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Hours Elapsed With Baby's Life on the Line

Posted on: Tuesday, 4 October 2005, 06:00 CDT

By Bill McKelway

On Nov. 21, 2001, Danielle Moore was two days from the date her baby was due. Just before midnight, a sharp pain ripped through her stomach.

Her cramped trailer home near Alberta was a 25-minute ride through tobacco and soybean fields to the hospital in South Hill. But the former prison guard had been nervous about the care she would receive at Community Memorial Healthcenter there.

For the past few months, she'd been getting prenatal care an hour and a half away in Richmond at VCU Medical Center's Nelson Clinic.

Her first prenatal visit was at Community, but an emergency room doctor told her she had a medical condition that made her a high- risk patient.

"They said I was high-risk because I had placenta previa," Moore recalled in an interview at her home. This is a condition in the womb where the placenta can precede the baby. It increases the chances of a hemorrhage late in the pregnancy.

"They said I should go to Richmond."

But at VCU, doctors said her pregnancy appeared uncomplicated, according to Moore; there was no placental problem, they said.

Given the differences in her diagnosis, Moore said she was happy to keep taking the Medicaid bus north to Richmond for care.

But on the morning of Nov. 22, with the pain still throbbing inside her, proximity overruled her previous judgment. Moore headed to Community's emergency room. She arrived shortly after 10 a.m.

Moore had just turned 28 and was the single mom of a healthy 8- year-old named Jakela.

During a 90-minute visit, doctors checked Moore's condition and the baby's heart rate. They concluded she wasn't in active labor and told her she should head for Richmond.

Medical records show that Moore was having contractions 6 to 7 minutes apart. And her baby's heart rate went from a low of 140 beats per minute, which is considered normal, to the 160s and 170s, which is considered worrisome, especially if the reading persists.

Moore couldn't find transportation to Richmond. "My cousin refused to take me the way I was," Moore recalled. "She thought we would be having the baby on the highway."

Besides, it was Thanksgiving Day. Dinner was waiting with friends and family.

By 5 p.m., the pain was getting unbearable.

Her cousin had called Dr. John Raviotta, a South Hill obstetrician she knew and trusted, for advice.

Moore and her family didn't know that Raviotta was in the midst of a bitter fight with the hospital's management. A month before, Raviotta had lost his hospital privileges because he'd copied records that were off-limits to him. He was facing a grueling formal hearing into his conduct and care.

Raviotta said Danielle needed to go to the emergency room, a place Raviotta had been alleging for years was not properly assessing emergency situations involving late-term pregnant women.

A larger issue had been Raviotta's contention that staff at the rural hospital wasn't trained in handling emergency surgical deliveries when the regular operating room staff was busy with another procedure or not around. But that training had occurred and a state-approved policy was in place to handle cases like Moore's in November 2001.

Danielle Moore traveled back to South Hill and was admitted shortly after 5 p.m. At 6:21, hospital records listed the baby's heart rate as "non-reassuring." It was still showing 170 beats a minute.

By 7:35, contractions were one to two minutes apart and strong; Moore was getting supplementary oxygen, usually an indication that the baby is under stress; the baby's heart rate remained non- reassuring, according to medical records.

"Notified anesthesia of high-risk status of mom and ... baby," a nurse recorded at 7:35. Her notes show she originally had written "mom and dad" but then replaced "dad" with "baby." A pediatrician, who would have to be on hand to resuscitate the baby if necessary, was paged but there was no response.

Drug doses to speed labor were increased at 8:15 and 9 p.m.; the baby's heart was racing at 170 beats and there was minimal variability and no accelerations in her heart rate, a sign of dangerous complications.

Drug levels were boosted again at 9:15 to push the pregnancy and still again 15 minutes after that.

The baseline heart rate of the baby, which is supposed to sustain a long-term, steady average rate, dropped precipitously. Nurses changed the mother's position, an effort that often means they are trying to remove pressure on the umbilical cord. When compressed, the cord can cause problems in a baby's heart rate as the fetus suffers from the shutoff of oxygen-rich blood through the cord.

Just before 10 p.m., Moore's uterus began hyperstimulating, meaning it was uncontrollably contracting, for up to seven minutes at a stretch, hospital records show. Nurses shut off the drug, pitocin, and called the on-duty obstetrician by pager.

