(CNN) – A doctor who gave a yearly checkup to a woman in a vegetative state about 37 weeks before she gave birth wrote that there were no major changes in her health, according to medical records sent to an Arizona court.
The woman gave birth on December 29 at a health care facility in Phoenix for people who need long-term medical care. Caregivers were taken by surprise at the birth, telling 911 dispatchers, “We had no idea she was pregnant.”
Police conducting a sexual assault investigation have said the baby was in distress when it was born, but they haven’t said whether the woman had a full-term pregnancy.
The medical records say the woman had an external exam on April 16. The doctor notes her “firm belly” in the abdomen section. There were no notes about a pelvic exam, or urine or blood tests on the forms.
The doctor had given the woman her physicals since 2009, when a court appointed her mother as legal guardian.
CNN is not reporting the woman’s name because police are investigating the case as a sexual assault.
“This woman was unable to move, she was unable to communicate, in other words she was helpless,” Phoenix police Sgt. Tommy Thompson said. “This started as a sexual assault investigation from day one.”
The woman, who is now 29, has been at the Hacienda HealthCare facility, which is a nonprofit, since 1992, a court investigator wrote in a 2009 report included in the documents.
He described her as “severely developmentally disabled” and unable to communicate.
She also had “no activities or outside hobbies due to her level of care. She is not alert/oriented and susceptible to many different illnesses. The (patient) is unable to make any decisions or give consents due to her disability.”
Her condition declined through the years, the reports show.
Most of the yearly medical reports say her rehab potential and prognosis are “poor,” though the most recent report used “guarded” for her prognosis. The records for two exams were not included in the 141 pages of documents.
The woman has a breathing tube and a feeding tube, the records show. In March she weighed 112 pounds.
The documents do not say why or how her brain became damaged.
Dr. Deborah Feldman, director for maternal fetal medicine at Hartford HealthCare Medical Group, who CNN talked to before obtaining the medical records, said the case “speaks to the fact that the patient actually had largely normally functioning organs.”
She added that although it is unusual that no one apparently noticed the Arizona patient’s pregnancy, many healthy women deliver babies with no prenatal care. “Most of the time, those babies are healthy and robust,” Feldman said. “Nature takes care of itself.”
“Patients who are not moving don’t really have any caloric expenditure, but they’re also not eating,” Feldman said. “(A feeding tube) really helps with the nutritional support, and babies tend to grow well even with just that.”
Police investigators have begun to gather DNA from men who work at the facility.
“We’re not going to point out who we’ve obtained DNA from or who we intend to get DNA from,” Sgt. Tommy Thompson said. “But suffice it to say, it is a large number of individuals. We have a very wide scope at this point.”
Hacienda representative David Leibowitz said federal regulations “preclude Hacienda from addressing any specifics about this patient or any patient.”
The company previously called the situation “a deeply disturbing incident” and said they are cooperating with law enforcement and state agencies.
Hacienda “will accept nothing less than a full accounting of this absolutely horrifying situation, an unprecedented case that has devastated everyone involved, from the victim and her family to Hacienda staff at every level of our organization,” said Gary Orman, executive vice president of the organization’s board of directors.