Anesthesia Errors and Birth Injuries

Spinal epidurals and spinal blocks are two common methods of administering anesthesia/analgesia to expectant mothers. Epidurals can provide pain relief during vaginal delivery; spinal blocks are more often used in Cesarean deliveries (C-sections) (1). Spinal epidurals and spinal blocks both come with risk factors (2); medical professionals are required to explain these risk factors to mothers and obtain informed consent before administering the anesthesia. Epidurals can interfere with the second stage of labor, increasing the likelihood that physicians will use forceps and vacuum extractors (2). Improper use of these instruments can result in birth injuries such as infant brain bleeds. Additional health risks associated with improper use of anesthesia/analgesia include heart problems in the mother, postpartum hemorrhage, abnormal uterine activity, maternal hypotension, fetal oxygen deprivation, and acidosis (2, 3, 4, 5, 12). If anesthesia/analgesia is misused during pregnancy and fetal distress results, infants may go on to develop permanent disabilities such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy (CP).

In the context of childbirth, there are two main types of pain-relieving drugs – analgesics and anesthetics. Though the two terms are often used interchangeably, analgesics refer to drugs that numb pain without a total loss of feeling, while anesthetics remove all sensation and feeling from an indicated area of the body (6). For the most part, analgesia is administered (via epidural or spinal block) to women in labor when vaginal delivery is attempted. Anesthetic is usually administered (via epidural or spinal block) to women undergoing a C-section, or a instrumental delivery (delivery with the assistance of forceps or vacuum extractors) (6).

Analgesics and anesthetics may be administered via an epidural, a spinal block, or a combination of both routes. Epidurals take longer to go into effect than the spinal approach, in which drugs are deposited directly into the cerebrospinal fluid (CSF).

Drugs for analgesic/anesthetic pain relief during labor and delivery include (1,7):

• Bupivacaine
• Lidocaine
• Ropivacaine
• Procaine
• 2-chloroprocaine
• Tetracaine

Maternal hypotension

Maternal hypotension (sometimes referred to as a hypotensive crisis) is a labor and delivery complication in which a mother’s blood pressure drops very low. Anesthesia/analgesia use during labor and delivery can trigger maternal hypotension (2). Women under anesthesia/analgesia often lie flat on their backs, which can create pressure-related issues. Prolonged maternal hypotension frequently causes nausea and vomiting in the mother, and can also be harmful to the fetus (2). Even brief episodes of maternal hypotension can result in fetal acidosis and lower Apgar scores (5). Maternal hypotension is associated with an increased risk of stillbirth, as well as pregnancy complications such as preterm birth, intrauterine growth restriction (IUGR), meconium stained fluid, and postpartum hemorrhage (3,8).

If a mother receives anesthesia/analgesia, her doctor must be vigilant for signs of hypotension. If promptly addressed, hypotension can often be improved by repositioning the mother or using a vasopressor (9). Physicians must also record the baby’s heart rate with a fetal heart rate monitor. This can show signs of fetal distress, which are indications that a baby is being deprived of oxygen. A baby in distress is in need of immediate medical attention and delivery.

Abnormal uterine contractions

Uterine contractions can become weaker and less frequent during anesthesia/analgesia epidural use (10). Doctors may then prescribe Pitocin (a synthetic version of the hormone oxytocin) to increase contractions. This is a risky drug, which can cause a complication known as uterine tachysystole. Also known as hyperstimulation and hypertonus, uterine tachysystole involves contractions that are too strong, frequent, or long. This can result in fetal distress due to a lack of oxygen. Moreover, when tachysystole is severe, the uterus can rupture (11). The epidural can mask the strength of the uterine contractions so that no one knows how strong they are, making it more difficult to predict uterine rupture. Uterine rupture is very dangerous for babies and sometimes results in hypoxic-ischemic encephalopathy (HIE) or death. It can also cause serious symptoms in the mother, such as postpartum hemorrhage.

Heart problems

During anesthesia/analgesia usage, mothers can experience bradycardia (an abnormally slow heart rate), heart block in which the electrical activity of the chambers of the heart become dissociated, and sometimes even cardiac arrest (12).

Respiratory arrest

Mothers can go into respiratory arrest (stop breathing) or experience other breathing difficulties when anesthesia/analgesia is used during childbirth (13).

