Dr. performing difficult c-section fails to timely call for help.

IN 2003 IRENE BLUE SOUGHT MEDICAL TREATMENT FOR HER FIRST PREGNANCY. Her treating physician, Dr. Angelina Gangestad, was an assistant professor in the department of obstetrics and gynecology at the Medical University of Ohio at Toledo. During Blue's prenatal care, an ultrasound examination revealed the presence of two fibroid tumors inside her uterus. One tumor was located on the anterior wall of the uterus, the other on the posterior wall near the top of fundus. Blue also informed Dr. Gangestad that in 1999, she had undergone a myomectomy, which involved the surgical removal of fibroid tumors from her uterus. Based upon these conditions the pregnancy was classified as "high risk" if a vaginal delivery were attempted. In addition, because the myomectomy involved abdominal surgery, it posed a risk of scar tissue in the abdominal cavity. Dr. Gangestad scheduled the patient for a low, transverse c-section whereby the incision would be below both the anterior fibroid tumor and the placenta, which also was located anteriorly. On January 2, 2004, at 8:27 a.m., Dr. Gangestad made the first skin incision of the c-section. Typically, during a c-section cuts are made through multiple layers of tissue beginning with the skin, then fatty tissue, then the fascia, a tough layer of tissue that overlies the muscle, then the rectus muscle, the peritoneum. In a routine c-section the individual layers of tissue are quickly identified, cut through, and held open using retractors to isolate the uterus. However, in this case, when Dr. Gangestad reached the layer of fascia, she discovered that the patient's abdominal tissues were adhered to one another, making it impossible to identify the "tissue planes." The patient's abdomen was filled with scar tissue or "adhesions" that had to be cut away or "lysed" to clear an adequate passageway for delivery. Although Dr. Gangestad maintained that scar tissue from the myomectomy was a foreseeable risk prior to the c-section, she stated that both the abundance and density of the scar tissue were unusual. Dr. Gangestad lysed adhesions while a first-year resident assisted with retraction from 8:27 to 8:58 a.m. Dr. Gangestad described the adhesions beginning at the fascia level as being very dense the tissue as thick and firm, "almost like cement." The peritoneum, normally thin and stretchable, was not normal. Dr. Gangestad made an incision into the uterus at 8:58 a.m., and then ruptured the membranes. Typically, in a c-section delivery, the time needed to cut the uterus, rupture the membranes, and deliver the baby is less than two minutes. However, in thiscase the time that passed was 41 minutes. Dr. Gangestad attempted various maneuvers using her hands, a vacuum extractor many times, and making multiple additional cuts to facilitate delivery, but without success. At 9:18 a.m., Dr. Gangestad realized how much time had passed and paged Dr. Robert Blair for assistance. Although there was a discrepancy in the medical records, Dr. Blair arrived in the OR at some time between 9:20 a.m., and 9:39 a.m. A baby boy was delivered at 9:39 a.m., and was taken to the neonatal intensive care unit for treatment due to hypoxic ischemic encephalopathy. Mr. and Mrs. Blue brought suit against Medical University of Ohio.

WAS THE DELAY CAUSED BY DR. GANGESTAD'S FAILURE TO TIMELY CALL FOR ASSISTANCE THE PROXIMATE CAUSE OF THE BABY'S INJURIES? The court noted that Dr. Blair, who came to respond to Dr. Gangestad's page, did not arrive in the delivery room until after the delivery of the baby. In addition, there were other discrepancies regarding the time line in question. The court concluded that upon review of all of the evidence submitted, the court was compelled to find that the expert testimony of Dr. Gubernick, the plaintiffs' medical expert, was most persuasive. The court found that Dr. Gangestad became aware of the unusual amount and density of the patient's abdominal adhesions prior to making the uterine incision. Further, the court concluded that during the 30 minutes Dr. Gangestad spent lysing adhesions, she knew or should have known that Dr. Sutton, a first-year resident, was not authorized or qualified to assist her by either lysing additional adhesions or by making additional cuts to the abdominal tissue should the need arise. In addition, all physicians involved in the case testified that a reasonable expectation of delivery in a c-section, following uterine incision, is one to two minutes. Acordingly, the court found that a physician of ordinary skill, care and diligence would be cognizant both of the passage of time after the uterine incision was made and the increased risk of hypoxic injury.

THE COURT CONCLUDED THAT THE UNNECESSARY DELAY CAUSED BY DR. GANGESTAD'S FAILURE TO TIMELY CALL FOR MUCH NEEDED ASSISTANCE WAS THE PROXIMATE CAUSE OF THE BABY'S INJURIES. The court, noting that the case had been tried to a jury only on the issue of liability, remanded the case to the trial court solely for a determination as to the amount of damages to be awarded the plaintiffs. Blue v. Medical University of Ohio, 2009-Ohio-1995 (4/13/2009)-OH

Meet the Editor & Publisher: A. David Tammelleo, JD. is a nationally recognized authority on health care law. Practicing law for over 40 years, he concentrates in health care law with the Rhode Island firm of A. David Tammello & Associates. He has presented seminars on medical, nursing and hospital law throughout the United States. In addition to his writings as Editor of Medical Law's, Nursing Law's & Hospital Law's Regan Reports, his legal articles have been published in the most prestigious health law journals. A prolific writer, his thousands of articles, as well as his achievements as an attorney and lecturer, have won him recognition in Martindale-Hubbell's Bar Register of Preeminent Lawyers, Marquis Who Who in American Law, Who's Who in America and Who's Who's in the World.

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