A minor child, by his Parents and Natural Guardians, Emily Millette, Casey Millette, and Emily Millette, Individually, Casey Millette, Individually vs Park Nicollet Clinic, 27-CV-20-1375, 04032021_Oth (2024)

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`Electronically Served
`8/4/2020 4:20 PM
`Hennepin County, MN
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`27-CV-20-1375
`27-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`STATE OF MINNESOTA
`
`COUNTY OF HENNEPIN
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`Ronin Millette, a minor child, by his Parents
`and Natural Guardians, Emily Millette and
`Casey Millette, et al.,
`
`
`Plaintiffs,
`
`
`v.
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`Park Nicollet Clinic,
`
`
`Defendant.
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`DISTRICT COURT
`
`FOURTH JUDICIAL DISTRICT
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`Case Type: Medical Malpractice
`Court File No.: 27-CV-19-1375
`The Hon. Laurie Miller
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`Affidavit of Expert Identification of
`Kenneth L. Naylor, M.D.
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`STATE OF MARYLAND
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`
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`COUNTY OF BALTIMORE
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`)
`) ss.
`)
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`
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`Katrina Wallace, first being duly sworn on oath, deposes and states as follows:
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`1.
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`2.
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`That I am an attorney for the above-named Plaintiffs.
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`That this Affidavit is made pursuant to Minn. Stat. § 145.682, and as an amendment
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`to Plaintiffs’ Answers to Defendant’s Interrogatories.
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`3.
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`That Plaintiffs expect to call Kenneth L. Naylor, M.D., Obstetrics & Gynecology
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`Specialists, P.C., 5350 Eastern Avenue, Davenport, Iowa, 52807, as an expert in obstetrics and
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`gynecology to provide testimony on issues of standard of care, causation, and damages.
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`4.
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`That the basis for Dr. Naylor’s opinions are his review of the medical records of
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`Emily Millette and Ronin Millette, the discovery materials, and depositions, as well as his
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`background, training, and experience as a physician board-certified in obstetrics and gynecology.
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`Dr. Naylor also relies on his understanding of the relevant medical literature in the fields of
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`obstetrics and gynecology.
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`27-CV-20-137527-CV-20-1375
`
`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`I.
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`QUALIFICATIONS
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`Dr. Naylor is a physician licensed to practice in the State of Iowa. He completed medical
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`school at the University of Utah in 1986, and then completed his residency at the University of
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`Iowa Hospitals and Clinics in 1990. He then became board-certified in obstetrics and gynecology
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`in 1992, and has been practicing gynecology for 30 years at Obstetrics & Gynecology Specialists,
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`P.C. His practice is comprised of approximately 50% obstetrics and 50% gynecology and he has
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`extensive experience working with triage and labor and delivery nurses. He has delivered roughly
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`125-150 babies in each of the last 30 years.
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`Dr. Naylor has held numerous academic, hospital, and professional appointments over his
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`career. He is a member of the Iowa State Board of Medical Examiners. He is also accredited by
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`the American Institute of Ultrasound Medicine. Since 1990, he has been an Adjunct Clinical
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`Associate Professor at the University of Iowa. Also since 1990, he has been a Clinical Lecturer for
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`the Genesis Family Practice Residency Program, where he works with family medicine
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`practitioners who care for obstetric patients. Dr. Naylor has been the OB-GYN Department
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`Chairman for Genesis Medical Center from 2006-2017, and has been Medical Director for
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`Women’s Health since 2012. He also led the medical staff in implementation of electronic medical
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`records at Genesis Health System.
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`Dr. Naylor completed a National Patient Safety Leadership Fellowship through the Health
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`Research & Educational Trust and the National Patient Safety Foundation in 2007. Thereafter, he
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`served as Co-Director of the Genesis Health System Patient Safety Leadership Fellowship from
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`2007-2012, and currently serves on the Genesis Health System Patient Safety Oversight
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`Committee.
