Johnson v. United States (65 F. Supp. 3d 595, 2014)

FINDINGS OF FACT AND CONCLUSIONS OF LAW

Honorable THOMAS M. DURKIN, United States District Judge

Joseelyn Johnson, individually and as the special administrator of the estate of Nakia Marie-Amore Burress, deceased, filed this lawsuit under the Federal Tort Claims Act, 28 U.S.C. §§ 1346(b), 2671-80, alleging medical malpractice during the delivery of her baby, Nakia. Johnson alleges that Dr. Emanuel Javate breached the standard of care in four ways and that one or more of the breaches proximately caused the death of her baby. Former defendants Lori Schwartz, R.N., and Schwartz’s employer, Sisters of St. Francis Health Services, Inc., settled with Johnson. R. 54; R. 72. The case proceeded to a four-day bench trial in January 2014, during which the Court heard testimony from numerous lay and opinion witnesses. The Court asked the parties to submit their proposed findings of'fact and conclusions of law, which they both did. R. 67; R. 68; R. 69. This opinion sets forth the Court’s findings of fact and conclusions of law pursuant to Federal Rule of CM Procedure 52(a). These findings are based on the stipulations and submissions of the parties, documentary evidence, and testimony at trial. They are also the result of the Court’s credibility determinations after observing each of the witnesses testify at trial. In light of the Court’s factual findings and conclusions of law, the Court finds in favor of Johnson and enters judgment against the United States.

FINDINGS OF FACT

1. Background — Risk Factors

Johnson was approximately 5'1", 200 pounds at the time of her delivery. Tr. 288, 293. Johnson had “some borderline high blood pressure,” and Dr. Javate considered her to be hypertensive and, thus, a high risk patient — discussed further below. Tr. 70. A pregnant patient who is hypertensive has an increased risk of placental abruption or separation, which can manifest itself through vaginal bleeding. Tr. 70, 548, 605-06. Dr. Javate also considered Johnson a high-risk patient because she was diagnosed as a gestational diabetic (which carried with it the risk of delivering a larger baby), and was obese. Tr. 69-70, 163-64, 173. Johnson already had a history of macrosomia, which means giving birth to large babies. Tr. 66. Indeed, an ultrasound performed on February 8, 2008, revealed that Johnson’s baby was already at least 9 pounds. Tr. 317. When a larger baby is delivered, there is an increased risk for shoulder dystocia and the baby suffering a brachial plexus injury. Tr. 68. Johnson’s due date was February 20, 2008. Tr. 510.

II. Johnson’s Delivery at St. James Hospital

A. Early Stages of Labor: February 8, 2008, 11:00 a.m. to February 9, 2008, 7:30 a.m.

Dr. Javate saw Johnson at St. James Hospital in Chicago Heights on the morning of February 8, 2008. Tr. 67. Johnson went to the hospital for a non-stress test and a “biophysical profile,” Tr. 75, which are fairly routine evaluations. Dr. Javate examined Johnson and decided that she should be admitted to the hospital that day to be induced into labor. Tr. 71. This decision was made in response to the fact that Johnson was a high-risk patient — i.e., “was diabetic and ... was having borderline hypertensive readings” — and that her baby might “grow too big.” Tr. 7172. At the time, Johnson had been carrying her child for just over 38 weeks. Tr. 72. Forty weeks is considered “full term.” Tr. 72. Even though Johnson was already at the hospital, Dr. Javate said she - could go home and pack before returning to the hospital to be admitted. Tr. 631. Later that day, at 6:44 p.m., Johnson was admitted through the emergency room to St. James Hospital for induction of labor. Exh. 1 at 29.

All patients at St. James Hospital are typically assigned a one-on-one labor and delivery nurse who is responsible for monitoring the fetal and maternal statuses. Tr. 177-78, 183. To satisfy that obligation, the nurse is required to take and record a patient’s blood pressure and heart rate (or pulse) every hour. Tr. 26566; Exh. 6 at 424. The nurse also must evaluate the fetal monitoring strips — printed recordings of the fetal heart rate from external monitors that are attached to the patient— and report any “non-reassuring” pattern on the strips to the attending physician. Exh. 7 at 427. A non-reassuring pattern may be an indication that the baby is not receiving a sufficient amount of oxygen. ■Tr. 534-35. It is exemplified by a heart rate variation that is not within the normal limits for a fetus, which is usually 120 to 160 beats per minute (“bpm”). Tr. 796. Furthermore, the nurse is also tasked with numerous other responsibilities, including performing regular vaginal examinations, Exh. 5; evaluating the patient’s contractions every 30 minutes; evaluating “bloody shows” (explained further below); evaluating the patient’s complaints of pain, Exh. 6; administering medications like Cervidil and Pitocin to induce and augment delivery at the direction of the attending physician, Exh. 9, Exh. 10; and assisting the physician during delivery, Exh. 12. If there are any abnormalities in the labor process, including fetal heart rate, contractile patterns, or vital signs, the nurse is required to report that to the attending, physician — in this case, Dr. Javate. Tr. 179,182-83.

At 9:50 p.m., at Dr. Javate’s direction, Johnson was given Cervidil to assist with the induction. Tr. 76. Cervidil is a “pros-taglandin drug” that, in essence, “primes the uterus” for delivery. Tr. 73. About three-and-a-half hours later, at 1:23 a.m. on February 9, 2008, Dr. Javate visited Johnson to evaluate the maternal and fetal status of Johnson and her baby. Tr. 77. Johnson was sleeping when Dr. Javate arrived. Tr. 632-33. Nurse Wagner was Johnson’s one-on-one nurse at the time. Tr. 689; Exh. 1 at 141-42. Upon examination of Johnson, Dr. Javate determined that there were good fetal heart tones and noted that Johnson was comfortable. Exh. 1 at 74. He left the hospital' shortly thereafter. Tr. 77. Nurse Wagner continued to tend to Johnson throughout the night and verified that Johnson and her baby were doing fine. Tr. 77, 189. Johnson’s heart rate and blood pressure readings were normal during that time period, confirming Nurse Wagner’s evaluation. Exh. 1 at 141-44. For example, at 3:51 a.m., Johnson’s heart rate was 79 bpm and her blood pressure was 136/78. Exh. 1 at 143. A normal heart rate for a woman not in labor is generally between 60 and 100 bpm. Tr. 176, 284. A normal blood pressure is generally anything less than 140/90. Tr. 176.

At 7:00 a.m., Johnson had a spontaneous rupture of membranes, Exh. 1 at 144, which means that her water broke, and was now committed to delivering the baby. Tr. 195-96. Nurse Wagner performed a vaginal examination to confirm the finding. Exh. 1 at 144. At approximately 7:15 a.m., Dr. Javate was notified that Johnson’s delivery was progressing quickly and that Johnson was dilating approximately 1 centimeter per hour. Tr. 128. At 7:35 a.m., Nurse Wagner made an entry in the nurses’ notes indicating that she had contacted Dr. Javate to report on her vaginal examination. Exh. 1. at 144. She also made a note in regards to Dr. Javate: “Presence Requested.” Dr. Javate does not have an independent recollection of what was said during the conversation. Tr. 199. At the same time Nurse Wagner was entering her notes in the system, the nurse taking over for her, Nurse Lori Schwartz, made a note that Johnson was restless with an “urge to push.” Exh. 1 at 144. Johnson testified that she woke up in the morning around 7:30 a.m. with pain she associated with “going-through-labor pains” and that she informed Nurse Wagner of the pain. Tr. 633.

