Opinion ID: 1765780
Heading Depth: 1
Heading Rank: 3

Heading: Breach of the Appropriate Standard of Care

Text: Drs. Huddleston, Faustin, and Davis testified that prenatal fetal testing should be performed beginning at the 42d week of pregnancy. Dr. Faustin's testimony as to the appropriate standard of care is as follows: Q. In 1981 at the time this child was delivered, isn't it true that most of the obstetrical literature recommended antepartum testing only from the 42d week forward? A. No. that'sin 1981 we were doing nonstress testing at 41 weeks. Q. No, that's not my question. My question is in 1981 isn't it true that most of the obstetrical literature recommended nonstress testing beginning with the 42d week?
Q. All right, sir. And isn't it true that the recommendations of the American College of Obstetrics and Gynecology in 1981 recommended nonstress testing beginning at the 42d week? A. I would say yes. Q. So the American College did not recommend doing nonstress testing in the 41st week or the 40th week, did it? A. That's true, probably true. . . . . Q. Now, do you say that the standard of care required a nonstress test prior to her admission to the hospital? A. The standard of care is that at the 42d week definitely you do a fetal monitoring. Q. Prior to the completion of the 42d week? A. This is what we do. Okay. I agree with you. I agree with you from the beginning that most recommendations were made from 42d week. Okay. Forty-second week gestation as a definition of postdated, but we now, okay, do it from the 41st week because we understand that the risk increases progressively. Mrs. McGee was admitted to the hospital at midnight on the morning of July 27. It is undisputed that Dr. Bradford did not perform fetal testing prior to admission. Bentley was born at 10:30 a.m. on July 27. Thus, the critical questions in determining a breach are 1) whether Bentley had reached a gestational age of 42 weeks prior to admission and 2) whether Dr. Bradford should have known this and, in accordance with accepted medical practice, should have performed fetal testing to discover and then to prevent health problems associated with post-term infants. Fetal gestational age is derived by counting the weeks between the last menstrual period (LMP) and the delivery date. It was uncontradicted at trial that, due to the increased risk of fetal harm caused by prematurity or post-maturity, setting an accurate due date is extremely important. It was also uncontradicted that the patient's LMP determines when the due date should be set. Mrs. McGee testified that she told Dr. Bradford that her LMP occurred on September 8, 1980. Dr. Bradford testified that on one visit Mrs. McGee informed him of a September 8 LMP but that on another visit she told him it had occurred on October 8. In his efforts to determine Mrs. McGee's LMP, Dr. Bradford performed a pelvic examination and consulted with a radiologist, who conducted two ultrasound tests. An ultrasound is a technique used to estimate fetal age. The first ultrasound test, which was performed on January 22, 1981, indicated a fetal age of 14 weeks and confirmed an October 8 LMP. The second ultrasound test, which was performed later in the pregnancy, in April, indicated a fetal age of 28 weeks and confirmed a September 8 LMP. Based on the results of the pelvic examination and the first ultrasound test, Dr. Bradford estimated an October 8 LMP and upon that estimation calculated the due date for July 14. Dr. Huddleston, an obstetrician who testified on behalf of Dr. Bradford, stated that the appropriate standard of care requires a doctor to perform fetal testing once the fetus reaches an age of 42 weeks. He also testified that the procedure Dr. Bradford employed to estimate a due date was appropriate and that calculating the due date for July 14 was within the standard of care. Even upon consideration of the second ultrasound test, which indicated an older fetal age, and Mrs. McGee's belief that her LMP had occurred in September, Dr. Huddleston testified that Dr. Bradford's actions were entirely appropriate. Dr. Davis, another obstetrician who testified for Dr. Bradford, agreed that fetal testing should be performed at 42 weeks. But, he also agreed that Dr. Bradford did not breach the appropriate standard of care in his calculation of fetal age and in setting the due date. Dr. Davis testified that an estimated due date is a clinical judgment based on three factors: 1) menstrual history, 2) the size of the uterus calculated by performing a pelvic examination, and 3) results from ultrasound tests. He testified that