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`Dr. Naylor is a member of the American College of Obstetricians and Gynecologists
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`(ACOG), and has served in several leadership positions, including Chairman of the ACOG District
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`VI Patient Safety Committee from 2009-20011, as well as the ACOG National Patient Safety
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`Committee from 2010-2011. He currently serves as a Reviewer for the ACOG Voluntary Review
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`of Quality Care.
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`This experience, education, training, and knowledge of obstetrics and gynecology, years
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`of teaching and education of other doctors, and continued leadership in patient safety efforts, has
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`made him familiar with the management of obstetrical patients such as Emily Millette. This
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`familiarity includes proper obstetric and nursing management of a pregnant mother during her
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`prenatal care, labor and delivery, including proper triage, examination, management, and
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`assessment of laboring patients, proper interpretation of fetal heart rate patterns and electronic fetal
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`heart monitoring, and proper communication among health care providers.
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`Dr. Naylor’s education and experience are more fully detailed in his curriculum vitae,
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`attached hereto.
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`II. MATERIALS REVIEWED
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`Emily Millette Medical Records
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`A. Park Nicollet Clinic
`B. Fairview Ridges Hospital
`C. Fetal Heart Tracing
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`Ronin Millette Medical Records
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`A. Fairview Ridges Hospital
`B. University of Minnesota Medical Center
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`Discovery Materials
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`A. Park Nicollet Protocols
`B. Plaintiffs’ Answers to Interrogatories
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`C. Dr. Leland Cheng’s Deposition
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`Dr. Naylor also intends to review the depositions taken in this case, Defendant’s Expert
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`Witness Disclosures, and additional medical records and discovery materials when they become
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`available.
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`III. MEDICAL BACKGROUND
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`A. PRENATAL CARE
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`Mrs. Millette was 30 years old at the time of Ronin’s delivery. Ronin is Mrs. Millette’s
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`only child. Her last menstrual period was 6/19/16 and her estimated due date was March 26, 2017,
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`which was confirmed with an ultrasound (US) on August 24, 2016. She had an essentially
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`uncomplicated past medical history. Her prenatal labs were normal.
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`Due to a history of a maternal grandfather who had a deep venous thrombosis (DVT) with
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`pulmonary embolism (PE), Mrs. Millette was tested and found to have a heterozygous prothrombin
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`2 gene mutation and protein S deficiency. The patient had no personal history of a DVT or PE.
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`Due to this history, she was seen by a maternal fetal medicine specialist, Dr. Leslie Pratt, on
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`9/13/16. Dr. Pratt did not recommend antenatal thromboprophylaxis but did recommend
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`anticoagulation if she required a cesarean section.
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`Mrs. Millette’s prenatal course was unremarkable. Her blood pressures were normal and
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`she gained 21 lbs. during her pregnancy. Ultrasounds showed normal growth and development.
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`She had a growth US on February 1, 2017 which revealed an estimated fetal weight (EFW) at the
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`15.6th percentile. A repeat growth US March 1, 2017 revealed an EFW at the 28th percentile.
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`Mrs. Millette was seen by Allison Coindreau, APRN at Park Nicollet Clinic on March 13,
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`2017 at 38 weeks 1 day of gestation complaining of three episodes of possible fluid leakage over
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`the preceding 36 hours along with cramping every 15 minutes. She denied vagin*l bleeding and
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`noted “good FM [fetal movement]”. Examination did not reveal rupture of membranes. Her cervix
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`was closed and blood pressures were 130/89 and 128/77.
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`B. FIRST PHONE CALL
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`There was a “Telephone Encounter” documented by David M. Whitcomb, RN at 23:45 on
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`March 13, 2017 who noted: “Patient calling 38 weeks pregnant due to having abdominal
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`pain/tightening all day today that at times last for a hour tightening is very noticeable but not very
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`intense. Also having low back pain. No change in discharge or bleeding.” There was no
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`documentation of the presence or absence of fetal activity. Nurse Whitcomb told Mrs. Millette that
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`she “may need to be seen” and that the “doctor will want to talk to you to decide what is best.”