B. February 9, 2008 — 8:00 a.m. to 11:00 a.m.

Dr. Javate returned to the hospital at 8:00 a.m. but he did not visit Johnson in her room or perform an evaluation of her. Tr. 78-79, 209-10. In fact, he did not personally check on Johnson until over three hours later at 11:04 a.m. Tr. 209-10. Between 8:00 a.m. and 11:04 a.m. on February 9, 2008, Johnson was the only patient in labor at the hospital, though Dr. Javate had other postpartum and gynecological patients to evaluate. Tr. 78. It is undisputed that patients who are in active labor take priority over non-laboring patients who are in the hospital. Tr. 7879, 800.

At 8:20 a.m., Nurse Schwartz noticed that Johnson had vaginal bleeding that she characterized as a “good bloody show.” Tr. 277; Exh. 1 at 145. A “bloody show” is a “combination of [a] small amount of blood that a [patient in labor] can get from [a] cervical change [that includes a] moderate amount of blood mixed with secretions in the vagina, mucus material.” Tr. 211-12. Nurse Schwartz testified that the blood was fresh, red, and liquid, and did not contain any mucus and that she considered it to be a normal incident of labor. Tr. 269-70. At approximately 8:30 a.m., Nurse Schwartz communicated her findings of the bloody show to Dr. Javate, Tr. 277, as well as the overall maternal status of Johnson. Tr. 204-05; Exh. 1 at 145. She also told Dr. Javate that Johnson had requested to see him. Tr. 275. She did not, however, report the vital signs of Johnson because they had not been taken since 7:30 a.m, even though hospital policy and procedures required them to be taken hourly. Tr. 88, 273. Nurse Schwartz could not remember if Dr. Javate had requested the vital signs at that time, though it is undisputed that Dr. Javate did not go into Johnson’s room to evaluate her or learn of Johnson’s vitals after being informed of the first bloody show. R. 273-74.

At 8:57 a.m., Dr. Javate was present at the nurses’ station, and Nurse Schwartz informed him that Johnson was 8 centimeters dilated. Exh. 1 at 145. A woman is “fully dilated” at 10 centimeters. Tr. 181; see Tr. 615; Exh. 146. At. 9:00 a.m., Nurse Schwartz informed Dr. Javate of a second bleeding episode; this one characterized as a “large bloody show.” Tr. 90. Nurse Schwartz testified that it had “clear amniotic fluid” and that she did not “see any sign of heavy bleeding.” Tr. 287. Nurse Schwartz described the episode as being no different than what she had seen many times before; however, the blood mark on the pad under Johnson was at least a “few inches” larger than the first bloody show. Tr. 287. Again, Dr. Javate did not request or learn of Johnson’s vitals, or enter the room to personally examine the consistency, color, or texture of the bloody show. Tr. 83, 85, 240-41. He simply “presumed the vitals were normal.” Tr. 240. Dr. Javate also testified that he did not rule out the possibility at that time that Johnson was suffering from a placental abruption or internal bleeding. Tr. 240.

Between the hours of 7:30 a.m. and 9:30 a.m., Johnson’s blood pressure and heart rate were not taken. Tr. 266, 277-78, 308. At 9:30 a.m., Johnson’s heart rate was 146 bpm, which is “tachychardic,” or abnormally high — normal is generally between 60 to 100 bpm. Tr. 98. Dr. Javate never received this information, even though he had numerous methods to obtain it. Tr. 98. He could have: (1) asked for the attending nurse to pull up the vitals, Tr. 98; (2) looked through the nurses’ notes on the computer at the nurses’ station; or (3) checked Johnson’s heart rate himself, Tr. 216, 272. Prior to 11:15 a.m., Dr. Javate never asked for Johnson’s vitals or asked Nurse Schwartz to repeat Johnson’s vitals to verify their accuracy. Tr. 100, 288-89.

Labor itself may increase a woman’s pulse as a result of pain and the stress of pushing, but a pulse over 120 bpm could be of concern and should be investigated. Tr. 406-07. Other causes of a heart rate that high during labor are fever, infection, severe pain, or internal bleeding. Tr. 98. Nurse Schwartz did not view the 146 heart rate as unusual, testifying, “It’s high. For a woman in pain, [however,] I felt that it was acceptable.” Tr. 284. At that time, Johnson was not in severe pain, as she had only received the prescription medication Stadol at 7:00 a.m. and had not requested any additional pain medication. Tr. 98-99, 286. She also did not have a fever or any infection. Tr. 285-86, 406. Prior to the 9:30 a.m. reading, the highest Johnson’s heart rate had been during her labor was 79 bpm, when it was taken at 7:33 a.m. Exh. 1 at 141-46. The nurses’ notes indicate that Nurse Schwartz entered the vital information obtained at 7:33 a.m. into the nursing log at 8:37 a.m. Tr. 310-13; Exh. 1 at 144. The vitals were not, however, automatically printed in the nurses’ notes or onto the fetal monitor strips .at either 7:33- a.m. or 8:37 a.m. Exh. 2 at 323-30.

An external toeodynamometer (“tocome-ter”) is a device that is attached to a woman’s abdomen with a strap around her midsection and used to measure- and record a woman’s uterine contractions. The tocometer had been continuously picking up moderate to strong contractions throughout the morning of Johnson’s delivery, including at 7:29 a.m.; 7:47 a.m.; 8:07 a.m.; 8:19 a.m.; 9:10 a.m.; 9:41 a.m.; and 10:02 a.m. Exh. 1 at 144^15; Exh. 2(b) at 340. At 10:08 a.m., the tocometer attached to Johnson stopped recording contractions. Tr. 117; Exh. 2(b) at 340. This could have meant one of two things: either Johnson stopped having contractions or the machine was no longer able to pick up the contractions, which is not necessarily an unusual occurrence. Tr. 118. The second scenario is more likely true because Nurse Schwartz was able to palpate (feel using her hands) strong uterine contractions all the way up to 11:00 a.m. Tr. 118, 828. At 11:04 a.m., the tocometer was noted to be “adequately placed on [Johnson’s] abdomen,” despite the fact it was no longer picking up any contractions. Tr. 129. If there are difficulties when measuring a mother’s contractions, an intrauterine pressure catheter can be inserted into the mother to more accurately measure the strength of the uterine contractions. Tr. 119. No intrauterine pressure catheter was ever used during'Johnson’s delivery. Tr. 119.

