Documented, but not done – Missed IUGR
Simple, but effective – the use of fundal height measurements in obsteterics
The growth of a baby during the gestational period is one of life’s true miracles. A yolk sac turns into a human being. When things go right, the placenta does its job and supplies all the oxygen and nutrients the baby needs to do grow adequately and into a healthy baby.
There are many ways that obstetricians and perinatologists measure the growth of the baby during the pregnancy. The most technical way is with an ultrasound machine that looks at ultrasonographic pictures of the baby. But, one of the easiest methods for checking growth is by measuring the fundal height. The fundal height is literally measured using a measuring tape. The obstetrician will measure, in centimeters, the distance between the pubic bone and the top of the uterus. Studies have shown that after the 24th week of pregnancy the fundal height is supposed to match the number of weeks of pregnancy. For example, a woman who is 32 weeks pregnant should have a fundal height that measures 32 centimeters.
When the fundal is lagging (i.e., falling behind), or is excessive (i.e., too high), that should raise suspicion that something may be wrong with the growth of the baby. This could mean there is Intrauterine Growth Restriction or IUGR. The established standard of care is that if the fundal height is lagging or excessive by greater than 2 or 3 centimeters, than an ultrasound is required to make sure the growth is appropriate.
Intrauterine growth restriction (or IUGR)
Intrauterine growth restriction, or IUGR, is a major problem in obstetrical care. Intrauterine growth restriction is defined as a baby who is measuring less than 10th percentile when compared with the growth of his or her peers. Growth charts can be found all over the internet, so if you are curious about learning more about this topic, all you need to do is Google “IUGR, growth charts” and you will find a plethora of informative articles.
IUGR is basically caused by the baby not receiving enough blood and oxygen from the placenta. Some of the most common causes of IUGR are preeclampsia, high blood-pressure, diabetes, and maternal infection. However, sometimes the cause of IUGR can never be determined. The timely detection of IUGR is vital for ensuring a good outcome, and for avoiding permanent brain damage the baby.
The case of Peter Geffen
Peter’s mother became pregnant with Peter in the fall of 2008. Ms. Geffen promptly established prenatal care with an experienced obstetrician, Dr. Matts. As is standard, Ms. Geffen had an ultrasound performed at 20 weeks. According to that ultrasound, Peter was measuring perfectly well in-utero. Thereafter, Ms. Geffen had routine prenatal visits at 24 weeks, 28 weeks, 30 weeks, 32 weeks and 34 weeks. At each of those visits Dr. Matts documented that the fundal height was measuring consistent with the gestational age (i.e., at 30 weeks, the fundal height measured 30 centimeters and so on).
At approximately 35 weeks and 1 day, Ms. Geffen woke up in the morning and felt that Peter had not been moving as much. She drank some orange juice and tried laying on her side to see if she could get Peter to move around. Despite those efforts, Peter was still not moving. Ms. Geffen called Dr. Matts who told her to immediately report to the hospital. She did as she was told.
When Ms. Geffen arrived at the hospital she was hooked up to an electronic fetal monitor. The fetal monitoring showed a heartbeat, but the heartbeat was slow. A biophysical profile test was performed to see how Peter was doing in utero. The biophysical profile was scored as a 4 out of 8, indicating that Peter was struggling in utero. Concerned that Peter may be hypoxic and suffering from a lack of oxygen, the doctors at the hospital performed an urgent cesarean section delivery.
When Peter was born, he was in very poor condition. He was extremely tiny, and he needed to be intubated. During his newborn admission it was discovered that Peter had suffered damage to his brain from a chronic lack of oxygen. He was also diagnosed with IUGR given his small size at birth. At two years old, he was diagnosed with cerebral palsy.
The initial investigations
Convinced that Peter’s cerebral palsy was from medical malpractice, Ms. Geffen began contacting lawyers in 2009 when Peter was around one year old. Lawyer after lawyer turned down her case. The size of the placenta was small and there were other indications that Peter had stopped growing around 25 weeks. But the prenatal records were not indicating that anything was missed by Dr. Matts. The 20-week ultrasound was accurate and the fundal height measurements all seemed appropriate. Ms. Geffen was repeatedly told that sometimes IUGR is just missed and it was not anyone’s fault. So, the case went cold.
WVFO gets involved
Six long years went by when the mother of another child who was represented by WVFO suggested to Ms. Geffen that she contact us. WVFO went through the typical process by undertaking a statute of limitations analysis and then by obtaining all of the relevant medical records. The records were reviewed in-house by the lawyers at WVFO and were then reviewed by an obstetrical expert and a perinatology expert. The legal team at WVFO and the experts remained stumped at first. But no one gave up.
If at first you don’t succeed…
WVFO kept at the Geffen case when one of its lawyers finally made a startling revelation. When Ms. Geffen had presented to the hospital at 35 weeks and 1 day, at Dr. Matts’ instruction, a history and physical had been performed. However, the history and physical documentation was missing from the medical record and no one, for a period of six years, realized that it was missing. WVFO contacted the delivering hospital and notified them of the missing documentation. Several months went by when finally the hospital found the missing records.
How can that be?
The history and physical paperwork was only one page. But that one page held the clue that was needed to solve this cold case. As part of the history and physical, one of the nurses had performed a fundal height assessment. Again, Ms. Geffen was 35 weeks and 1 day pregnant at the time. Thus, a normal fundal height would have been 33-37 centimeters. But the nurse documented that Ms. Geffen’s fundal height at 35 weeks and 1 day was 27 centimeters! This was a huge breakthrough because it immediately indicated that Dr. Matts’ medical records were wrong about the fundal heights he recorded.
It now made perfect sense. Dr. Matts had apparently been documenting the fundal height measurements, but he had not been doing them. Given that Peter’s weight and measurements at birth were consistent with a 27 week baby, it was now crystal clear that the fundal heights at her prenatal visits at 30 weeks, 32 weeks and 34 weeks were totally wrong. When Ms. Geffen was questioned about whether she recalled Dr. Matts ever measuring her belly she was emphatic in her answer. We showed her what fundal height measurements entailed and she swore that they were never done!
With an Affidavit from Ms. Geffen, and the newly discovered records, WVFO was able to get the expert support necessary to bring a case against Dr. Matts and his practice group. The theory was that Dr. Matts had failed to timely diagnose IUGR by failing to take fundal height measurements, which resulted in the failure to timely deliver Peter before he suffered his chronic brain injury.
When he testified, Dr. Matts could not credibly explain how the fundal height at 35 weeks and 1 day was 27 centimeters, yet in his office 8 days earlier, the fundal height he recorded was 34 weeks.
Shortly after his deposition testimony, the case settled for several million dollars.
CASE CLOSED.