Anesthesia complications during the second stage of labor

With large doses of anesthesia/analgesia, the mother may lose the ability and instinct to bear down and push (10). When this happens, medical professionals are more likely to use forceps and vacuum extractors during delivery. Forceps and vacuum extractors put a baby at risk for head trauma and brain bleeds, which can cause permanent brain damage. Prolonged labor also has risks, such as oxygen deprivation and brain bleeds.

Operative anesthesia requires a more intense block because the pain and stimulation from surgery are different and more intense than the pain of labor. While anesthetic should be avoided in vaginal deliveries because it interferes with pushing, it is desirable for C-section delivery to obtain abdominal muscle relaxation. This block is achieved by administering a high concentration of local anesthetic.

Scheduled vs. emergency C-sections

For a scheduled C-section, the rapidity of anesthetic induction is less of a concern, so all anesthetic options are available. For more urgent C-sections (e.g., in instances of fetal distress), a faster anesthetic technique is preferable. If the C-section is a true emergency, the time required to achieve anesthesia and facilitate a rapid delivery may be of critical importance to the well-being of the baby and/or mother. This is one of the main reasons it is critical to have a skilled team readily available at all deliveries, and it is crucial that all team members – especially the obstetrician and anesthesiologist – communicate effectively when a C-section is about to take place.

Fetal monitoring during C-sections

For low-risk mothers and babies undergoing scheduled C-section delivery, the presence of a normal fetal heart rate should be ascertained and documented before administration of anesthesia. When an emergency C-section is about to occur, continuous fetal heart rate monitoring should be maintained until the abdominal sterile preparation has begun, at which time the external monitor may be removed. If an internal monitor is being used, it may be removed when the abdominal sterile preparation is complete.

The introduction of a sterile field does not necessitate discontinuation of fetal heart rate monitoring. Indeed, there are certain instances in which monitoring should continue until the baby is delivered. Sterilizable probes are available for use with certain Doppler monitors. If a hospital does not have these types of probes, a condom can be placed over the probe to allow for fetal heart rate monitoring during a C-section.

• Motor Block: Epidural anesthesia/analgesia can cause a motor block, resulting in temporary paralysis, even of respiratory muscles (14).
• Accidental Spinal Anesthesia: When an epidural accidentally turns into a spinal anesthetic, many complications can occur, including (15):
  • Postspinal headaches
  • Dysfunction of the bladder (this is common)
  • Numbness and tingling of the lower limbs and abdomen (this is less common)
  • Unilateral footdrop (paralysis of the muscle that lifts the foot) has occurred
  • Permanent nerve damage (conditions called chronic, progressive adhesive arachnoiditis or transverse myelitis) can occur.
  • These lead to paralysis of the lower parts of the body.
  • Deaths have been reported
  • Difficult breathing
  • Increased incidence of forceps deliveries
• Medication interactions:  A hidden danger of epidural anesthesia/analgesia is its interaction with medications commonly used to soften the cervix and start labor (prostaglandins). The use of prostaglandins is common in hospitals and creates a potentially dangerous situation in which the usual medications used to treat low blood pressure will no longer work.
• IV Cannulation: Accidental injection of the anesthetic solution into the bloodstream can occur and cause the mother to twitch, have convulsions, or lose consciousness. Seizures can occur from the toxic effects of the anesthetic agent entering the bloodstream (15).
• Trauma to the blood vessels near the spinal column (2).
• Punctured dura (a covering of the brain) (2).
• Infection at the site of injection (2).

Mothers tend not to be adequately informed about the risks associated with epidurals during labor and delivery; therefore, many doctors do not truly obtain informed consent. Not obtaining informed consent is a form of medical negligence. Other examples of negligence surrounding the use of anesthesia/analgesia include:

• Failure to properly administer the drugs and closely monitor the mother and baby
• Failure to have a skilled team present during anesthesia/analgesia use.
• Failure of the medical team members to communicate effectively with one another during labor and delivery
• Failure to continuously monitor the baby’s heart rate
• Failure to perform an emergency C-section when a baby is showing signs of distress

If standards of care are not followed and the mother or baby suffer injury as a result, it is medical malpractice.