent harm to the baby. Unfortunately, this is not how things always work out in practice. The failure to provide appropriate fetal monitoring is a frequent allegation in labor and delivery medical malpractice birth injury lawsuits.

Negligence can be based upon

1. inadequate training regarding how to properly use of a fetal monitor,
2. inadequate training in the interpretation of fetal monitoring results,
3. failure to observe the monitor frequently enough,
4. failure to use or prematurely discontinuing the use of the fetal monitor,
5. failure to notify a or timely notify a physician regarding fetal monitor results and
6. failure to go up the chain of command if the doctor ignores the nurses

Mistakes and improper use of the fetal heart monitor are far too commonplace and can often have serious consequences. A review of birth injury malpractice cases reveals that EFM mistakes tend to fall into three categories: (1) ignoring EFM warnings, (2) misinterpretation of EFM patterns, and (3) failure to use or improper setup of EFM devices.

Cerebral Palsy and Fetal Heart Monitoring

Because cerebral palsy is such a challenging condition and because so many cerebral palsy lawsuits start with a feal monitor error, this topic deserves its own attention.

Cerebral palsy  in newborns is associated with various factors during pregnancy, labor, and delivery, including fetal distress that leads to inadequate oxygen (hypoxia) or blood flow to the brain.

One of the key elements in preventing cerebral palsy related to birth complications is the accurate monitoring and interpretation of fetal heart rate patterns to detect signs of distress promptly. Mistakes in fetal monitoring, particularly errors in interpreting fetal heart rate patterns, can potentially contribute to adverse outcomes, including cerebral palsy, especially if they result in delayed response to fetal distress.

The biggest mistake our cerebral palsy lawyers see in cerebral palsy lawsuits is failing to recognize signs of fetal distress, which might be evident through abnormal heart rate patterns such as

• bradycardia (slow heart rate)
• tachycardia (fast heart rate)
• late decelerations
• minimal to absent variability (little to no fluctuation in the heart rate baseline)

This is the baby telling us that it is not receiving enough oxygen. Doctors are too often casual in the face of distress symptoms. Why? Because they usually resolve on their own. Most signs of distress do not manifest as a problem.  But when they are a sign of trouble and doctor and nurses in labor and delivery blow off those warning signs, you see awful injuries like cerebral palsy and HIE.

Ignoring EFM Warnings – Verdicts & Settlements

Below are sample verdicts and reported settlements from recent medical malpractice cases for different types of EFM mistake category:

• • Doe v Roe Hospital (California 2023) $4.9 million settlement. During the delivery of the plaintiff, fetal heart rate monitors recorded abnormal readings, and Hospital staff administered Pitocin. A C-section was eventually ordered approximately five hours later. The plaintiff was born dead after bleeding out due to a fetal-maternal hemorrhage. It was not until 10 minutes later that the minor plaintiff began displaying vital signs. The plaintiff suffered hypoxic ischemic encephalopathy, causing life-long brain damage and disability. The plaintiff alleged hospital staff failed to abide by internal policies barring the use of Pitocin when fetal heart rate monitors indicated abnormal sinusoidal/sawtooth patterns.
  • Burke v. Jefferson Healthcare (Washington 2020) $24 million verdict: A baby girl has the umbilical cord wrapped around her neck.  The doctors and nurse alleged that missed clear signs on the fetal heart rate monitor that the baby was in trouble and needed to come out quickly.  The plaintiff’s experts testified at trial that she would have permanent cognitive impairments and challenges with speech and motor skills that would require lifetime care.   
  • Plaintiff v OB/GYN (Massachusetts 2018) $5 million settlement: The mother was admitted to labor and delivery at 4 am and put on a Pitocin drip to induce labor.  Pitocin is a common theme in fetal heart monitor mistake lawsuits. Fetal monitoring patterns were normal until around 4 pm when the mother began experiencing sudden pain. The fetal monitoring tracings remained at category II but became non-reassuring around the same time that the mother reported pain. The doctor chose to ignore the non-reassuring EFM patterns and continued the Pitocin drip. Over an hour later, it was discovered that a uterine rupture had occurred, and an emergency C-section was performed. The baby had no heartbeat at delivery, requiring resuscitation, and was diagnosed with hypoxic-ischemic encephalopathy. The parties agreed to settle the malpractice case for $5,000,000.
  • Epple v Umstead (Florida 2018) $6.6 million: A mother with a high-risk pregnancy was admitted for labor at 42 weeks. FHR monitoring initially showed normal accelerations and the absence of decelerations. Several hours later, however, the monitoring strips began to deteriorate with diminished fetal heart rate, variable decelerations, and absent accelerations. The nurse called the OB/GYN at home to report the situation and EFM tracings, but he told her to continue with labor and vaginal delivery, at which point the doctor went back to sleep. The jury in Pinellas County found the doctor was negligent in ignoring the EFM warnings and awarded total damages of $6,684,673.