The baby's heart rate soared into the 180s and crashed to 50 beats per minute. At 10:30 the rate was down to the 60s for five minutes.

The doctor ordered an emergency surgical delivery, called a Caesarean section, at 10:26, according to hospital records. At 10:30 he was scrubbing up for the delivery.

"[The obstetrician] had no [operating room staff] or support staff present, the baby's pediatrician ... was not present. He had been paged but did not call back," another pediatrician wrote in his operative notes. He had been stopped in the hallway of the hospital and stepped in to help with the delivery.

Hospital records say it took only two minutes to deliver the baby after the incision at 10:55. The effort was so hurried that no sponge or needle count was done, although an X-ray later showed Moore's abdomen was clear of foreign objects.

The OR team, according to hospital Chief Executive W. Scott Burnette and medical staff Vice President Dr. Wallace Horne, arrived at the hospital too late to participate in the operation. But the situation was handled appropriately using obstetrical nurses and a backup plan, the two men said. (Moore gave written permission for the executives to discuss her case with a reporter.)

Horne said that the obstetrician used his best judgment about when to deliver the baby and said that his review of the record indicates that there was good communication between the obstetrician and the nurses throughout the evening.

The baby presented a new emergency.

A full-term, 7-pound, 7-ounce infant, she was alive only by the slimmest of margins.

At one minute and five minutes after her arrival, she showed no vital signs, registering zeroes for five markers of vitality called Apgar scores. There was no heart rate and there was no discernible spontaneous breathing.

At 10 minutes, after being administered drugs and having oxygen forced into her system, she recorded a 6 of a possible 10 points.

But she was showing apparent seizures and needed constant assistance to keep breathing. With no ventilator available to help her breathe, doctors worked for two hours forcing oxygen into her lungs using a bag and mask system.

Because Community Memorial has no neonatal intensive-care unit suitable for such severely injured infants, the hospital summoned a neonatal transport team from Richmond.

The VCU team was called at 11:30, some 90 minutes after medical records chart emergency conditions. The team arrived in South Hill at 1:15 in the morning with its on-board ventilator and got back to Richmond at 4:50.

"They told me she probably wouldn't live and I would have to name her before she left South Hill," Danielle Moore said. The struggling little girl would be called Adashia, Moore told nurses from her hospital bed.

So Adashia Moore made it to VCU Medical Center after all; she was given little chance of survival.

When Danielle reached her daughter in Richmond, a doctor whispered some private advice: "A doctor told me that people would blame me, that they would say I had taken drugs and that was what hurt my baby.

"But the doctor said don't believe it because my baby had been hurt by not getting oxygen," Moore said.

Adashia would remain hospitalized in intensive care at VCU until Jan. 4, 44 days after her traumatic birth.

Today, almost four years later, Moore said no physician has fully explained why Adashia has severe cerebral palsy and likely will never walk or talk. She is fed through a stomach tube and is incontinent. Her awareness of her surroundings is almost strobe- like. Her face registers a flash of recognition, there is a smile, and then her eyes roll back in her head. This pattern plays itself out unceasingly hour after hour. Her breathing registers a deep gurgling inside her chest.

"The most they have told me was that Adashia would not be normal. Every time I take her to a doctor in South Hill, they say I should go to Richmond," Moore said.

An early medical assessment of the little girl painted a grim portrait: "Adashia shows pleasure when touched and handled; quiets when picked up, and responds to voices.

"She is not cooing or laughing or varying the pitch, length or volume of her cries. She is unable to regard an adult's face, establish eye contact, or cuddle when held."

Adashia is still recovering from hip-socket surgery to correct painful growth pressures. The operation, in Richmond, resulted in another unexpected problem -- she returned home with one leg 4 inches shorter than the other after the surgeon cut away bone.

"Her legs were supposed to be the same length after the operation; now it won't be as easy to learn to walk or stand up, if that can ever happen," Moore said.

One time a therapist, frustrated that Adashia wasn't showing improvement, called her "a lemon, no good," Moore said.

Adashia will be "not normal" for many, many years; she could live well into midlife and is powerfully built despite her injuries.

Moore has tried to make ends meet for her family of three on an $8-an-hour salary sweeping leavings at a tobacco plant. Jakela, her 11-year-old daughter, is a joyful, healthy assistant practiced in Adashia's delicate care.

Just as the doctor predicted, for much of Adashia's life people have whispered that drug use by Moore hurt her baby.

