Font ResizeShe and her boyfriend, Clemente Monroy, 32, were excited about the birth of their first child, who was just a few days overdue.
About a half-hour after being admitted to Highland Hospital in Oakland, a doctor told Guerrero and her family that the baby's heart rate was very low and that she needed to perform an emergency Caesarean section right away.
The baby's heart rate then normalized, but the doctor told Guerrero that she didn't want the baby's heart rate to drop too low again, Guerrero said in an interview at her family's tidy and spacious home on a quiet street in San Leandro.
Guerrero was prepped for emergency surgery. But she lay there waiting for the procedure for at least 10 or 15 minutes, she and family members said.
Unknown to Guerrero and her family, the anesthesiologist on duty had left the hospital, according to eyewitness accounts.
Staff paged the anesthesiologist repeatedly, and she finally responded by cell phone 12 minutes after the first page. Sixteen minutes after the first emergency page, the anesthesiologist ran into the unit, according to witnesses who spoke on condition of anonymity for fear of losing their jobs.
"They didn't tell me why I had to wait," Guerrero said through a Spanish interpreter.
Once the C-section was under way, Guerrero and her family said the obstetrician seemed inexperienced and nervous. "We felt like she was a novice," said Monroy through a Spanish interpreter.
The couple's baby was born with a condition known as meconium aspiration syndrome. Meconium is the first bowel movement a baby makes. If a full-term baby is in distress, then the anus relaxes, releasing the meconium into the womb. If the baby takes its first breath while exposed to this meconium, it can get sick and sometimes die. The longer a baby is left in the womb with the meconium, the greater the risk.
"Babies can get very sick. It impacts their breathing," said Dr. Carol Miller, clinical professor of pediatrics at the University of California, San Francisco. Miller specializes in high-risk babies and is not affiliated with Highland Hospital.
Guerrero's baby was born covered in meconium, sources who work at the hospital said. The umbilical cord was cut, then the baby's nose and mouth were cleaned out. A pediatrician then gave the baby CPR behind a curtain near where Guerrero had just given birth, family members said.
"The baby didn't cry, but he was alive," Monroy said. "He wasn't purple or anything. He was the right color."
A little later, the pediatrician who had given the baby CPR told the couple their baby had died. Miller said a newborn rarely dies so quickly from the aspiration syndrome.
"You see the baby is in distress and there's a lot of things we can do," Miller said, adding that newborns can be put on a ventilator to allow their lungs time to recover from breathing in the fecal matter. "It doesn't usually happen that a baby would die that quickly. That's very unusual."
As for the C-section delay, Miller said without knowing the details it was hard to say if that was a contributing factor.
Dr. Arthur D'Harlingue, chief of neonatology at Children's Hospital Oakland, said a small percentage of newborns will die from meconium aspiration syndrome no matter what the intervention.
"It's more a question of why did that baby develop meconium in the first place," D'Harlingue said. "Maybe the baby wasn't getting enough blood flow through the placenta. ... Sometimes the lungs just don't form properly. It looks like meconium but there's an underlying condition. Sometimes it's just fatal."
Guerrero and Monroy said they never saw the obstetrician again after she performed the C-section. Hospital sources said the doctor was so upset over the loss that she could not face the family.
The official causes of death listed were neonatal demise, meconium aspiration syndrome and failure to resuscitate, according to hospital documents given to Guerrero.
The couple is still distraught at the loss of their first son, whom they named Tristan. Said Monroy, "It's like the words get caught in your throat and you can't talk."
