case study

At 41 weeks of an uneventful pregnancy, Mrs. W arrived at Beth Israel Deaconess Medical Center one night in November 2000.

Sometime before 10 p.m. Exam revealed cervix closed, patient given drug to induce labor.

10 p.m. Sent home. On the way had contractions, returned to hospital.

Midnight Admitted in active labor, breathing uncomfortable, contractions, vomiting.

1:30 a.m. Contractions every 1 to 2 minutes.

4:30 a.m. Fetal heart rate showed an unusual ''sawtooth" pattern, cervix dilated 4 to 5 centimeters.

5:50-5:53 a.m. Fetal heart rate drops to 90 beats per minute.

5:53-6:04 a.m. Fetal heart rate further slows.

6:20 a.m. Forceps delivery failed, transferred to operating room, emergency caesarean performed.

6:45 a.m. Baby delivered stillborn.

In their words

Mrs. W (patient):

''We trusted a lot. We were at what I thought was the best possible hospital. . . . Looking back, had I just gotten up and yelled out in the hallway, right outside the door, I feel like that would have made something different happen."

Mr. W (husband):

''That night I saw residents who were afraid. They were either unable or unwilling to get the doctor, when clearly things weren't going the right way."

Dr. Benjamin Sachs, hospital's chief of obstetrics and gynecology:

''I saw great suffering in this case. I met with the family on a daily basis as they sat outside the ICU. I was the recipient of their anger, their appropriate anger."