Another important piece of data used in conjunction with the tocometer recordings is the information contained on the fetal heart monitor strips because they provide information on how the baby is doing during the course of labor. Tr. 107. The fetal heart monitor strips can show “late decelerations” — defined as a decrease in fetal heart rate beginning at the middle of a contraction and returning to baseline after the contraction is over, Tr. 391, 535 — which is indicative of the baby not getting enough oxygen during the delivery, Tr. 114-16, 360. The fetal monitoring strips from Johnson’s delivery between 7:10 a.m. and 8:10 a.m. showed recurring late decelerations.- Tr. 534. The baseline of the baby’s heart rate was between 140 and 150 bpm, which decreased to 120 bpm after the beginning of the contractions and then returned to the baseline after the contractions ceased. Tr. 114, 543-44. This suggests the baby was not receiving a sufficient amount of oxygen. Tr. 534. Fetal monitoring strips showing late decelerations are considered non-reassuring. Tr. 534-35.

Between 7:40 a.m. and 9:00 a.m., the contraction readings were “not very distinct,” Tr. 114-16, and the fetal heart strips were difficult to read, rendering it “difficult to tell whether [the heart patterns] were early, variable, or late decelerations,” Tr. 392. Dr. Javate never viewed the fetal monitoring strips after he arrived at the hospital between 8:00 a.m. and 11:04 a.m., however, so he was unaware of that information. Tr. 107. When the readings from fetal heart strips become difficult to interpret, an internal fetal heart electrode monitor can be placed on a fetus’s scalp to provide more accurate readings. Tr. 119, 746, 813. No internal scalp electrode monitor was ever used during Johnson’s delivery. Tr. 119.

The nurses’ notes at 10:11 a.m. indicate that a vaginal exam performed on Johnson revealed that Johnson was fully dilated, which meant she was almost ready to deliver the baby. Tr. 317; Exh. 1 at 146. Nurse Schwartz also noted that the baby was at +1 station. Exh. 1 at 146. The finding of a +1 station indicated that labor was progressing because a prior entry made at 8:34 a.m. revealed the baby was at 0 station. Exh. 1 at 145. “Station” refers to the position or location of a baby in the birth canal. See “Station,” Medical-Dictionary, http://medical-dictionary.thefree dictionary.com/station (last visited Sept. 2, 2014). A “0 station” designation would refer to furthermost portion of the baby’s head — assuming the baby is not breeched — being at an imaginary plane at the level of the ischial spines, which the arrows point to in the exhibit below. Id. Each number represents the estimated number of centimeters the baby is above or below that imaginary plane, with “minus” designations meaning the baby is further up the birth canal and “plus” designations indicating the baby is closer to being delivered. The following exhibit, which was used at trial, illustrates where a baby’s head is located at a given station designation:

At 10:25 a.m., Nurse Schwartz noted that “contractions [were] not recording” and Johnson had lost the urge to push. Exh. 1 at 146. Sixteen minutes later, at 10:41 a.m., Nurse Schwartz made a note that Johnson was in a “High Fowlers” position, or sitting upright, Tr. 296, 779, and was being “Coached on Pushing.” Exh. 1 at 146. Even though the monitor was no longer picking up uterine contractions around that time, Johnson told Nurse Schwartz that she was having them. Tr. 293-94; Exh. 1 at 146. Indeed, Nurse Schwartz testified that she palpated contractions up until 11:00 a.m., Tr. 293-94, and more than likely communicated that information to Dr. Javate. Tr. 244.

C. February 9, 2008 — 11:00 a.m. to 11:33 a.m.

At 11:04 a.m., Johnson’s delivery took a turn for the worse. Exh. 1 at 146. The baby’s head had been at +1 station, which can be described as being “deeply wedged into the birth canal,” during Nurse Schwartz’s latest vaginal examination at 10:11 a.m. Tr. 294; Exh. 1 at 146. Shortly after 11:00 a.m. Nurse Schwartz performed another vaginal exam and discovered that the baby’s head had receded up the vaginal canal to a -3 station. Tr. 296. This was the first time Nurse Schwartz had ever encountered a situation where a baby had receded up the birth canal in such a significant manner. Tr. 296. She also “felt a bulging in the wall of the vagina.” Tr. 302. Accordingly, Nurse Schwartz immediately summoned Dr. Ja-vate, who entered the room within seconds of Nurse Schwartz’s request. Tr. 296-97. Nurse Schwartz informed Dr. Javate that the baby’s head had gone straight up and receded from a +1 or +2 station to a -3 station. Tr. 127, 297. The fetal heart rate at that time appeared to be in the 140’s “with no obvious decelerations [and] minimal variability.” Tr. 129. Dr. Javate then performed his own vaginal examination, which confirmed that the baby’s head had receded to a - 3 station. Tr. 127-29. He did not view Johnson’s vitals, that were taken at 9:30 a.m., Tr. 226-27, nor did he take Johnson’s vitals at that time or ask Nurse Schwartz to take Johnson’s vitals. Tr. 132-33. He did, however, note that Johnson appeared to be alert and oriented, was not light-headed, and denied being in severe pain. Tr. 222. He also noted that there was no “brisk bleeding.” Tr. 223.

Dr. Javate was in the room for approximately 4 to 5 minutes before going back into the hallway. Tr. 225-26. At that point, his suspicion of a uterine rupture was “very low” because Johnson “never had a scarred uterus” and a uterine rupture is “such a rare, rare, rare thing to happen.” Tr. 222; see Tr. 563-64. Dr. Javate thus diagnosed Johnson as having “an ineffectual contractile pattern,” Tr. 224, and ordered Nurse Schwartz to start Pitocin in Johnson’s TV-line before leaving the room. Tr. 127-29, 428; Exh. 1 at 146. Pitocin is a prescription drug intended' to increase the strength or duration of a woman’s labor contractions, Tr. 139. In reality, however, Johnson’s uterus had likely ruptured around 11:04 a.m. Tr. 14647, 563-64. The nurses’ notes indicate Pitocin was started at 11:05 a.m., Exh. 1 at 146, but Nurse Schwartz testified that 11:05 a.m. was when she entered the order for Pitocin into the computer system. Tr. 298-99. She further testified that the Pi-tocin bag was not actually hooked up to Johnson’s IV until a few minutes after 11:05 a.m. Tr. 298-301.

After leaving Johnson’s delivery room, Dr. Javate discussed Johnson’s condition with his colleague, Dr. Dexter Arrington. Tr. 134-35. Dr. Javate got the idea during that conversation that the heart rate shown on the fetal monitor may have been Johnson’s, rather than her baby’s. Tr. 134-35. Indeed, it is a “known fact” that external fetal monitors sometimes pick np the mother’s heartbeat instead of the baby’s. Tr. 408. Dr. Javate then returned to Johnson’s room at approximately 11:15 a.m., at which time he (for the first time) requested that Nurse Schwartz take Johnson’s vitals. Tr. 134, 139-40. Nurse Schwartz stopped the Pitocin and then took Johnson’s vitals at 11:16 a.m., which were abnormal. Tr. 139 — 40, 298-301. Johnson’s heart rate was 146 bpm (a high reading for a woman in labor) and her blood pressure was 65/43 (a very low reading, meaning Johnson was hypotensive). Tr. 139-40, 418; Exh. 1 at 146. When a patient’s blood pressure drops significantly, the patient’s heart rate increases as a “compensatory mechanism ... to keep the patient alive.” Tr. 140. The drop in Johnson’s blood pressure was due to bleeding from the uterine rupture that must have occurred prior to the reading. Tr. 418, 56566.