Dr. Bradford properly considered all three factors. The following hypothetical questions posed by defense counsel and Dr. Davis's responses thereto are instructive: Q. [A]ssume these facts to be true: that in December 1981, Sandra McGee was a 20-year old married female who had a positive pregnancy test. Assume further that on December 11, 1980, she first saw Dr. Bradford, a board certified family practitioner, for prenatal care. Assume further that Mrs. McGee had been on birth control pills until the previous June. Assume further that she gave a last menstrual period history to Dr. Bradford's nurse of October 8, 1980. Assume further that she also gave Dr. Bradford a conflicting last menstrual period of September 8 during this visit. Assume further that Dr. Bradford spoke to the patient and performed an examination, and the examination revealed a uterine size of nine weeks. Assume further that the second prenatal visit occurred on January 22, 1981. Assume that Dr. Bradford ordered an ultrasound to be performed to assist him in determining the estimated date of confinement or due date. Assume that the ultrasound was obtained that day; that the ultrasound was performed by a radiologist; that the radiologist was able to obtain satisfactory biparietal diameters and that the radiologist reported that the estimated fetal age by the ultrasound was 14 weeks. Assume that Dr. Bradford's examination of the patient on that day, January 22, revealed a uterine size of 14 to 15 weeks. Assume further that Dr. Bradford assigned a due date or estimated date of confinement at that time of July 14, 1981. Let me stop you there. On the basis of those hypothetical facts, do you have an opinion as to whether or not the steps taken by Dr. Bradford in an effort to assign the estimated date of confinement were appropriate and within the standard of care? A. They were perfectly appropriate. Q. I want to also ask you if you have an opinion as to whether or not the due date assigned of July 14 was appropriate clinical judgment and was within the standard of care? A. It was. Q. Now, I want you to assume those facts I have given you and assume further these facts, please, sir: That following the January 22 visit, there were six more prenatal visits through April 16, 1981. On that day, Mrs. McGee was seen by Dr. Bradford complaining of lower abdominal pain and spotting. Assume further that Dr. Bradford obtained a second ultrasound to assist him in assessing the abdominal pain and spotting. Assume further that the ultrasound was again run by a radiologist and revealed a normal placenta, and an estimated fetal age of 28 weeks. Assume further Dr. Bradford maintained the estimated date of confinement of July 14, 1981. Again, let me stop you. Do you have an opinion based upon all the hypothetical facts I have given you as to whether or not it was appropriate and within the standard of care for Dr. Bradford to continue with the estimated date of confinement of June [sic; July?] 14, 1981? A. I believe with the two sonars and the uterine size, the EDC of the 14th of July is appropriate. Q. In light of all those facts, at that time, as of April 16, 1981, an EDC of July 14 was appropriate? A. Yes. The McGees introduced into evidence testimony from two medical experts, Dr. Daniel Faustin, an obstetrician from New York, and Dr. Gary Meyers, a specialist in pediatric neurology and neonatology. Dr. Faustin testified that at the time of admission Mrs. McGee had completed her 42d week of pregnancy: Q. All right. If the EDC was July 14, this pregnancy had not entered the 42d week at the time she was admitted to the hospital, had it? A. Yes, the pregnancy has completed the 42d. Q. The pregnancy has completed the 42d week? A. (Deponent nodding head affirmatively.) Q. All right. Your testimony is that with an EDC of July 14th, the pregnancy completed the 42d week? A. On the 20on the 27th, yes. It's a matter of one day and really 2020 the 28th would have been the full 42d week completed, and I don't think a day makes a difference. Thus, the appropriate standard of care required Dr. Bradford to perform fetal testing beginning at 42 weeks, which, he failed to do until July 27, when Bentley's gestational age had completed the 42d week. There is expert medical testimony that this constituted negligence. But, the plaintiffs' case does not end here. To recover damages, they must have established a causal connection between Dr. Bradford's negligence and Bentley's cerebral palsy. Specifically, did the delay in performing fetal testing, possibly by as much as six days, proximately cause Bentley's cerebral palsy?