"There was no drugs," Moore said firmly, saying there is proof. "I was getting tested because I worked at the prison." Tears formed in her eyes.

Convinced that doctors and the hospital were at fault for her child's condition, Moore said she sought legal help but was turned away by Richmond firms well-known for medical malpractice work.

The reason likely was that a look at the records made it clear that Adashia qualified for the state's birth-injury program. The program bars malpractice suits against participating doctors. Lawyers therefore lose out on getting a significant portion of any jury award but the child can receive lifetime medical care.

The doctor who delivered Adashia participated in the program. Now practicing in another state, he did not respond to repeated efforts to reach him for comment for this article. But no doctor or therapist, including the obstetrician, has ever mentioned to Moore that the program even exists, she said; some of Adashia's Richmond- area physicians were instrumental in the program's creation.

In turning away Moore, though, lawyers referred her to Gerald Walsh, a Fairfax lawyer who has helped more than a dozen families enter the birth-injury program. With Walsh's help, Moore applied in August 2002 and her daughter qualified for lifetime medical benefits within a few months.

Walsh said medical experts who reviewed the case concluded that he had meritorious grounds for a medical malpractice suit. Walsh said his experts concluded that Adashia should have undergone an emergency delivery long before she did.

Records of Moore's birth-injury case show that four obstetricians who reviewed the file concluded that Adashia's catastrophic brain injuries were caused by oxygen loss before her birth and in the hours afterward. One of the doctors said compression of the umbilical cord was the likely cause of injury.

The state Board of Medicine and the Department of Health are required by law to assess every birth-injury case for possible standard-of-care violations by the doctor and the hospital involved. But in more than 130 birth-act petitions filed since 1988, including Moore's, not a single sanction has been imposed.

Moore was able to replace her rickety trailer with a new handicapped-accessible trailer purchased by the program. And she received a handicapped-suitable van from the program, albeit a used one. She also receives nearly 100 hours of nursing help a week.

But the van has been breaking down for weeks at a stretch this past summer, and the mobile home is falling apart in places. The front door opens the wrong way, blocking exit from the home onto a ramp. "It's a fire hazard," said Moore.

Registered nurse Angie Oliver is a dedicated and enthusiastic helper to the family. But her agency bars her from taking Adashia to appointments. Because therapists won't visit the home, physical therapies Adashia normally receives at school in Alberta go wanting in summers.

Moore, because of vehicle breakdowns, has lost her job. Bills are going unpaid and the telephone recently was disconnected.

Valued at less than $70,000, the trailer represents a $100,000 savings to the program, which promises homeowners up to $175,000 in alterations to existing homes. The dwelling's value and the broken van have helped push Moore's worth above a level that would qualify her for welfare help, she said.

"I can't afford to pay to get the van fixed if something big goes wrong," said Moore. "The warranty is gone." The program supplied a replacement vehicle but it had an expired registration.

Moore's life is a maelstrom of frayed efforts and an uncertain end.

Adashia needs assistance every moment of her life; even when sleeping, she is subject to harm from breathing difficulties and falling from her bed.

"It's one day at a time for me," Moore said. When Tropical Storm Isabel hit in September 2003, Moore lost power for two weeks. Important electrically operated medical equipment couldn't function.

"I asked for a generator, but the birth program refused," Moore said. She sucks phlegm from her daughter's lungs with her mouth when the machine won't work.

Months after Adashia's birth, mention of it came up at hearings in early 2002 that resulted in the permanent revocation of John Raviotta's privileges to practice medicine at CMH. Raviotta, an obstetrician and angry critic of hospital policies and administrative procedures, had predicted infants would suffer tragic outcomes when delays occurred in performing emergency C-sections.

The brief reference to Adashia takes up only a few paragraphs in more than 3,200 pages of testimony involving Raviotta's allegations and allegations against him.

A nurse was asked about incidents in which the emergency backup plan had to be used for deliveries.

"Did the babies turn out OK?" a lawyer asked.

"We had one instance where a baby is permanently brain-damaged," the nurse said. "There were variables -- involving before she came to the hospital -- where she was supposed to be sent to MCV and she did not go ...

"This patient came back to the hospital?"

"Yes."

"And had to have one of these life-and-death kind of emergency C- sections?"

"Yes."

Source: Richmond Times - Dispatch

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