• Burke v Regional Medical Center (Alabama 2018) $6.5 million: admitted to the labor and delivery unit of Northeast Alabama Regional Medical Center (RMC). Fetal monitoring devices immediately indicated signs of fetal distress, but these signs were initially ignored. Doctors continued to ignore the EFM warnings and allowed the fetal distress to evolve into a sinusoidal heart rate before finally attempting to intervene. By the time the baby was delivered, she had suffered severe brain damage and was diagnosed with cerebral palsy. The doctors were found to be negligent in their decision to ignore the EFM warnings until it was too late.

Misinterpreting EFM Settlement Amounts and Jury Payouts

• S.K. v. Mercy Hosp. (Iowa 2022) $97 million: Doctors and hospital staff allegedly misinterpreted clear signs of acute fetal distress on fetal monitoring strips, resulting in prolonged oxygen deprivation. When the warning signs were finally acknowledged, the doctor attempted to intervene with a vacuum extraction instead of a C-section. The infant suffered severe brain damage, leaving him in need of 24-hour medical care for the remainder of his life.
• Florez v Northshore Univ. Hosp. (Illinois 2018) $50.3 million: doctors and hospital staff at a Chicago hospital allegedly failed to correctly interpret the heart rate patterns on the fetal monitoring devices, which should have warned them that the mother’s uterus was hyperstimulated in response to the use of Pitocin. Had they correctly interpreted the FHR tracings, they could have recognized the Category III strip and the danger it presented to the baby and performed an emergency C-section. Instead, they allowed the labor to continue, and the baby suffered oxygen deprivation, causing HIE brain injury and resulting in cerebral palsy. A jury in Cook County awarded $50.3 million in damages.
• Doe v Hospital (California 2017) $1 million: The mother was admitted for labor and delivery five days past her due date. Fetal monitoring strips that afternoon and evening showed increasingly non-reassuring findings, but the nursing staff at the hospital apparently misinterpreted the patterns and failed to appreciate the potential danger. As a result of this misinterpretation of the EFM tracings, the nurses did not call in or alter the doctor. When the doctor eventually arrived, he immediately delivered the baby, but it was limp and not breathing and had to be resuscitated. An MRI confirmed that the baby suffered a massive brain injury from oxygen deprivation during labor. The parties agreed to settle the case for $1 million.
• Wilson v AMISUB of S.C. (South Carolina 2009) $4.5 million: mother was admitted to the hospital for early labor and under the supervision of a nurse in training. After several hours, the cervix was not dilated, and the nurse informed the doctor that fetal monitoring strips did not show any late decelerations. Based on this information, the mother was sent home. However, the nurse had misread the EFM patterns, which apparently did show late decelerations with each contraction, which should have prompted immediate delivery. The mother came back to the hospital the next morning, and the baby was immediately delivered, but the damage had already been done. The baby was eventually diagnosed with spastic quadriplegic cerebral palsy. A jury in Charleston awarded $4.5 million in damages.

Failure to Use EFM Settlement and Jury Compensation

• A.S. V. Postell (New York 2022) $265,000 settlement. The infant reportedly suffered a birth-related neurological injury, resulting in learning disabilities as well as vision and hearing problems and requiring occupational, physical, and speech therapies during her delivery. The lawsuit alleged that the delivery team negligently failed to properly apply the fetal heart rate monitors and equipment, resulting in a delay in responding to fetal distress.
• Coates v. High Point Family Med. (Wisconsin 2018) $4.5 million: A mother with preeclampsia was admitted for labor at 38 weeks. The doctor opted to induce labor with Cytotec, which was administered vaginally. After administering the Cytotec, the mother was taken off the electronic fetal monitoring strips. The EFM strips remained off for a total of 4 hours, during which time the baby suffered oxygen deprivation and permanent brain injury. The doctor was found to be negligent in failing to keep the mother on the EFM strips after inducing labor.
• Plaintiff v Hospital (Massachusetts 2017) $3 million: mother went to the hospital at 41 weeks with labor. When her water broke, the amniotic fluid had meconium in it. Despite this undeniable sign of fetal distress, the doctors and hospital staff inexplicably failed to hook the mother up to any fetal monitoring devices and failed to immediately deliver the child, instead allowing the mother to labor for hours with no EFM. When the EFM strips were finally hooked up, the nurses allegedly failed to recognize the immediate signs of fetal distress. By the time an emergency C-section was done, the baby had suffered a hypoxic brain injury and was stillborn. The malpractice claims were settled for $3 million.

Contact Miller & Zois About Your Birth Injury Case

If your child was born with a birth injury negligent, we may be able to help you chart a course to put your child and your family in the best position economically. The birth injury attorneys at Miller & Zois can investigate your case and help you take appropriate action. Call us at 800-553-8082 to get an online case review.