D
Patient 1
A (B) (6) GESTATION CAME FOR SPONTANEOUS LABOR AT 2:26 AM. LABOR PROGRESSED NORMALLY UNTIL 10:23 AM. AT 10:18 AM, AN INTRAUTERINE PRESSURE CATHETER (IUPC) WAS INSERTED. AT 10:23 AM THE FETUS EXPERIENCED A PROLONGED DECELERATION WITH FETAL HEART RATES (FHR) DROPPING TO THE 70'S. INTRAUTERINE RESUSCITATION EFFORTS WERE INITIATED. IN SPITE OF EFFORTS, THE FETUS CONTINUED TO DETERIORATE, A STAT C-SECTION WAS PERFORMED AND THE FETUS WAS BORN WITHOUT ANY SIGNS OF LIFE. ATTEMPTS TO RESUSCITATE THE BABY WERE UNSUCCESSFUL. THIS WAS AN UNUSUAL EVENT AND AN EXTENSIVE INVESTIGATION HAS BEEN CONDUCTED OVER THE PAST 30 DAYS. WE HAVE BEEN UNABLE TO DETERMINE THE CAUSE OF DEMISE FOR THIS BABY. IT WAS NOT ORIGINALLY THOUGHT TO BE RELATED TO THE IUPC AS THE IUPC WENT IN EASILY AND CLEAR FLUID WAS RETURNED. THE STAFF DID NOT SAVE THE IUPC BECAUSE THEY DID NOT BELIEVE IT HAD ANYTHING TO DO WITH THE DEMISE. WE HAVE NO EVIDENCE THAT IT WAS RELATED TO THE IUPC. WE ARE REPORTING BECAUSE THE TIMING OF INSERTION OF THE IUPC AND THE DETERIORATION OF FHR.