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`Nurse Whitcomb paged Dr. Cheng informing him that Mrs. Millette’s abdomen was “tight.” Mrs.
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`Millette’s phone records show that her call with Nurse Whitcomb was initiated at 23:34 and lasted
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`for 5 minutes. Nurse Whitcomb paged Dr. Cheng at 23:40.
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`At 03:13 on March 14, 2017, Dr. Leland P Cheng, MD documented that “she called and I
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`spoke with her approx. 11:50 PM at which time she described her abd [abdominal] and back pain
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`as not being too bad, and not accompanied by any VB [vagin*l bleeding] or leaking of fluid. She
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`stated her fetus was active. Since her Cx [cervix] had been closed earlier that day and her sx’s
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`[symptoms] were not c/w labor definitively, I advised her to push fluids, take some Tylenol, and
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`tray a warm bath or heating pad to see if this relieved her sx’s, which at the time were most
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`consistent with B-H [Braxton-Hicks] ctx’s [contractions].” Mrs. Millette’s phone records show
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`that this call was at 23:41 and lasted 4 minutes.
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`Mr. and Mrs. Millette reported that she called because her symptoms were more concerning
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`to her than they had been at her appointment in the afternoon on March 13, 2017, and she
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`remembers telling Dr. Cheng that her abdomen was tight and that Ronin was moving around less
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`than before. They remember that Dr. Cheng’s first question was whether this was her first
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`pregnancy.
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`C. SECOND PHONE CALL
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`At approximately 01:09 on March 14, 2017, Mrs. Millette called the triage line again
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`because her pain was suddenly much worse. This call was documented by Lorraine Miller, RN
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`who noted: “Pt. calling back, pain all over abdomen is worse. Entire abdomen is constantly tight,
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`unable to time contractions. Has clear to pinkish vagin*l drainage. Good fetal movement. Pt. feels
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`she needs to come in. Call transferred to operator to speak with OB on call.” Records show that
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`Nurse Miller actually paged Dr. Cheng instructing him to call Mrs. Millette at 01:15.
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`At 03:13 on March 14, 2017, Dr Cheng documented his recollection of his second
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`conversation with Mrs. Millette: “She called me back approx. 1:15 am with increasing abd
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`[abdominal] pain, tightness now and back pain, as well as diarrhea. Still no frank VB, but some
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`pink d/c [discharge]. She requested to come in and I agreed that she should come right to L&D at
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`FVR [Fairview Ridges Hospital].” Mrs. Millette’s phone records show that Dr. Cheng called her
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`at 01:15 and they spoke for just 1 minute.
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`Mr. and Mrs. Millette reported that the purpose of this call was to inform the hospital that
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`they were on their way in, as they were instructed to do during Mrs. Millette’s prenatal care. They
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`went directly to the emergency department at Fairview Ridges Hospital, as they were instructed to
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`do. Dr. Cheng did not alert the emergency room or labor and delivery nursing staff that Mrs.
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`Millette was on her way into the hospital to be evaluated for a possible placental abruption. Mr.
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`Millette reports that hospital staff were not expecting them and they encountered several delays
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`before Mrs. Millette was evaluated by labor and delivery nursing staff.
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`D. ADMISSION
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`Mrs. Millette was admitted to the labor and delivery unit at approximately 01:34. Nurse
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`Sarah J. Eggerud, RN documented the following at 03:46, approximately 1 hour and 45 minutes
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`after Ronin’s delivery:
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`0134: Patient arrived onto LD [Labor and Delivery] via w/c [wheelchair] accompanied by
`husband, obviously uncomfortable. Able to stand and attempted to void for UA
`[urinalysis], unable to void. Returned to room, hunched over bed.
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`01:41: Patient in bed in LL [left lateral], abdomen moderate and patient feels like she is
`cramping frequently. Stated she had some pink discharge at home, unsure is she SROM
`[spontaneous rupture of membranes] at home.