Dr. Javate did not immediately call for a cesarean section (“C-section”) after learning of Johnson’s vitals. Tr. 141-43. He instead had Nurse Schwartz repeat taking Johnson’s vitals a second and third time to confirm that the blood pressure cuff had been properly placed and that the reading was accurate. Tr. 141-43. At 11:17 a.m., Johnson’s blood pressure was 68/37, and at 11:19 a.m., it was 57/31. Tr. 141; Exh. 1 at 146. Johnson’s heart rate was 141 bpm at 11:16 a.m. and 135 bpm at 11:19. Exh. 1 at 146. Upon learning this information, Dr. Javate diagnosed a uterine rupture and called for a C-section at 11:19 a.m., 15 minutes after he first learned that the baby had gone from a +1 station to a -3 station. Tr. 141, 143,14647.

Johnson’s baby was delivered 14 minutes later at 11:33 a.m. Tr. 233. During the surgery, Dr. Javate found the entire baby floating in Johnson’s abdomen cavity in a pool of blood; she had been fully extruded from the uterus. Tr. 144, 233, 248. Johnson had suffered a uterine rupture and a placental abruption. Tr. 595. At least a liter of blood was discovered in Johnson’s abdomen. Tr. 144. The severity of the damage to Johnson’s uterus, described as a “huge rupture,” Tr. 230, required Dr. Javate to perform a hysterectomy, Tr. 144-45. Johnson’s baby had died prior to its delivery. Tr. 253, 575-76. The cause of death was “intrauterine asphyxia due to uterine rupture due to placenta accrete.” Exh. 4 at 413.

CONCLUSIONS OF LAW

The Court has jurisdiction pursuant to the FTCPA, 28 U.S.C. §§ 1346(b)

606 65 FEDERAL SUPPLEMENT, 3d SERIES and 2671 et seq., as Dr. Javate is “deemed” a federal employee for purposes of this case, see 42 U.S.C. § 233(g). The FTCPA provides in part: “The United States shall be liable, respecting the provisions of this title relating to tort claims, in the same manner and to the same extent as a private individual under like circumstances, but shall not be liable for interest prior to judgment or for punitive damages.” 28 U.S.C. § 2674. It was “designed primarily to remove the sovereign immunity of the United States from suits in tort, and with certain specific exemptions, to render the Government liable in tort as a private individual would under the circumstances.” Richards v. United States, 369 U.S. 1, 6, 82 S.Ct. 585, 7 L.Ed.2d 492' (1962). Suits brought under the FTCPA are governed by “the law of the place where the act or omission occurred.” 28 U.S.C. § 1346(b)(1). The .conduct Johnson complains of occurred in the State of Illinois, so Illinois law applies to the claims. I. Legal Standards [3,4] Under Illinois law, a plaintiff must establish the following elements to prevail in a medical malpractice action: “(1) the standard of care in the medical community by which the physician’s treatment was measured; (2) that the physician deviated from the standard of care; and (3) that a resulting injury was proximately caused by the deviation from the standard of care.” Neade v. Portes, 193 I11.2d 433, 250 IlLDec. 733, 739 N.E.2d 496, 502 (2000). “A plaintiff must present expert testimony to establish all three elements.” Wilboum v. Cavalenes, 398 Ill.App.3d 837, doctor deviated from the relevant standard of care necessarily involves questions of fact.” See Campbell v. United States, 904 F.2d 1188, 1192 (7th Cir.1990); accord Iseberg v. Gross, 227 I11.2d 78, 316 Ill.Dec. 211, 879 N.E.2d 278, 284 (2007) ("Whether a duty is owed is a 338 Ill.Dec. 77, 923 N.E.2d 937, 949 (2010). The elements must each be proven by a preponderance of the evidence, “otherwise referred to as the ‘more probably true than not true’ standard.” Holton v. Mem’l Hosp., 176 I11.2d 95, 223 Ill.Dec. 429, 679 N.E.2d 1202,-1207 (1997) (citing Borowski v. Von Solbrig, 60 I11.2d 418, 328 N.E.2d 301, 305 (1975)). II. The Parties’ Experts Johnson retained two experts to satisfy her burden. The first expert, Mark Landon, M.D., is a medical doctor who specializes in obstetrics and gynecology. Tr. 520. He attended medical school at Cornell University Medical College and completed a residency and fellowship training at the University of Pennsylvania. Tr. 519-20. He later completed a fellowship in maternal-fetal medicine, which is a subspecialty of obstetrics and gynecology that involves high-risk or complicated pregnancies. Tr. 520. Dr. Landon is currently a professor and the chairman of the Department of Obstetrics and Gynecology at The Ohio State University College of Medicine. Tr. 521. He is an examiner for the American Board of Obstetrics in the maternal-fetal medicine division, Tr. 522-23, and has delivered thousands of babies in his career, Tr. 521. Furthermore, Dr. Landon is a “scientific reviewer” for various medical textbooks and journals, Tr. 523, and has published approximately 155 articles, some which specifically addressed uterine ruptures, Tr. 524. [5] Johnson’s second expert was Patricia Fedorka, R.N., Ph.D., a nurse who is certified by the National Certification Cor-question of law for the court to decide, while breach and proximate cause are factual matters for the jury.”). Accordingly, many of the conclusions reached in this section involve both legal and factual determinations. The same applies to the question of compensation.

poration for obstetric, gynecological, and neonatal nursing specialties. Tr. 350-51. She is a professor at the College of Nursing at Chamberlain College in Downers Grove, Illinois, where she was hired to help develop the Doctorate of Nursing Practice program for advanced-practice nurses- — e.g., nurse midwives, nurse practitioners, and nurse anesthetists. Tr. 352. Dr. Fedorka has been involved in the delivery of approximately 1,500 to 2,000 babies throughout the course of her career. Tr. 355. As particularly relevant to this case, Dr. Fedorka has authored various publications on the subject of electronic fetal monitoring and been a speaker at various conferences concerning the topic. Tr. 355-56. She considers herself to be an expert in the field of reading and interpreting fetal monitoring strips. Tr. 357-58.

The Defense retained an expert in rebuttal, Julie Levitt, M.D. Tr. 714. Dr. Levitt is a medical doctor who attended medical school at Northwestern University in Chicago, Illinois. Tr. 714. She has been board-certified in obstetrics and gynecology since 2001. Tr. 715. Dr. Levitt is currently a member of the Women’s Group of Northwestern, an eight-physician practice that specializes in gynecology and women’s health issues. Tr. 715. She has a general practice, encompassing -approximately 50% obstetrics and 50% gynecology. She also delivers babies, does surgeries, and provides prenatal care and gynecologic services to women of all ages. Tr. 715. Dr. Levitt delivers approximately 150 to 170 babies a year and has delivered approximately 2000 to 2500 babies over the course of her career. Tr. 716. Approximately 5% to 10% of her patients have had either gestational diabetes or pregnancy-induced hypertension. Tr. 716. Dr. Levitt is also a clinical instructor at the Northwestern University Feinberg School of Medicine, where she teaches students and instructs them while undertaking various procedures including deliveries and surgeries. Tr. 717.

