A 19-year-old gravida 1, Para 0 had an uneventful prenatal course. She came to the hospital in early labor at 0310 with contractions since 1230 every three minutes, lasting one minute. The primary care physician of record, a family practitioner, admitted her to the house obstetric service. An OB was made aware by telephone of the patient's condition. The fetal heart rate was in the 150's. The cervix was dilated to 1 cm, 50% effaced, and the fetus was at -2 station. The fetal monitor showed positive variability and accelerations. From 0520 to 0630 there was very poor fetal heart tone pickup on the external monitor. At 0630 the patient was 2-3 cm dilated, 9% effaced, and the fetus was at the 0 station. Membranes were noted to be bulging at 0645. At 0730 there was a fetal heart rate deceleration to 100 lasting 90 seconds and recovering to a rate of 120. At 0844 the family practitioner was informed the patient was 7-8 cm dilated and there were fetal heart decelerations to 90, associated with contractions, with return to a baseline of 140. At 0904 another family practitioner performed an active rupture of the membranes with a moderate amount of meconium staining in the amniotic fluid. Nursing notes between 1000 and 1100 indicate the fetal heart rate was in the 130's with short-term variability and further decelerations to the 80's and 90's. At 1200 the cervix was completely open and the fetus was at station +1 - +2. The OB was paged at 1213 and he arrived at 1230. The audible fetal heart rate was 180-200. The child was delivered with vacuum assistance at 1240 and taken immediately to the preheated radiant warmer due to meconium stained fluid. The attending pediatrician placed a size 3 ET tube. Another pediatrician applied suction to remove dark green mucous. The baby was extubated at 1242. APGAR's were 4 at one minute and 0 at 5 minutes. The baby was pink with a heart rate of 160 but no spontaneous respiration. Positive pressure ventilation was started with an infant ambu bag. The first pediatrician revisualized the cords and reintubated, connecting the oxygen tubing directly to the ET tube as a last resort. A nurse noted her voiced concern about the connection. The feeding tube was unsuccessfully passed. Another pediatrician arrived at 0100 and intubated the trachea and carried out ventilation with bag-valve with 100% oxygen. The baby's color deteriorated and he could not be ventilated. The baby's heart rate fell to zero and there were no respirations. He was pronounced dead at 0118. The autopsy diagnoses included peripartum asphyxiation with extensive amniotic fluid aspiration, non-distend lungs, prolonged and difficult labor with maternal exhaustion and vacuum extraction with abrasions of the scalp. The baby was noted to be adequate for gestational age. A medQuest OB reported the precise hierarchy of the managing physicians was unclear. The majority of the mother's course was inadequately managed by a junior family practitioner who only answered to the OB periodically. Abnormal fetal heart tracings were inadequately reported to the OB, who should have been present much earlier and provided more guidance. The decelerations at 0900 and 0930 were late in nature, persistent and clearly worrisome. The delivery should have been expedited at this time instead of three hours later. Timely obstetrical intervention would have decreased the risk of harm and increased the likelihood of survival. A medQuest pediatrician found the resuscitative efforts untimely and substandard. A code pink had been called at 1242 but the senior pediatrician did not arrive until 0100. The oxygen and ET tubes were misused. The baby should have survived.