Birth Trauma Injuries*

Birth trauma refers to injuries that happen to a baby during delivery.  While the term birth injury is usually used to describe something that affects a baby’s body system, the phrase birth trauma encompasses injury to the baby’s tissues and organs, as well as the long-term consequences of the injury, such as cerebral palsy, hypoxic ischemic encephalopathy (HIE), Erb’s palsy, seizures and intellectual disabilities.

Traumatic birth injuries are often caused by mechanical force, but can also be caused by the overuse of delivery drugs, abnormal presentation, the negligent use of forceps or vacuum extractors, attempts at delivering babies that are too big to fit through the mother’s pelvis, and attempts at delivering a baby whose shoulders are stuck. Doctors can often avoid birth trauma by following best care practices and being skilled in handling labor and delivery complications.

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The terms ‘birth trauma’ and ‘birth injury’ are often interchangeable, but birth trauma is usually thought of as being caused by mechanical damage, while the term birth injury typically refers to injury caused by a lack of oxygen to the baby’s brain or a brain infection, such as meningitis.

Labor and delivery can be traumatic for the baby.  However, if the medical team avoids risky practices, such as misuse of the labour drugs Pitocin and Cytotec and negligent use of forceps or vacuum extractors, and the physician quickly delivers the baby as soon as distress is evident on the fetal heart monitor, most instances of birth trauma can be avoided.

It also is important for the physician to be aware of any size or positional problems with the baby.  Attempts at vaginal delivery when the baby is too big for the size of the mother’s pelvis (cephalopelvic disproportion / CPD) or when the baby’s shoulder is stuck on the mother’s pelvis (shoulder dystocia) can cause the baby to experience permanent nerve damage, trauma to the skull, brain bleeds and hypoxic ischemic encephalopathy (HIE).  Most of these conditions can cause cerebral palsy and seizures.

Medical Explanations

What Causes Birth Trauma?

Birth trauma can usually be avoided if the physician and team adhere to the following:

  • Take a thorough history of the mother and perform proper evaluations in order to timely diagnose any issues that make the pregnancy and delivery high-risk, such as CPD, preeclampsia, and the baby being in an abnormal presentation.
  • The team must be aware of the baby’s position at the time of delivery, including knowledge of a shoulder dystocia situation.
  • Fetal heart rate monitoring must be initiated as soon as the mother arrives at the hospital with any pregnancy-related issues, and of course, fetal monitoring must be ongoing when the mother’s labor begins.
  • The baby must be promptly delivered as soon as fetal distress is noted on the heart rate monitor, in most cases.  The safest way to do this is almost always by C-section delivery, and many conditions require a C-section, such as certain breech and face presentations, CPD, uterine rupture and placenta previa.  All procedures – as well as the risks and alternatives – must be thoroughly explained to the mother.

Birth Trauma from Forceps and Vacuum Extractor Misuse

Forceps and vacuum extractors are very risky because they attach to the baby’s head and are used to help pull her out of the birth canal.  Traction is usually applied during a contraction, when the mother is pushing.  Physicians often lack skills in the use of these instruments.  Forceps and vacuum extractors must be precisely positioned on the baby’s head, traction must not be applied for too long, and there should not be too much traction (force) used to pull the baby out.

vacuum-extraction-with-fetal-head-injury

Forceps look like salad tongs and are applied to each side of the baby’s head.  They can cause trauma to the skull and spinal cord, as well as brain bleeds and hemorrhages.

Vacuum extractors are more commonly used.  A vacuum extractor is a small cup that is placed on the baby’s head.  The pressure of the suction cup can cause a type of bleed called a subgaleal hemorrhage.  This occurs when the vacuum ruptures a vein and the vein bleeds into the space between the scalp and the skull.  This can cause severe oxygen deprivation.  If the bleed is not properly managed, almost half of the baby’s blood volume can end up in the subgaleal space.

Injuries from forceps and vacuum extractors can cause different types of brain bleeds and hemorrhages, hypoxic ischemic encephalopathy (HIE), seizures and cerebral palsy.