III. Liability

A. Standard of Care & Breach of Duty

The standard of care in a medical malpractice case is “the relevant inquiry by which we judge a physician’s actions.” Neade, 250 Ill.Dec. 733, 739 N.E.2d at 502. The physician is “held to 'the reasonable skill which a physician in good standing in the community would use in a similar case.’ ” Id. (quoting Newell v. Corres, 125 Ill.App.3d 1087, 81 Ill.Dec. 283, 466 N.E.2d 1085, 1094 (1984)). In other words, the relevant consideration is the “degree of knowledge, skill, and care which a reasonably well-qualified physician in the same or similar community would bring to a similar case under similar circumstances.” Purtill v. Hess, 111 Ill.2d 229, 95 Ill.Dec. 305, 489 N.E.2d 867, 872 (1986). A breach occurs when a physician fails to use “reasonable skill” that “ ‘physicians in good practice ordinarily use and would bring to a similar case.’ ” Cummings v. Jha, 894 Ill.App.Sd 439, 333 Ill.Dec. 837, 915 N.E.2d 908, 920 (2009) (quoting Pugh v. Swiontek, 115 Ill.App.2d 26, 253 N.E.2d 3, 5 (1969)). This pertains to both making diagnoses and rendering treatment. Id.

Johnson contends that Dr. Javate breached the standard of care in four ways: (1) failed to adequately monitor Johnson’s labor; (2) failed to promptly diagnose maternal abnormalities and fetal distress; (3) failed to call for and perform a timely cesarean section; and (4) ordered Pitocin subsequent to the onset of a uterine rupture. Because the breaches tend to overlap, the Court will address the first two sets of alleged breaches together and the third and fourth alleged breaches together.

1. Failure to Adequately Monitor Johnson’s Labor & Failure to Promptly Diagnose Maternal Abnormalities and Fetal Distress

One of the underlying issues in this case is whether Johnson was a high-risk patient due to her gestational diabetes and hypertension. Dr. Landon opined that Johnson was a high-risk patient, Tr. 530; Dr. Levitt disagreed with that assessment, Tr. 725-26, 752-53. Dr. Levitt opined that a “high-risk patient” generally involves “something that is not in the realm of a general OB-GYN based on their training and preparation being able to handle,” and the issues with Johnson were not of that nature. Tr. 726-28. The Court finds that Dr. Levitt’s opinion is not credible. While there may be a more technical definition of the term, Tr. 727, Dr. Javate himself thought that Johnson was a high-risk patient, Tr. 70,164. Johnson went to see Dr. Javate for a routine visit on February 8, 2008 — two weeks before she was considered full term — and Dr. Javate told Johnson that she had to go to the hospital that day to be induced. Tr. 72. Dr. Javate may have told Johnson that she had time to pack first, but Johnson nevertheless went to the hospital within a relatively short time after a routine doctor’s appointment. Tr. 631. That fact in and of itself indicates that Dr. Javate recognized that Johnson was at high risk and needed to begin labor almost immediately. It also diminishes Dr. Levitt’s credibility throughout the case because she did not agree with a conclusion even the defendant doctor himself reached.

a. Failure to Visit Johnson

The fact Johnson was a high-risk patient is critical to the assessment of Dr. Javate’s conduct in relation to what a reasonably-careful physician would do under like circumstances. It is, in essence, the foundation for Dr. Landon’s opinion that the standard of care required Dr. Javate to visit Johnson when he arrived at the hospital after being summoned at 7:35 a.m., as well as numerous times before 11:00 a.m., Tr. 529-32. The Court finds this opinion credible. As to the issue of the breach of that standard of care, Dr. Javate demonstrated a seemingly-indifferent attitude towards Johnson’s labor and delivery. To his credit, Dr. Javate told Johnson on February 8, 2008, to go to the hospital after a routine appointment, which indicates a level of concern for Johnson. Tr. 631. He also visited Johnson at the hospital at approximately 1:30 a.m. when Johnson was sleeping and not in labor. Tr. 188-89, 583; Exh. 1 at 142. However, when Dr. Javate returned the next morning at 8:00 a.m., he never returned to Johnson’s room to cheek on her until at least 11:00 a.m. Tr. 78. Dr. Javate did not check on Johnson despite the unrebut-ted testimony that he was summoned to the hospital by Nurse Wagner, Tr. 234; Exh. 1 at 144, and that Johnson asked to see him on at least three occasions, Tr. 337, 635, 793. Indeed, Christopher Bur-ress, the baby’s father, testified that he actually went to look for Dr. Javate himself after the nurse told him that Dr. Ja-vate was doing rounds, though he was unsuccessful in his attempt. Tr. 670. Even Nurse Schwartz testified that on at least two occasions, between 8:30 a.m. and 9:00 a.m., she reminded Dr. Javate that Johnson wanted him to visit her. Tr. 278. Dr. Javate did not do so until 11:00 a.m., roughly 2 hours later. Tr. 78.

Dr. Levitt opined that the standard of care did not require Dr. Javate to visit Johnson upon arriving at the hospital, Tr. 739, but this opinion is not credible for two main reasons. First, the Court has concluded that Johnson was a high-risk patient, which obviously should put a physician on high alert for problems during the delivery. Tr. 530-32. Because the Court has not credited Dr. Levitt’s opinion that Johnson was not a high-risk patient, her opinion that the standard of care did not require Dr. Javate to visit Johnson on various occasions throughout the morning of February 9, 2008, is also not credible. Second, Dr. Levitt testified that the nurse requesting Dr. Javate’s presence at the hospital did not explicitly note that Dr. Javate needed to visit the patient. This opinion was based on Dr. Levitt’s assessment of the nurses’ note that said “Presence Requested,” as opposed to “Presence Requested to the Bedside.” Tr. 739-40. This differentiation is not persuasive. If a patient is in labor and a doctor is requested to come to the hospital, there must be a particular reason for that summons, and the doctor should at a minimum see for himself how the patient is doing. As Dr. Landon testified to this obvious and unremarkable point, “[A]s a general principle, if the physician is in the hospital and they’re being summoned by the nursing staff to see the patient, they should come and see the patient.” Tr. 532. The nurse should not have to specify where exactly the doctor should go once he arrives at the hospital. Put simply, it makes no sense in this situation (where the mother in labor was a high-risk patient) that the note would simply mean “be ‘in the facility,’ ” as Dr. Levitt testified, Tr. 739.

The Defense further contends that Johnson just wanted “to say hi” to Dr. Javate, Tr. 337, so there was no particular reason for Dr. Javate to visit Johnson. That contention is irrelevant in light of all the other information presented to Dr. Javate. Tr. 532-33. For instance, Johnson repeatedly asked to see Dr. Javate, and a patient oftentimes can provide more information about how she is feeling than other means, such as the external monitors. Tr. 801. The repeated requests for Dr. Javate, and Burress’s corresponding attempts to find him, should have demonstrated more was going on than a simple request to say “hi.” Additionally, the uncontroverted testimony was that a patient in active labor (meaning the patient is dilated from 3 to 4 centimeters, Tr. 478) takes priority over other patients, Tr. 7879, 799, and Johnson was Dr. Javate’s only patient in active labor on the morning of February 9, 2008, Tr. 78, 263, 323, 533.

