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A 38-year-old woman at 39w5d gestation went to the OB office complaining of decreased fetal movement.

An ultrasound revealed the umbilical cord around the baby’s neck, and she was sent to the hospital for a nonstress test which was reactive.

The OB (Dr. B) said there was no urgency to deliver. Her induction was in 2 days, but Dr. B recommended she come back the following day to be induced.

Induction was started the following day and an epidural placed in the evening by the anesthesiology (Dr. N).

Artificial rupture of membranes took place just prior to 1:00am.

At 1:06am she began complaining of shortness of breath and chest pain.