The MedMal Room - When Minutes Matter: The $200 Million Lesson in Fetal Monitoring and Team Response

The Safety Ledger: A Pennsylvania jury’s verdict underscores why hospitals should define — and enforce — exact thresholds for when to stop oxytocin and call a cesarean.

The story of Dajah Hagans and her baby is now publicly known. The 19-year-old first-time mother arrived at the Hospital of the University of Pennsylvania in active labor with clear signs of infection — fever, maternal and fetal tachycardia, and elevated blood pressure. Within hours, her baby would be born with hypoxic-ischemic encephalopathy, leading to cerebral palsy and lifelong disability. A Philadelphia jury ultimately awarded more than $200 million to the child, one of the largest malpractice verdicts in U.S. obstetric history.

Some details are disputed, and as in many malpractice cases, parts of the timeline may remain uncertain. But the medical record and expert testimony reveal a familiar and preventable chain of events.

What Happened

At 11:45 a.m., Hagans was triaged at 7 cm cervical dilation with fever and fetal tachycardia — a clinical picture consistent with chorioamnionitis, infection of the placenta. But fetal tachycardia, and elevated fetal heart rate, can also be a sign of fetal hypoxia, not getting enough oxygen. And both an infection and not getting enough oxygen can overlap. By 1:00 p.m., the fetal heart tracing showed a prolonged deceleration lasting over four minutes with minimal variability. Plaintiff experts testified this should have triggered an immediate cesarean call, with delivery ideally by 1:30 p.m.

Instead, oxytocin (Pitocin) was initiated at 1:53 p.m. — despite the abnormal tracing and ongoing infection. Pitocin is contraindicated when there are concerns about the fetal tracing, a because pitocin increases contractions which can decrease blood flow to the placenta and eventually the babyu. Within ten minutes, the tracing deteriorated further, and Pitocin was stopped. The cesarean order was placed at 2:11 p.m., and delivery occurred at 2:36 p.m. By then, the damage had been done: the baby was born with signs of severe asphyxia and later diagnosed with HIE. It is important to mention that causality is important, and is often difficult to prove.

The System Failure

This case is not about one bad decision but about the absence of a shared mental model for emergency response. The staff recognized the risk, documented their concerns, and even planned for cesarean if things didn’t improve. Yet the plan lacked time specificity. “If no improvement, proceed to C-section” is not the same as “If tracing remains category III for more than 5 minutes, call cesarean immediately.”

The gap between recognition and action — in this case, about an hour — proved fatal to the baby’s brain.

It is also important to acknowledge that hospitals must establish a clear timeline between when the decision is made to do a cesarean delivery for fetal reasons is made and the actual initiation of the cesarean. Minutes often count.

Obstetric units often rely on individual judgment, but without explicit institutional parameters, judgment can drift. What counts as “non-reassuring”? How long is “too long” to wait? When does augmentation and giving oxytocin become contraindicated? When do you stop debating and start moving?

These gray zones become the breeding ground for tragedy.

Why Protocols Must Be Explicit

Hospitals need clear, enforced guidelines that define:

1. When to start and when to stop oxytocin.
   In my experience, oxytocin is associated with many adverse neonatal outcomes. Oxytocin can only be given to what seems to be a healthy fetal tracing and should be discontinued at the first sign of problems such as recurrent late decelerations or prolonged minimal variability. Every labor unit should have a nurse-empowered stop rule that does not require physician approval to halt the infusion.

2. When to call a cesarean.
   If fetal tracings remain category III (absent variability with recurrent decelerations or bradycardia) for more than 5 minutes, an immediate cesarean should be initiated. In cases of “fetal distress”, teams should train for “decision-to-incision” benchmarks of under 30 minutes , but preferably under 10 minutes.

3. When to escalate and who owns the call.
   Every unit should have a designated chain of command that empowers nurses and residents to activate the attending and anesthesia teams without delay or fear of reprimand.

4. How to document and communicate.
   Real-time documentation of interventions, including the exact times oxytocin is started, stopped, or restarted, should be standardized. Missing or unclear time stamps, as in this case, erode both safety and defensibility.

Lessons Beyond the Verdict

The jury’s award reflects outrage, but the deeper issue is cultural, not legal. Obstetrics has long struggled with how to balance vigilance and patience. We celebrate “normal birth,” yet our greatest disasters often occur when teams hesitate to pivot to surgical intervention.

Pitocin can be lifesaving or devastating, depending on timing and context. It should never be used when the fetal heart tracing is already concerning or there are already too many contractions. Protocols must override personal optimism.

Simulation training and real-time safety huddles can help close these delays. Every hospital should regularly run drills on category III tracings and “failed resuscitation” scenarios, rehearsing the shortest possible window between decision and delivery.

Reflection

In the end, this case is not about a single nurse, doctor, or resident. It is about a system that appear to lack explicit rules for moments when seconds decide a lifetime. Or if there were rules, they were not followed. The question for every obstetric team is simple: If the same tracing happened today, would your system respond faster? And what system changes have we implemented to improve our response.

Hospitals cannot promise perfection. But they can promise clarity — and clarity saves babies.