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`01:42: Attempted BP [blood pressure] with no result, patient appears pale and
`uncomfortable. Assessment questions in process.
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`01:44: Patient to semi-fowler’s position. Second BP [blood pressure] with no result. Toco
`[tocodynamometer] placed.
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`01:45: U/S [ultrasound] to lower abdomen, no FHR [fetal heart rate] detected, attempting
`to scan abdomen. Patient unable to state last time she felt baby move due to increase in
`pain. Also verbalized placenta is anterior.
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`01:46: Pulse heard at 60’s [beats per minute] but unable to determine maternal or fetal.
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`01:47: Placed patient supine to check SVE [sterile vagin*l exam]: 1/60/-1 [1 cm dilated,
`60% effaced, -1 station], no blood observed but scant clear discharge seen. Attempted to
`detect FHR [fetal heart rate] in supine position with again what sounded 70’s [beats per
`minute].
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`01:48: Called out to desk to have Dr. Cheng notified and come to bedside immediately
`with bedside U/S [ultrasound]. HUC paged and reported he was on his way.
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`01:50: Dr. Cheng at bedside.
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`01:51: Dr. Cheng using U/S [ultrasound] and found concerning fetal heart rate, wanted
`external monitor U/S placed to listen also, found again 60’s at 01:52.
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`01:52: Dr. Cheng called emergency C/S process started. Called out to LD [labor and
`delivery] charge [nurse] and HUC, process started.
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`01:54: IV started in left hand by J. Malecha, RN.
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`01:57: Entered OR [operating room] 1 in LD [labor and delivery] unit via cart. Support
`provided to husband and to patient.
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`02:06: Baby boy.
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`E. DELIVERY
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`Mrs. Millette entered the operating room at 01:57, anesthesia was started at 02:00, and Dr.
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`Cheng made the incision at 02:03. Dr. Cheng performed an emergency primary low transverse
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`cesarean section under general anesthesia with a preoperative diagnosis of intrauterine pregnancy
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`at 38 weeks 0 days and fetal bradycardia of unknown etiology in the setting of maternal abdominal
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`pain.
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` Dr. Cheng’s delivery report notes that the delivery was complicated by “severe placental
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`abruption.” He noted that there was a large retroplacental clot and a couvelaire uterus.
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`F. NEONATAL COURSE
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`Ronin was delivered at 02:06. He severely depressed. Ronin’s Apgar scores were 0, 0, 1,
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`2, and 3 at 1, 5, 10, 15, and 20 minutes respectively. (BABY 2-16) His cord blood gases were
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`arterial: pH < 6.75, pCO2 of 139, and pO2 of 20, and venous: pH 6.83, pCO2 96, pO2 30, and
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`base deficit of 18.3. (BABY 2-16) Ronin required extensive resuscitation.
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`Shortly after delivery, Ronin was transferred to the NICU at the University of Minnesota
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`Medical Center. At admission, he was noted to be hypovolemic with severe metabolic acidosis.
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`(BABY 2-9) His admissions diagnosis was “severe HIE.” (BABY 2-10) He met the following
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`criteria for cooling: (1) known adverse perinatal event – abruption with fetal bradycardia, (2)
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`Apgar of 1 at 10 minutes, (3) > 10 minutes of mechanical ventilation, (4) cord blood gases: arterial
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`- < 6.75, 139, 20, venous – 6.83, 96, 30, and a base deficit of 18.3, and (5) clinical signs of severe
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`encephalopathy. (BABY 1-4, 1-9) He required two blood transfusions on the day of delivery.
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`(BABY 2-49) At admission, Ronin weighed 3.17 kg (46th percentile), he was 51 cm long (72nd
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`percentile), and his head circumference was 33 cm (12th percentile). (BABY 2-11)
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`Ronin required an oscillating ventilator from March 14, 2017 through March 22, 2017.