Dr. Javate testified that he was visiting other postpartum patients and conducting rounds throughout the morning, Tr. 78, but that testimony does not adequately explain why he did not visit Johnson when he arrived at the hospital or waited until 11:00 a.m. to go into Johnson’s room. In fact, there is no good explanation for what Dr. Javate was doing for 3 hours that could have taken priority over at least visiting Johnson upon her repeated requests. Even Dr. Levitt conceded that “it’s [their] custom and practice to appease the patient and to reassure them and to do what [they] can, time permitting and situation permitting, to visit.” Tr. 798. There are no facts in this case that would demonstrate Dr. Javate was prevented from visiting and checking on Johnson, a high-risk patient, when he arrived at the hospital until he first saw Johnson at 11:00 a.m. There is also nothing demonstrating that Dr. Javate was so busy dealing with postpartum patients in such a way that he did not have the time to visit the one patient whom he should have been affording the greatest priority. Tr. 209. Even Dr. Ja-vate testified that there was not an emergency or anything out of the ordinary that would have prevented him from going to Johnson’s room. Tr. 209.

The Court finds that the standard of care required Dr. Javate to check in and visit Johnson before 11:00 a.m., Tr. 590-91 — and more than likely, “shortly after [Dr. Javate’s] arrival” at the hospital, Tr. 547. Dr. Javate failed to do that, which is a breach of the applicable standard of care. This inexplicable failure began a cascade of missed opportunities that ultimately resulted in the death of Johnson’s baby,

b. Failure to Insert Internal Monitoring Devices

If Dr. Javate had visited Johnson at approximately at 8:00 a.m. when he arrived at the' hospital, the standard of care would have required him to observe the fetal monitoring strips and the uterine contraction readings and to conclude they were not reassuring. Both Dr. Landon and Dr. Fedorka testified that the strips themselves revealed non-reassuring information about the status of the baby between 7:00 a.m. and 9:00 a.m. Tr. 380-88, 392-93, 534. There were documented late decelerations between 7:00 a.m. and 7:40 a.m. and ambiguous tracings beginning at 7:40 a.m. Tr. 557-58. That testimony is in conflict with Dr. Levitt’s testimony that the information on the strips was reassuring. Tr. 765. Nevertheless, the Court again finds Dr. Landon and Dr. Fedorka’s opinions on this subject to be more credible than those of Dr. Levitt. Dr. Levitt is a more recent medical school graduate who is more active in the clinical setting at this point in her career. However, Dr. Landon also has an extensive breadth of experience and has been involved with the publication of numerous articles, some which specifically dealt with the issue of uterine ruptures. Tr. 524. Conversely, Dr. Levitt only has one article her to credit — an article that she was not the primary author on — and it was not in the field of uterine rupture. Tr. 785. This does not undermine Dr. Levitt’s qualifications as an opinion witness. Both Dr. Landon and Dr. Levitt were impressive and being more published by itself does not necessarily make one opinion witness more credible than another. But in the end, Dr. Landon’s remarkable background, both in the academic and clinical settings, along with his clear and straightforward answers to cross-examination questions and the non-combative manner in which he answered them, makes him the more credible witness. This credibility determination is bolstered by Dr. Fedorka, an experienced nurse who is an expert in the reading of monitoring strips, whose testimony was consistent with Dr. Landon’s. It is also bolstered by the fact that Dr. Levitt, who is familiar with Dr. Landon’s work because of his prominence in the field, commented that Dr. Landon is “generally respected amongst his peers.” Tr. 850-51.

Thus, if Dr. Javate had simply gone into Johnson’s room at 8:00 a.m., he would have seen the non-reassuring or ambiguous patterns and taken steps to alleviate the uncertainty — e.g., inserting an intrauterine contraction monitor or applying a fetal scalp monitor. Had he not done so, he would have failed to meet the standard of care by not recognizing them as non-reassuring. It is not possible to know what would have occurred here, however, because Dr. Javate never even went into the room. At the very least, if the strips showed ambiguous information (as opposed to non-reassuring information), Dr. Javate could have confirmed the health status of the baby by inserting the internal monitoring devices. Tr. 546, 554-55. Dr. Landon and Dr. Fedorka testified that they are easy to insert, do not pose any unreasonable risks to the mother or the baby, and give accurate readings. Tr. 36468, 554-55. Dr. Landon further testified that inserting the internal monitoring devices is. the proper procedure when a physician is presented with non-reassuring patterns on the strips in order to accurately assess the status of the baby. Tr. 546, 554-55. Dr. Levitt agreed that using a fetal scalp electrode can resolve the question of whether the external monitor is recording the mother’s heart rate or the baby’s. Tr. 812-13. Dr. Levitt also agreed that many nurses, including Nurse Schwartz, are trained to apply the internal fetal scalp electrode. Tr. 772. Here, Dr. Javate failed to utilize any internal monitoring devices and, thus, also failed to adequately monitor the status of the baby.

The same analysis • applies to what occurred at 9:30 a.m. when Johnson’s pulse was finally recorded at 146 bpm — an hour too late according to hospital policy, Tr. 461, 804-05 — and the fetal heart rate was in that range. The standard of care required Dr. Javate to investigate whether the readings were of Johnson’s heart rate or her baby’s. Tr. 364-65, 554-55. The first step would have been repeating the vitals every 15 minutes or so to “monitor the stability of the situation.” Tr. 555, 765. That obviously did not occur. And then, if the monitor continued to give a reading for Johnson’s heart rate that was more consistent with a normal fetal heart rate (between 110 and 160 bpm), the standard of care would have required Dr. Ja-vate to put an internal scalp electrode on the baby to confirm whose pulse was being recorded. Tr. 555-56. Dr. Javate did not do that, which was also a breach of the standard of care.

c. Failure to Investigate the Bloody Shows

Dr. Javate was informed of a “good bloody show” at approximately 8:30 a.m. Tr. 270; Exh. 1 at 145. Dr. Landon testified that the standard of care required Dr. Javate to evaluate the bleeding and look at Johnson’s vital' signs. Tr. 547-49. This opinion was grounded in his belief that it is “fairly uncommon” to have that type of bleeding, or at least bleeding described as a bloody show, “at that point in labor” with Johnson being 6 centimeters dilated. Tr. 548. Conversely, Dr. Levitt testified that the standard of care did not require Dr. Javate to personally evaluate Johnson after learning of the first bloody show.. Tr. 747-48. Dr. Levitt further testified that the standard of care did not require Dr. Javate to ask for Johnson’s vitals after Nurse Schwartz reported a bloody show. Tr. 753.