Birth Trauma from Pitocin and Cytotec Misuse

Birth trauma can also occur from the cumulative effect of prolonged periods of contractions and pushing, forcing the baby’s head repeatedly against the mother’s pelvis in a setting where the baby is a tight fit, which can happen in cases of CPD and macrosomia.  This increases the baby’s risk of suffering a brain bleed or hemorrhage.  Pitocin (oxytocin) is often used in this scenario in an attempt to avoid a C-section, and Pitocin can increase the intensity of the contractions and risk of brain bleeds.

hyperstimulation-and-hie

Excessive Pitocin can cause contractions to occur less than 2-3 minutes apart, thereby reducing the ability of the placenta to replenish its supply of oxygen-rich blood for the baby.  Excessive frequency and strength of contractions is called hyperstimulation.  When hyperstimulation prevents replenishment of oxygen in the placenta, the baby’s brain can be deprived of sufficient oxygen, with the deprivation getting progressively worse.  Hyperstimulation with Pitocin is indeed very dangerous because there are no precise methods of measuring the effects of Pitocin on the uterus.  The effects of any given dose vary widely; they can range from excessive and severe contractions and fetal oxygen deprivation to absolutely no discernible effect on uterine contractility.

Cytotec is also used to induce labor.  It works by ripening the cervix and producing contractions. The drug has serious risks, however, which include uterine rupture and hemorrhage.  The dosage and method of administering Cytotec raises many concerns.  Unlike Pitocin, Cytotec is a pill that is inserted vaginally.  The pill is usually cut into quarters, with one quarter inserted every four hours.  However, this drug can affect every pregnant woman and baby differently, and there is no way to predict how they will tolerate Cytotec.  If the mother or baby has an adverse reaction to the drug, it cannot be rapidly discontinued like other drugs since the medication is absorbed into the body.  In recent years, there have been concerns over the number of birth injuries that have occurred in cases where Cytotec was used.  Like Pitocin, Cytotec causes hyperstimulation that can cause serious oxygen deprivation in the baby.  When hyperstimulation is evident, there is also a danger that the umbilical cord is being compressed and the baby is not receiving enough oxygen.  This is an obstetrical emergency which requires an immediate C-section delivery.

Uterine rupture occurs when the excessive contractions associated with hyperstimulation cause the uterus to tear, either partially or completely.  The baby then must be delivered by an emergency C-section.

Birth Trauma and Breech Presentation

A breech birth is the birth of a baby from a breech presentation, which occurs when the baby enters the birth canal with the buttocks or feet first, as opposed to the normal head first position. Though labor and vaginal birth are possible for some breech positions, certain fetal and maternal factors influence the safety of vaginal breech birth.  The majority of breech babies should be delivered by C-section.

Obstetrical diagram of fetal presentations, including breech presentation and vertex presentation

Obstetrical diagram of fetal presentations, including breech presentation and vertex presentation

At the beginning of labor, the baby is generally facing either the right or left side of the mother’s back.  Delay in descent is a sign of possible problems with the delivery of the head.  Umbilical cord prolapse may occur, particularly in the complete, footling, or kneeling breech positions.  This is caused by the lowermost parts of the baby not completely filling the space of the dilated cervix. When the waters break the amniotic sac, it is possible for the umbilical cord to drop down and become compressed.  This can severely diminish the flow of oxygen-rich blood to the baby, and even completely cut off the baby’s supply of oxygen from the mother.  Cord compression is an emergency that requires immediate delivery, usually by C-section.

Oxygen deprivation may occur from either cord prolapse or prolonged compression of the cord during birth, as in head entrapment.  If this deprivation of oxygen is prolonged, it may cause HIE and cerebral palsy.  Injury to the brain and skull may occur due to the rapid passage of the baby’s head through the mother’s pelvis.  Positioning the baby incorrectly while using forceps to deliver the after-coming head can damage the brain, spine or spinal cord and cause brain bleeds, which can result in hypoxic ischemic encephalopathy (HIE) and cerebral palsy.

Birth Trauma from Shoulder Presentation (Transverse Lie)

This is when the arm, shoulder or trunk enter the birth canal first.  When a baby is in transverse lie position during labor, the only way to successfully deliver her is by C-section delivery.  Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa or a small fetus (which can occur when the baby has intrauterine growth restriction (IUGR)) are at risk of the baby being in a transverse lie position.  Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position.  Thus, a C-section should ideally be performed before the membranes break.

Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe oxygen deprivation due to cord compression and trauma to the baby.  This can lead to HIE and cerebral palsy.

Birth Trauma from Face Presentation

Face presentation occurs when the baby’s face is the first part of the baby to present at the opening of the birth canal.  Face presentation occurs when the baby’s neck is extended backward so that the back of the head touches the baby’s back.  This inhibits head engagement and descent of the baby through the birth canal.  If face presentation is mismanaged, serious birth complications can occur, such as facial and skull trauma and swelling, brain bleeds and hemorrhages, and prolonged labor.  Trauma during labor can cause swelling in the upper airway.  This can result in respiratory distress in the baby at birth, which can cause complications, such as overventilation injuries, hypoxic ischemic encephalopathy and cerebral palsy.

If the baby’s chin is facing the front of the mother, vaginal delivery may be attempted, but it is still very risky.  In all other types of face presentation, a C-section delivery is required.

Birth Trauma from Macrosomia and Cephalopelvic Disproportion (CPD)

A baby can become very large when a pregnancy is post-term or when the mother has gestational diabetes. This can make it traumatic to deliver vaginally.  Macrosomia may prompt a physician to use forceps or a vacuum extractor for delivery assistance, which increases the likelihood of birth trauma to the baby, such as brain bleeds and head injuries.  Macrosomia also increases the chances of prolonged labor due to problems such as shoulder dystocia or cephalopelvic disproportion.  The risks associated with macrosomia can lead to the baby having permanent brain damage and cerebral palsy, as well as Erb’s palsy.

cephalopelvic-disproportion-copy

CPD injuries occur when the baby’s head or body is too large to pass through the mother’s pelvis.  Initially, physicians will have information about the mother’s pelvis type and size by x-ray, examination and ultrasound.  It also is important to know how the baby’s head is positioned in the pelvis.  Some parts of the head can mold to conform to the pelvis.  Except for macrosomia, physicians will usually not assume CPD based on measurements alone, although measurements are one piece of information that should be considered when deciding whether to deliver vaginally or by C-section.  CPD requires a C-section delivery.  One indication of CPD is failure to progress, which means that labor either stops or does not move as quickly as it should.  Physicians should identify any risk factors for CPD before the start of labor.  Risk factors include:

  • Small or abnormal pelvis
  • Macrosomia
  • Large head measurement of baby
  • Mother with diabetes or gestational diabetes
  • Post-term pregnancy
  • Mother over age 35

Sometimes it may be necessary to plan to deliver the baby early.  When CPD is present, attempts to deliver the baby vaginally will typically cause trauma, which can lead to brain bleeds, oxygen deprivation, HIE and cerebral palsy.

Some mistakes made by physicians when CPD is present that can cause birth trauma include the following:

  • Pitocin: Physicians may react to CPD by administering Pitocin, which can cause hyperstimulation, which can then cause hypoxia, ischemia and resultant cerebral palsy.
  • Continued Labor:  Physicians may allow labor to progress for too long.  Labor is stressful and traumatic for babies,
    and when prolonged, it can cause brain bleeds and HIE, which can lead to cerebral palsy.
  • Shoulder Dystocia:  When CPD is present, babies are more likely to have shoulder dystocia injuries, including Erb’s Palsy, Klumpke’s palsy, or hypoxia leading to cerebral palsy.
  • Prolapsed Umbilical Cord:  When there is less room in the uterus, either because of a large baby or a small pelvis, a prolapsed umbilical cord is more likely, which puts the baby at risk for HIE and cerebral palsy.

Birth Trauma from Shoulder Dystocia

Shoulder dystocia occurs when the baby’s shoulder gets stuck on the mother’s pelvis during delivery.  When this causes a failure of progression during labor, physicians often apply too much force to the baby’s head to try and deliver her.

vaginal-delivery-head-and-neck-injuriesIn some cases, physicians may use forceps or vacuum extractors to assist with vaginal delivery.  During attempts at delivery, if the physician applies too much pressure to her head in order to deliver her, this can cause the nerves in the shoulder area, called brachial plexus nerves, to stretch and tear, which can cause partial or full paralysis of the arm.  This arm paralysis is called Erb’s palsy.  Use of forceps and vacuum extractors can not only cause Erb’s palsy, but can also cause brain bleeds and hemorrhages and resultant cerebral palsy.