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`(BABY 2-66) He was weaned to a traditional ventilator on March 22, 2017, and to nasal cannula
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`on March 26, 2017. He was Ronin was weaned to room air on March 30, 2017, (BABY 2-486) but
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`required nasal cannula for oxygen therapy due to frequent desaturations by April 3, 2017. (BABY
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`2-139, 2-489) He was discharged from the NICU on April 9, 2017 with home oxygen therapy
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`which continued until May 2017. (BABY 2-153, 2-2009-2011, 3-56-64)
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`On March 24, 2017, Ronin underwent an MRI of his brain which showed a pattern of
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`damage associated with severe HIE with diffuse involvement of the cerebral white matter and deep
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`grey nuclei. (BABY 2-81)
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`Ronin was discharged on April 9, 2017. At the time of his discharge, he weighed 3.41 kg
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`(7th percentile), he was 50.5 cm long (5th percentile), and his head circumference was 34.5 cm (3rd
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`percentile). (BABY 2-11) He was noted to be hypertonic, but was responsive to stimuli.
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`Ronin’s current diagnoses include cerebral palsy, epilepsy, cortical vision impairment, and
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`global developmental delay. He is non-verbal, wheelchair bound, and dependent on a feeding tube.
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`G. POSTPARTUM
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`Mrs. Millette was diagnosed with severe pre-eclampsia postpartum with elevated blood
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`pressures, elevated liver enzymes, and thrombocytopenia and was started on magnesium sulfate.
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`She developed disseminated intravascular coagulation (DIC) and received multiple units of blood
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`products. She was transferred to the University of Minnesota Medical Center on March 15, 2017
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`and discharged on March 18, 2017 on Nifedipine.
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`IV. Opinions:
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`Placental abruption is the premature separation a normally implanted placenta. Placental
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`abruption occurs in approximately 1-3% of pregnancies. Abruption can be “total,” involving the
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`entire placenta, or “partial,” where only a portion of the placenta detaches from the uterine wall.
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`During an abruption, the baby is deprived of sufficient oxygenated blood. If the baby is not
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`delivered, the lack of oxygenated blood leads to hypoxia, asphyxia, brain damage, and death. The
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`consequences of placental abruption vary based on the severity of the abruption. In cases of
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`significant abruption, the time between onset of fetal bradycardia and delivery often controls the
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`outcome. A significant abruption is a medical emergency requiring rapid intervention; minutes
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`may make the difference between death and survival.
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`Symptoms of placental abruptions include abdominal pain, back pain, abdominal
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`tightening, and decreased fetal movement. The abdomen is often hard upon palpation. Abruption
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`can be “revealed,” meaning there is vagin*l bleeding, or “concealed,” meaning the blood
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`accumulates behind the placenta and there is no visible bleeding. Approximately 10-20% of
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`abruptions are concealed, with the blood being trapped between the fetal membranes and decidua,
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`rather than escaping through the cervix and vagin*. In cases of significant abruption, the baby often
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`becomes bradycardic. Unless vagin*l delivery is imminent, the standard of care usually
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`necessitates delivery via emergency cesarean section when abruption is suspected.
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`A. BREACHES OF THE STANDARD OF CARE:
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`1 – Delayed Diagnosis of Placental Abruption
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`Placental abruption can be a medical emergency threatening the life of both mother and
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`baby. When abruption is suspected, prompt examination is required. When a patient complains of
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`abdominal or back pain with decreased fetal movement or abdominal tightness, the applicable
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`standard of care requires immediate evaluation, including physical examination and fetal heart
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`monitoring.
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`Mrs. Millette’s Answers to Interrogatories indicate that when spoke with the triage nurse
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`during the first phone call she reported abdominal pain and tightness, back pain, and decreased
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`fetal movement. The nurse’s documentation of the call does not mention the presence or absence
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`of fetal movement. The triage nurse instructed her that she may need to be seen, but the doctor
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`would speak with her to determine the best course of action. The triage nurse paged Dr. Cheng
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`describing Mrs. Millette’s concerns in a text: “[Patient] Dr. Bowlin re stomach is tight 38 weeks.”