While the Court again credits Dr. Levitt as a qualified opinion witness, Dr. Landon’s background and extensive experience, along with his manner of testifying, renders his opinion more credible. Dr. Levitt’s manner of testifying came across as defensive in that she was would not concede any point that was in any way inconsistent with her overall conclusion, even when the point appeared obvious and could have been conceded without doing damage to her overall opinions. For example, she would not concede that the uterine rupture must have been occurring by 11:04 a.m., Tr. 819, which both Dr. Javate and Dr. Landon both believed, Tr. 145-46, 568. Additionally, as previously discussed, Dr. Levitt did not believe Johnson was a high-risk patient despite Dr. Javate and Dr. Landon concluding otherwise. Dr. Levitt replied, “Ideally, yes,” when asked whether “[she] as the doctor [has] the responsibility to do everything' [she] reasonably can to deliver a healthy baby.” Tr. 838. Yet taken together, her testimony regarding the bloody show implied that all Dr. Javate was required to do was rely on the nurses’ conclusions (e.g., that the vitals were “okay” without knowing exactly what they were, Tr,. 758), and that Dr. Javate did not have his own duty to seek out the information that would warrant a particular conclusion unless the nurse asked him to do something. Tr. 752, 796-97, 837. The Court finds Dr. Levitt’s opinion regarding what Dr. Javate had to do when learning of the bloody show to be not credible.

Furthermore, Dr. Levitt testified that there would have been more bleeding if there was a problem requiring Dr. Javate’s presence, and the nurse would have alerted him to the amount. Tr. 754. Despite that, however, Dr. Levitt admitted the possibility that there could have been more significant bleeding into Johnson’s abdomen or that the baby’s head, which at the time was at +1 station, may have been acting as a form of a “cork” or blockage preventing more blood from reaching the pad. 'Tr. 600, 737, 760. That concession substantially weakens her argument that the bloody shows could only have been routine events during the course of a mother’s delivery. Additionally, Dr. Levitt made several mistakes in her assumptions about testimony that undermine the credibility of her opinions. In particular, Dr. Levitt was of -the opinion that the vitals of a patient were to be taken every two hours, when in fact, St. James Hospital requires them to be taken at least every hour. Tr. 803-04. This important mistake cuts directly against many of her conclusions because it demonstrates that Dr. Javate did not have “current vital signs” throughout much of the morning, Tr. 804-05 — especially when it mattered, such as when determining the significance of the bloody, shows and evaluating Johnson when the baby receded to a -3 station.

In recognizing that the standard of care required Dr. Javate to act when he learned that Johnson had a bloody show, the Court notes that Dr. Javate was at the nurses’ station when he received the information, which is only a few feet away from Johnson’s room. Tr. 79. Although a bloody show is generally a “relatively common” occurrence during active labor, Tr. 81-82, Johnson was a high-risk patient with a risk of placental abruption, so internal bleeding (and necessarily, a uterine rupture or placental abruption) should have been on his differential diagnosis. Tr. 548, 553, 807, 836. Dr. Javate even testified that the first thing a physician should rule out when presented with bleeding is a placental abruption. Tr. 82. Yet, Dr. Javate did not examine the pad or the blood. He did not conduct a vaginal exam or ask Johnson how she was doing. Tr. 82. Although Dr. Javate was a few steps from Johnson’s room, he failed to even enter the room or take any simple investigative steps after learning of the bloody show. Tr. 82.

Dr. Javate testified that he was not required to do anything because Nurse Schwartz assumed that there was nothing wrong with the bleeding (even though she felt the need to notify him about it), and “the rest of the maternal status and the fetal status was perfectly fine.” Tr. 82, 86-87; see Tr. 327. But there is no evidence Dr. Javate even knew what the vitals were. It is illogical for Dr. Javate to testify that the maternal and fetal statuses were fine when he was unaware of the information that would justify such a conclusion. That is true even if a physician can generally rely on a nurse to report complete and accurate information. Tr. 74849. Dr. Javate testified that a physician must consider “the whole clinical picture,” Tr. 84, yet he was unaware of even the most basic information (i.e., the vitals) that he had a duty to know, Tr. 553. This stark detail is highlighted by the fact that the vitals had not been taken since 7:30 a.m., an hour before, when Dr. Javate learned of the first bloody show at 8:30 a.m. Tr. 83.

Dr. Javate’s failure to monitor Johnson’s labor and delivery is even more apparent when the information concerning Johnson’s second bloody show is considered. At approximately 9:00 a.m., Dr. Javate was notified of a “large bloody show” and that Johnson was 8 centimeters dilated approximately 25 minutes earlier at 8:34 a.m. Tr. 211, 277, 552; Exh. 1 at 145. Dr. Landon testified that “having frank bleeding when [a patient is] beyond 6 centimeters, let alone 8 centimeters, is not a common event and should always raise a question as to whether this is something more than just bleeding from cervical dilation.” Tr. 55051. Based on that, Dr. Landon further testified that even if Dr. Javate had been told Johnson was progressing well, Dr. Javate was still required to evaluate the patient himself at that point. Tr. 551-52. Again, however, Dr. Javate did not enter Johnson’s room, ask Johnson how she was doing, examine the bloody show, or learn of Johnson’s vitals or request that they be taken. Tr. 90-92. In Dr. Javate’s own words, he just “ruled [internal bleeding and placental abruption] out in [his] head at that time.” Tr. 93. Had Dr. Javate done the minimal work of simply walking into Johnson’s room, he could have observed whether this second bloody show in less than an hour, one that was classified as being large, indicated that something troubling was occurring or could occur.

If Dr. Javate had entered the room after learning of the bloody shows at 8:30 a.m. and 9:00 a.m., the standard of care would have been to ask for the vitals and, if they had not been taken (as the Court finds is the case), to request the attending nurse to take them. Tr. 553. The undisputed testimony is that Nurse Schwartz would have been required to take Johnson’s vitals if Dr. Javate requested them. Tr. 267. It is thus clear that Dr. Javate violated the standard of care because he did not enter the room at either 8:30 a.m. or 9:00 a.m. The earlier discussion regarding the standard of care and inserting the internal monitoring devices applies equally to when Dr. Javate should have entered the room after learning of the bloody shows as well.

Furthermore, as Dr. Javate conceded, the standard of care required him to rule out the worst possible medical situation before assuming everything was normal. Tr. 88. Dr. Levitt conceded as much on cross examination. Tr. 807. Even so, Dr. Javate just assumed that the second bloody show was “probably just part of [Johnson’s] labor.” Tr. 88. That thought process is exactly backwards. When conducting a differential diagnosis, a doctor should not assume that the most benign cause is the most likely scenario. Instead, a doctor needs to factually eliminate the worst causes before assuming the least dire or risky situation is occurring. Dr. Javate’s incorrect and uninformed assumption, combined with Dr. Javate’s failure to take any steps to rule out a placental abruption or uterine rupture during Johnson’s delivery when learning of the bloody shows — the first differential diagnosis he should have ruled out, Tr. 90 — was also a breach of the standard of care.

2. Failure to Call for and Perform a Timely C-Section & Ordering Pitocin

Johnson contends that the standard of care required Dr. Javate to immediately call for a C-section when learning that the baby had receded up the vaginal canal from a +1 station to a -3 station. Dr. Landon’s testimony on this point was absolutely clear and unequivocal: “[T]he diagnosis if you’re going from +1, to +2 to — 3, the differential diagnosis would go like this: Number one, uterine rupture. Number two, uterine rupture. Number three, uterine rupture.” Tr. 564. Dr. Landon opined that a uterine rupture was the only explanation for what could have occurred, and the standard of care required Dr. Ja-vate to immediately call for a C-section. Tr. 564-65. Dr. Levitt disputed that contention, testifying that the baby could have just been rolling around or repositioning itself, so Dr. Javate was not required to immediately call for a Csection. Tr. 775-77.