How Birth Trauma Can Cause Brain Bleeds, Hemorrhages, HIE and Cerebral Palsy

All the conditions discussed above increase a baby’s risk of experiencing birth trauma and brain bleeds and hemorrhages.  Listed below are different types of brain bleeds and hemorrhages associated with birth trauma.

Intracranial hemorrhages.  Intracranial hemorrhage refers to any bleeding within the skull or brain.

  • Cerebral hemorrhage. This is a form of stroke where bleeding occurs within the brain.
  • Subarachnoid hemorrhage. This occurs when there is bleeding within the subarachnoid space, which is the area between the innermost two membranes that cover the brain.  This type of bleeding usually occurs in full term babies and produces seizure activity, lethargy and apnea.
  • Intraventricular hemorrhage.  This is bleeding into the brain’s ventricular system, where spinal fluid is produced.  It is the most serious type of intracranial bleeding and is usually seen in premature infants and infants with low birth weight.  This is because blood vessels in the brain of premature infants are not fully developed.
  • Subdural hemorrhage or subdural hematoma. This occurs when there is a rupture of one or more blood vessels that are in the subdural space – the area between the surface of the brain and the thin layer of tissue that separates the brain from the skull. These ruptures are usually caused by difficult deliveries.  Seizures, high levels of bilirubin in the blood, rapidly enlarging head, a poor Moro reflex, or extensive retinal hemorrhages (bleeding of the vessels in the retina) sometimes occur with these kinds of hemorrhages.

brain-hemorrhage-in-infantExtracranial hemorrhages.  These are brain bleeds that occur just outside the skull, and they can be life threatening.

  • Cephalohematoma. This is bleeding that occurs between the skull and its covering, starting as a raised bump on the baby’s head.  It occurs a few hours after birth and lasts anywhere from 2 weeks to a few months.
  • Subgaleal hemorrhage.  This occurs when veins rupture and bleed into the space between the scalp and the skull.  This is life threatening for the baby and can cause severe oxygen deprivation.  If the bleed is not properly managed, about 50% of the baby’s blood volume can end up in the subgaleal space.  A vacuum extraction delivery puts a baby at a high risk of experiencing this type of bleed.

How Elective C-Sections Can Decrease the Risk of Birth Trauma

Research shows that when babies are delivered by C-section as opposed to vaginal delivery, they are less likely to have traumatic birth injuries, or birth trauma.  Physicians must perform thorough histories and physicals of the mother and closely monitor and assess the baby during pregnancy to be aware of any risks that can make labor and delivery high risk.  It is very dangerous to attempt to deliver a baby vaginally when certain high-risk conditions are present, such as CPD, abnormal presentations, and shoulder dystocia.

c-sectionIn many instances, a C-section is required.  Repeated attempts at vaginal delivery – especially in instances in which vaginal delivery is against the standard of care – can cause brain bleeds and other traumatic injuries that can cause hypoxic ischemic encephalopathy and cerebral palsy.  When any signs of distress appear on the fetal heart rate monitor, the baby must be delivered as quickly as possible, and C-section delivery is usually the best and safest way to do this.

Your Legal Options

Legal Help For Your BirthTrauma Injury Case

Our medical negligence expert solicitors work with our team of specialist medical consultants whose disciplines include birth injuries and noenatal disciplines.

If you feel that you or your baby have suffered medical negligence we will assist you in obtaining answers to the question – what went wrong. We will obtain your entire medical records. If we are satisfied that negligence occurred we will guide you through the process of filing suit with a view to obtaining justice and financial compensation.

During the legal process we engage Senior Counsel who have extensive and vast experience in dealing with medical negligence cases and in particular birth injury and noenatal litigation. We secure the attendance in court of all our expert witnesses and to give evidence in the case should the claim not be settled in advance.

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