Several hours before delivery, a New Zealand woman named Carla Grobler began suffering from a very high fever. A vaginal delivery was attempted, but physicians had difficulty delivering the baby. A C-section was ordered, but there was a delay in its performance because the midwife neglected to inform the anesthesiologist about Grobler’s previous problems with epidurals, and Grobler could feel the scalpel at the start of the procedure. Delivery and C-section had to be further delayed while different anesthesia was administered.
When baby Amelia finally arrived, she had to be resuscitated, and she immediately began to have seizures. Amelia was later diagnosed with hypoxic ischemic encephalopathy (HIE), which is brain damage caused by a lack of oxygen (hypoxia) and/or blood flow (ischemia) to the brain.
Grobler later found out that she had chorioamnionits, a bacterial infection that can ascend from the vagina into the womb and cause permanent damage to the baby, including HIE. The ascension of bacteria is associated with prolonged labor, which Grobler experienced. Furthermore, prolonged labor can cause hypoxia, fetal distress and HIE in a baby. A judge recently ruled that Grobler’s chorioamnionitis contributed to Amelia’s injury, and the delay in delivery added significantly to its severity.
A diagnosis of chorioamnionitis can be made based only on signs, such as maternal fever. A clinical diagnosis can be made when fever is present with two other signs, such as uterine tenderness, maternal or fetal tachycardia (fast heart rate), and bad smelling amniotic fluid. Antibiotics need to be administered as soon as a diagnosis is made, and when a woman is close to or in labor, antibioticis typically are administered even if chorioamnionitis is suspected. Physicians need to act quickly when chorioamnionitis may be present so that risk of infection spreading to the baby is minimized. Indeed, chorioamnionits can have devastating consequences for babies, including the condition Amelia has, HIE.
Chorioamnionitis and HIE
When ascending bacteria infects the baby, as in chorioamnionits, the infection plus an inflammatory response occurs that can lead to white matter damage of the brain. This damage can cause permanent injury such as cerebral palsy, seizure disorders and periventricular leukomalacia (PVL). When this happens, a timely delivery must be performed.
Amelia was exposed to chorioamnionitis, as well as the hypoxic conditions of prolonged labor without a timely delivery. Seizures can be caused by hypoxia and HIE, and in fact, HIE is the most common cause of seizures. Seizures can cause brain damage, and brain damage can cause seizures; the two conditions can perpetuate each other. Furthemore, when the presence of multiple brain injuring events are present – such as chorioamnionitis and hypoxic conditions – the chances of permanent brain damage are greatly increased.
HIE, or birth asphyxia, occurs when a lack of oxygen to a baby’s brain causes cell death and damage to the central nervous system, which includes the brain and spinal cord. This deprivation of oxygen typically is due to a lack of oxygen in the baby’s blood (hypoxia) and restricted blood supply (ischemia) to the brain tissue. These consequences can lead to long-term damage of the baby, including learning disabilities, delayed development, seizure disorders and cerebral palsy. Even a short deprivation of oxygen to the baby can cause severe problems. In general, the longer a baby is deprived of sufficient oxygen, the more severe and permanent the injury will be.
Some conditions that can cause HIE include a ruptured uterus, placental abruption, preeclampsia, prolapsed or compressed umbilical cord, prolonged labor, delayed emergency C-section and untreated or improperly treated infection in the mother.
If chorioamnionitis is even suspected during labor, the standard of care is to give appropriate antibiotics. If physicians do not properly monitor a mother and baby during pregnancy, labor and delivery, and if they fail to recognize and treat chorioamnionitis, it is negligence. Furthermore, prolonged labor can cause many complications in a baby, including fetal distress and HIE. An extended labor – especially when a C-section is indicated – should be avoided. Failure to follow standards of care and promptly perform an indicated C-section is negligence. If negligence leads to permanent injury in a baby, it is medical malpractice.