The Court finds Dr. Levitt’s explanation neither logical nor credible when considered in light of Dr. Landon’s testimony that the change in station could only be caused by a uterine rupture. Dr. Landon has extensively published on the issue, and even though a uterine rupture is itself rare — and even more rare in a patient who has not previously undergone a C-seetion, Tr. 597 — the fact Dr. Landon has made this area a focus of his academic interests means that his experience on the topic far exceeds that of Dr. Levitt. Moreover, although Dr. Levitt said she had encountered the same situation .a week or so prior to her testimony and did not immediately call for a C-section during that delivery, Tr. 777, the Court does not find credible Dr. Levitt’s description of that situation as being equivalent to what occurred here, which Dr. Landon unequivocally stated was a sign of a uterine rupture, Tr. 600.

Accordingly, the Court finds credible Dr'. Landon’s opinion that a baby receding from a +1 station to - 3 station is such a rare occurrence that “the bells should [have been] going off’ that something was wrong and that a C-section was necessary. Tr. 565-67. Nurse Schwartz noted on a prior occasion that the baby’s head was “deeply wedged” in Johnson’s vagina, Tr. 413, so it must have been a traumatic event that caused the baby to recede in such an extreme matter because, as Dr. Landon opined, this was a “very unusual circumstance and should not happen.” Tr. 573-74. Dr. Landon testified that taking Johnson’s vitals at that time while preparing her for a C-section would have satisfied the standard of care. Tr. 566-67. However, Dr. Javate did not even request that Johnson’s vitals be taken until approximately 10 minutes later, Tr. 604, instead ordering that Johnson be given Pitocin and leaving the room, Tr. 129-32. This situation appears to have been something Dr. Javate had never seen before. It likewise may be extremely rare for a uterine rupture to occur in a woman who had not previously had a C-section. Tr. 222. That does not, however, excuse Dr. Javate from simply ordering Pitocin and waiting 15 minutes until 11:19 a.m. to bring Johnson to the operating room. In an emergency situation, time is of the essence and minutes matter, especially when it comes to an emergency C-section. Tr. 835. Tragically, it certainly mattered in this case.

The Defense contends that Dr. Javate acted reasonably by evaluating Johnson and performing a vaginal exam when learning that the baby had receded. The Court agrees that Dr. Javate acted reasonably in verifying the information Nurse Schwartz communicated to him by conducting a vaginal exam at roughly 11:04 a.m. It was his conduct following his examination that results in another breach of the standard of care: taking too much time to figure out what had occurred, waiting at least 10 minutes to order Johnson’s vital signs, and failing to immediately order a C-section after confirming the baby receded to a -3 station from a +1 station. Tr. 571-74. When presented with a situation that Dr. Landon described as having “no real other good explanation,” Tr. 608, Dr. Javate should have immediately ordered a C-section, Tr. 605-06, 621. No additional time at that point should have been lost. Dr. Javate’s failure to timely order a C-section at 11:04 a.m. and his decision to, instead, order Pitocin were violations of the applicable standard of care. Tr. 571.

B. Causation

“Proximate cause [in a medical malpractice] case must be established by expert testimony to a reasonable degree of medical certainty. Any causal connection between treatment, or a delay in treatment, and the claimed injury ‘must not be contingent, speculative, or merely possible.’ ” Walton v. Dirkes, 388 Ill.App.3d 58, 327 Ill.Dec. 921, 903 N.E.2d 18, 20 (2009) (quoting Aguilera v. Mount Sinai Hosp. Med. Ctr., 293 Ill.App.3d 967, 229 Ill.Dec. 65, 691 N.E.2d 1, 7 (1997)) (internal citations omitted). The Illinois Pattern Jury Instructions define proximate cause as “[any] cause that, in the natural or ordinary course of events, produced the plaintiffs injury. [It need not be the only cause, nor the last or nearest cause. It is sufficient if it combines with another cause resulting in the injury.]” Illinois Pattern Jury Instructions, Civil, No. 15.01 (2009) (second set of brackets in original). In short, the plaintiff must establish both that: “(1) the defendant ‘deviated from the standard of eare[,]’ and (2) ‘that that deviation was [a] proximate cause of the plaintiffs injury.’ ” Buck v. Charletta, 373 Ill.Dec. 576, 994 N.E.2d 61, 72 (2013) (quoting Snelson v. Kamm, 204 Ill.2d 1, 272 Ill.Dec. 610, 787 N.E.2d 796, 821 (2003)). This can be done by presenting “ ‘[ejvidence which shows to a reasonable [degree of medical] certainty that negligent delay in diagnosis or treatment ... lessened the effectiveness of treatment^]” N. Trust Co. v. Louis A. Weiss Mem’l Hosp., 143 Ill.App.3d 479, 97 Ill.Dec. 524, 493 N.E.2d 6, 12 (1986) (quoting James v. United States, 483 F.Supp. 581, 585 (N.D.Cal.1980)). “[T]he plaintiff exclusively bears the burden of proof to establish the element of causation ... and ... a defendant has the right to rebut such evidence and to also establish that the conduct of another causative factor is the sole proximate cause of the injury.” Ready v. United/Goedecke Servs., Inc., 238 Ill.2d 582, 345 Ill.Dec. 574, 939 N.E.2d 417, 422 (2010) (quoting Nolan v. Weil-McLain, 233 Ill.2d 416, 331 Ill.Dec. 140, 910 N.E.2d 549, 563 n. 4 (2009)) (internal quotation marks omitted) (emphasis added).

The Court has identified numerous breaches of the standard of care. These include failing to see the patient when requested, failing to recognize non-reassuring fetal strip results, failing to evaluate Johnson or learn of her vitals after learning of the first and second bloody shows, and failing to act in a timely fashion when learning that the baby had receded to a -3 station at 11:04 a.m. The difficulty is determining whether any of these breaches actually caused the harm to Johnson’s baby. The reason for this is none of the experts were able to opine exactly when Johnson’s uterine rupture occurred. Tr. 593-94, 818-19. Additionally, on cross examination, Dr. Landon conceded that none of the breaches before 10:08 a.m. were the proximate cause of Johnson’s baby’s death. Tr. 593. The Court credits the uncontroverted testimony that the uterus was more than likely intact at 10:08 a.m. Nevertheless, certain other facts allow for a finding of proximate cause based on the totality of the breaches of the standard of care for which Dr. Ja-vate was responsible.

The Defense argues that Dr. Landon could not testify to a reasonable degree of medical certainty that the two bloody shows were related to the uterine rupture, so Johnson cannot prove that failing to evaluate them proximately caused the baby’s death here. R. 68 ¶ 213; see Tr. 593-94. But that ignores the totality of the medical situation. It was Dr. Javate’s initial failures to visit Johnson, learn of and evaluate her vital signs, and insert the internal monitoring devices that led to the later failures that caused the baby’s death. Tr. 593. In Dr. Landon’s words, which the Court finds credible, “[the initial brea