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`(HP 1034) Several minutes later, Dr. Cheng called Mrs. Millette and asked several questions about
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`her symptoms. He quickly determined that she was not in labor and advised her that it was not
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`necessary for her to come to the hospital. Dr. Cheng did not even consider the possibility of
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`placental abruption. At his deposition, Dr. Cheng admitted that he did not consider placental
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`abruption a possibility, despite Mrs. Millette’s report of several symptoms of placental abruption.
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`To the extent that Dr. Cheng required additional information from Mrs. Millette in order to
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`ascertain the cause of her symptoms or the appropriate instructions to give, he has a duty to ask
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`the necessary questions to elicit the information from the patient. Dr. Cheng breached the standard
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`of care when he failed to consider placental abruption as a possible cause of Mrs. Millette’s
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`symptoms. Additionally, Dr. Cheng breached the standard of care when he failed to instruct Mrs.
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`Millette that she should come to the hospital to be evaluated as soon as possible.
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`Dr. Cheng indicated in his deposition that his typical practice is to instruct patients to come
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`in after they call with complaints a second time. Mrs. Millette was seen at a scheduled prenatal
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`care appointment approximately 9 hours before her first call, where she reported cramping and
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`possible leaking amniotic fluid. At that time, she was reassured that she was not in labor but that
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`she should call if she had any concerns. When she called later that evening to report additional
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`concerning symptoms, it was the second time she had raised concerns about that day. Dr. Cheng’s
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`failure to appreciate that Mrs. Millette had already raised concerns earlier that day, and that her
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`first phone call with him reflected an escalation in symptoms, constitutes an additional violation
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`of the standard of care. Dr. Cheng’s decision to wait for Mrs. Millette to raise her concerns for a
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`third time lead to a delay of approximately 90 minutes.
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`2 – Failure to Prepare for Mrs. Millette’s Arrival
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`When Mrs. Millette spoke with Dr. Cheng at approximately 01:15 on March 14, 2017, Dr.
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`Cheng should have appreciated that her condition was a potential emergency and prepared to assess
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`her condition immediately upon her arrival. Dr. Cheng testified at deposition that the only entrance
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`to the hospital available at this time of day is the emergency room, and that the emergency room
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`typically sends pregnant patients to labor and delivery. When a pregnant patient reports abdominal
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`pain and/or back pain with decreased fetal movement or abdominal tightening, a physician should
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`suspect that placental abruption is a possibility and alert the emergency room staff of the urgency
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`of the situation. Alerting the emergency room that a potentially emergent patient was coming into
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`the hospital would have enabled the Millette’s to get to the labor and delivery unit more quickly.
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`Similarly, the standard of care requires that Dr. Cheng alert the labor and delivery nursing
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`staff of a patient coming in with a potential placental abruption. Had nursing staff known that Mrs.
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`Millette had a potential placental abruption, they would have started fetal heart monitoring as soon
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`as Mrs. Millette arrived at the labor and delivery unit and notified Dr. Cheng of the concerning
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`fetal heart tracing at 01:35, approximately 14 minutes earlier.
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`Placental abruption is a medical emergency requiring rapid intervention; minutes may
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`make the difference between death and survival. Every minute counts, and every minute wasted
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`27-CV-20-137527-CV-20-1375
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`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
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`resulted in increased academia, hypoxia, and ischemia. It is more likely than not that delivery even
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`five minutes earlier would have resulted in significantly less severe injuries.
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`B. CAUSATION
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`As a result of the placental abruption, Ronin did not receive sufficient oxygenated blood
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`just prior to delivery. This caused hypoxia, ischemia, metabolic acidosis and severe permanent
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`brain injury (hypoxic ischemic encephalopathy, or HIE). Had the abruption been permitted to
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`continue without intervention, Ronin would have died. Ronin’s current diagnoses, which are the
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`result of the HIE he suffered just before delivery as a result of the placental abruption include
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`cerebral palsy, epilepsy, cortical vision impairment, and global developmental delay. He is non-
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`verbal, wheelchair bound, and dependent on a feeding tube. There is no evidence supporting any
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`alternative cause of injury, including infection or genetic abnormalities.
