A pregnant mother entered a hospital’s emergency room with symptoms of fluid leaking from her vagina. Her baby was almost 32 weeks of gestation, and his fetal heart rate was noted to be good; it was reactive with a baseline rate of 140 – 150 beats per minute (bpm) and average long-term variability. The mother was evaluated and was told she had experienced premature rupture of the membranes (PROM). The external monitor revealed contractions every 2 – 3 minutes, and the mother was given betamethasone (a steroid to help facilitate the baby’s lung maturity), magnesium sulfate (which helps prevent brain damage in babies that are anticipated to be born prematurely), and IV antibiotics for unknown Group B Strep (GBS) status, which is an infection that can travel to a baby during delivery and cause brain damage.
The labor was uneventful throughout the night and early morning. At around 7:45 a.m., however, problems with the baby’s heart rate began to develop. As the mother neared 7 centimeters of dilation, the fetal heart rate dropped to 90 bpm for 4 minutes, with a slow recovery to baseline. At this point, the decision was made to bring the plaintiff’s mother to the operating room for a C-section. The mother was in the OR by 8:00 – at which time the fetal heart rate dropped to 60 bpm – but no C-section was performed. Records show that the baby’s heart rate remained at 60 bpm until 8:55, when the physicians finally decided to perform a C-section.
The baby boy was born severely bruised and profoundly depressed. He required resuscitation, which is an emergency procedure used to help improve a baby’s breathing, circulation and heart rate. His arterial cord blood pH at delivery showed acidemia (pH of 6.94), an indication that severe oxygen deprivation had occurred in the womb. Head ultrasounds were performed on the baby boy when he was 3 and 6 days old. The ultrasounds showed a serious brain bleed, called a subependymal hemorrhage, as well as evidence of early periventricular leukomalacia (PVL). By the age of 4, the little boy was diagnosed with spastic diplegia, which is a type of cerebral palsy. He has to use braces and crutches to help him move around.
When the little boy was 4 years old, his attorneys sued the hospital, claiming that the physicians were negligent when they delayed a C-section for over an hour in the setting of a premature baby with a clear intolerance to labor who was exhibiting nonreassuring heart tones on the fetal monitor. The attorneys argued that the little boy’s brain injuries were consistent with a lack of oxygen (hypoxia / asphyxia) and were not related to his prematurity. The hospital settled with the family, paying $2.5 million, which will help pay for the lifelong care and therapy that the little boy will need.
This case emphasizes the critical importance of paying attention to and acting upon nonreassuring heart tones in a baby. Indeed, PROM can cause distress in a baby. Oftentimes, a nonreassuring heart tracing is the only indication that a baby is in distress. Fetal distress is almost always an indication that the baby is being oxygen deprived. When this occurs, the baby needs to be removed from the oxygen depriving conditions immediately so that the medical team can help his heart, circulation and breathing. If a C-section is necessary for quick delivery of the baby, the team cannot wait over an hour to perform the procedure, and physicians certainly should not keep a baby in distress for this long.
PREMATURE RUPTURE OF THE MEMBRANES (PROM)
The little boy’s mother suffered preterm PROM, or PPROM. PROM is a condition in which there is rupture of the membrane of the amniotic sac and chorion more than an hour before labor begins. In other words, this is when the mother’s water breaks prior to the start of labor. PROM can lead to fetal distress and other complications before labor or the end of the third trimester. Without the sterile, protective amniotic fluid, an unborn baby is exposed to potential complications, such as umbilical cord prolapse. When a baby’s heart rate drops below 100 bpm for 60 seconds or more, there is a significant chance the cord is compressed. Extremely close monitoring is crucial at this point, and baby often needs to be delivered right away by C-section.
NONREASSURING FETAL HEART TRACINGS
An electronic fetal monitor records the mother’s contractions and the baby’s heart beat in response to the mother’s contractions. When a fetal heart tracing is nonreassuring, it means that the baby is in distress and is not getting enough oxygen. Prompt and appropriate actions must be taken when this occurs.
The normal baseline fetal heart rate is 110 – 160 beats per minute (bpm). A deceleration is a decrease in the fetal heart rate below the baby’s baseline heart rate. Values below 110 bpm are termed bradycardia (slow heart rate). An abrupt descent of the fetal heart rate can be caused by cord compression. In general, decelerations are caused by a sudden reduction in oxygen or a stepwise decrease in oxygen to the baby caused by maternal low blood pressure or hypertonic contractions (contractions that are so fast and strong that they can deprive the baby of oxygen – this can occur when Pitocin or Cytotec are given).
Bradycardia is very serious and can be caused by hypoxia, or it may be the cause of hypoxia. Bradycardias that occur near the end of the second stage of labor can lead to hypoxia if sufficiently prolonged and severe. These bradycardias can be the result of head compression and sudden umbilical cord compression. If bradycardia becomes severe, oxygen and carbon dioxide transfer will become impaired and the baby’s blood will become acidic, which is what occured in this case.
Indeed, when the fetal heart rate is under 100 bpm for more than 3 – 5 minutes – independent of uterine contractions – it means the baby is not getting enough oxygen and severe asphyxia is occurring. This is an emergency and means the baby must be delivered immediately by C-section to avoid or decrease brain damage.
DELAYED RESUSCITATION OF A NEWBORN
Resuscitation is performed on a baby to correct breathing problems and failure to breathe, heart beat cessation or irregularities, and / or very low blood pressure. These are all life-threatening conditions that can severely deprive a baby’s brain of oxygen.
It is critical that at every birth, a skilled team be immediately available to help resuscitate the baby, should the need arise. When a baby is considered “high risk” – which is the case when a baby’s mother has PROM – it is recommended that a resuscitation team be in the room for the baby’s birth. If a baby is showing significant distress and appears to need help with is heart, he should be delivered right away, in most cases. Resuscitation includes maneuvers such as the following:
- Performing chest compressions on the baby in order to increase a slow heart rate or to get a stopped heart to start beating;
- Placing a mask over the baby’s nose and mouth and giving the baby breaths by using an inflatable bag, which is a bag that the team squeezes to force air into the baby’s lungs;
- Giving the baby medications or blood in order to increase the baby’s blood pressure.
DELAYED EMERGENCY C-SECTION
When required, an emergency C-section should be performed as quickly as possible, and many times it should be performed within 10 – 18 minutes or less.
Tragically, the little boy in this case was left in stressful, oxygen-depriving conditions and he was born in poor condition and suffered permanent brain damage. When a baby is oxygen-deprived, the hypoxia can get progressively worse. Mere minutes can make a difference in how much damage hypoxia inflicts on the brain. When distress occurs, there is no room for physicians to gamble that a baby will be okay inside the womb. Small amounts of time can make a difference when fetal distress and other complications are occurring, which is why it is imperative that hospitals be fully prepared to timely deliver a baby by C-section. This means that the facility must have proper anesthesia and surgical personnel to permit the start of C-section delivery within 30 minutes of the decision to perform the procedure, according to guidelines set forth by the American Congress of Obstetrics and Gynecology (ACOG) and the American Society of Anesthesiologists (ASA). Furthermore, experts state that in certain cases, a C-section must be performed in a matter of minutes, such as when the baby is high risk and has a nonreassuring heart rate.
PERIVENTRICULAR LEUKOMALACIA (PVL)
PVL is characterized by the death of the white matter near the cerebral ventricles due to softening of the brain tissue. It can affect fetuses or newborns; premature babies are at the greatest risk of the disorder. PVL is caused by a lack of oxygen or blood flow to the periventricular area of the brain, which results in the death or loss of brain tissue. If resuscitation maneuvers are not performed properly and quickly, brain damage can occur or worsen.
More than 60% of babies who have PVL will develop cerebral palsy which, if the PVL was accompanied by intraventricular hemorrhaging, may also include intellectual disabilities.
SPASTIC DIPLEGIA CEREBRAL PALSY
Cerebral palsy is a term used to describe a group movement disorders that can range from mild to very severe. Spastic diplegia is a type of brain damage that inhibits proper development of cells (motor neurons) in the brain that carry information to the muscles. This affects various parts of the brain and spinal cord, and the result is that certain muscles become hypertonic or spastic, which means they remain very stiff.
The abnormally high muscle tone creates difficulty with voluntary and passive movement, and generally creates stress over time. Depending on the severity of the condition, the continuous spasticity ultimately produces pain, muscle and joint breakdown, physical exhaustion, contractures, spasms, and misalignments of bone structure around areas of tightened musculature that get worse over time.
Spastic diplegia is acquired around the time of birth. Exposure to toxins (such as too much bilirubin / untreated jaundice), traumatic brain injury, encephalitis, meningitis, PVL, hypoxia, hematoma and hemorrhages in the brain, or the presence of certain maternal infections (such as GBS and chorioamnionitis) during pregnancy can all lead to spastic diplegia.
HELP FOR FAMILIES WHOSE BABIES HAVE CEREBRAL PALSY
When a baby suffers from permanent brain damage, it is devastating. When negligence on the part of trusted medical personnel causes the damage, it is especially tragic.
Failure to properly monitor a baby who is in a high risk situation is considered negligence. In addition, failure to recognize distress and perform a timely C-section when one is indicated also constitutes negligence. When this negligence causes injury in the baby, it is medical malpractice.
Due to the complex nature of birth injury cases, it is imperative to have skilled and experienced attorneys such as the Michigan cerebral palsy attorneys at Reiter & Walsh ABC Law Centers: Birth Injury Lawyers. Our attorneys will research your case, find the cause of injury and determine if negligence occurred. For decades, we have been helping families in Michigan and throughout the nation, and we have numerous multi-million dollar verdicts that attest to our success. We will fight to obtain the compensation you and your family deserve for lifelong care, treatment and therapy of your child, and you never pay any money until we win your case. Call us at 888-419-2229.