`
`C. TIMING OF INJURY
`
`Placental abruption generally occurs gradually over time, with the placenta slowly
`
`separating from the uterus. During the early stages of abruption, there are often no consequences
`
`to fetal or maternal wellbeing. As the abruption progresses, the baby’s supply of oxygenation blood
`
`is interrupted which, if ignored, can quickly lead to hypoxia, asphyxia, acidosis, brain damage,
`
`and death. It is most likely that the symptoms Mrs. Millette reported during the first calls on March
`
`13, 2017 (23:34 with Nurse Whitcomb and 23:41 with Dr. Cheng) were caused by the early stages
`
`of placental abruption. This is because she had key symptoms of abruption (abdominal tightness
`
`and decreased fetal movement), but she was not yet experiencing severe pain and Ronin was still
`
`moving. During the early stages of the abruption, Ronin was still receiving sufficient oxygenated
`
`blood through the placenta. By the time of Mrs. Millette’s second call with Dr. Cheng, she was
`
`likely suffering a significant abruption, since by that time she had severe abdominal pain and other
`
`
`
`13
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`

`

`
`
`27-CV-20-137527-CV-20-1375
`
`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
`
`very concerning symptoms such as weakness and dizziness. This is consistent with the symptoms
`
`observed by providers upon her arrival at the hospital including fetal bradycardia and maternal
`
`hypotension.
`
`Ronin’s presentation at delivery also shows that the abruption developed gradually over
`
`several hours, with Ronin starting to show signs of hypoxia approximately 30 minutes before
`
`delivery, and starting to suffer brain injury approximately 15-20 minutes before delivery. Brain
`
`injury caused by intrapartum hypoxia is progressive, starting with minor short-term injury, which
`
`progresses to permanent brain damage or even death if the hypoxia is permitted to continue. Had
`
`Ronin been delivered even 15-20 minutes earlier, it is likely that he would have been spared
`
`significant permanent brain damage.
`
`
`
`The risk of death or permanent brain injury increases proportionately to the degree of
`
`metabolic acidosis. During an episode of fetal bradycardia, base deficit increases 1 mmol for every
`
`two minutes of inadequate blood flow in the fetal circulation, including to the brain. Had Ronin
`
`been delivered 15 minutes earlier, his base deficit would have been approximately 11, rather than
`
`18.3. A base deficit of 11 is associated with a significantly lower risk of cerebral palsy or other
`
`permanent brain injury. Additional evidence that Ronin would have escaped permanent brain
`
`injury had he been delivered even 15 minutes earlier includes:
`
`• Normal fetal growth and development throughout pregnancy,
`
`• Discovery of placental abruption during cesarean section, an acute event known to
`cause acute loss of oxygenated blood flow to the baby’s brain,
`
`• Abnormally low Apgar scores of 0, 0, 1, 2, and 3 at 1, 5, 10, 15, and 20 minutes
`respectively,
`
`• Depression at birth,
`
`• Requirement for resuscitation at birth with a breathing tube and positive pressure
`ventilation.
`
`
`
`14
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`

`

`
`
`27-CV-20-137527-CV-20-1375
`
`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
`
`Dr. Naylor reserves the right to supplement or amend his opinions upon receipt of
`
`additional information.
`
`Dr. Naylor holds these opinions to a reasonable level of medical certainty.
`
`Further your Affianl sayeth not.
`
`The undersigned hereby acknowledges that sanctions may be awarded pursuant to Minn.
`
`Stat. § 549.2: I.
`
`Datcdzflgizozo
`
`Katrina Wallace. Esq.
`
`15
`
`

`

`
`
`27-CV-20-137527-CV-20-1375
`
`Filed in District Court
`State of Minnesota
`3/4/2021 4:00 PM
`
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