New research shows that hypoxic ischemic encephalopathy (HIE) occurs during labor and delivery (intrapartum) rather than before (antepartum)

A study published this month in Pediatrics suggests that the intrapartum period (occurring during delivery) is necessary to the pathway leading to acute (sudden onset) encephalopathy and hypoxic ischemic encephalopathy (HIE).  HIE is a serious condition whereby a lack of oxygen to the baby’s brain causes cell death and damage to the central nervous system, including the brain.  This deprivation of oxygen is due to a lack of oxygen in the baby’s blood (hypoxia) and/or restricted blood supply (ischemia) to the brain tissue.  Neonatal HIE occurs near the time of birth and can lead to permanent injury in the baby, including learning disabilities and developmental delays, seizures, cerebral palsy and periventricular leukomalacia (PVL).

The study examined both antepartum (occurring near the time delivery) and intrapartum risk factors in HIE, and the authors concluded that the data does not support antepartum factors as being critical.  Increased gestational age was the only antepartum factor independently noted to increase the risk of neonatal HIE.   In comparison, multiple intrapartum factors were found to be independently related to HIE.  These factors are:

  • Prolonged Rupture of MembranesPremature rupture of the membranes 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.  Prolonged rupture of membranes is usually defined as rupture of membranes more than 24 hours prior to delivery.  Prolonged rupture of membranes 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 beats per minute 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.
  • Abnormal fetal heart rate 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 receiving enough oxygen.   Prompt and appropriate actions must be taken when this occurs.  When the fetal heart rate is under 100 beats per minute 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.
  • Thick meconium.  Meconium is a combination of the baby’s first stool and amniotic fluid.  If there is stool in the amniotic fluid, it is an indication that fetal distress occurred.  Sometimes a baby inhales meconium into her lungs, and this can cause very serious complications, such as difficulty breathing at birth and respiratory distress.
  • Shoulder dystocia.  This is a condition whereby the baby’s shoulder gets stuck on the mother’s pelvis during delivery, making it difficult or impossible for labor to progress.  Labor can be very stressful, and when it fails to progress, it can cause fetal distress.  In addition, the umbilical cord often gets compressed during shoulder dystocia, which can severely deprive a baby of oxygen.   When this occurs, physicians sometimes pull too hard on the baby’s head  – either with their hands or with the use of a delivery instrument – and the major nerves of the arm and shoulder get stretched or torn, which can cause the arm to be either temporarily or permanently paralyzed.  This condition is called Erb’s palsy.
  • Tight nuchal cord.  A nuchal cord is when the baby’s umbilical cord gets wrapped around her neck.  This can impede or stop the flow of oxygen-rich blood to the baby.  When this occurs, a baby must be delivered immediately, usually by emergency C-section.
  • Failed vacuum delivery.  A vacuum extractor uses a cup that is applied to the top and back of the baby’s head.  A tube runs from the cup to a vacuum pump that provides suction.  During a contraction, the physician applies gentle traction to the baby’s head while suction from the vacuum assists in pulling the baby’s head out of the birth canal.  Problems can occur if the suction cup of the vacuum extractor is not placed correctly.  The physician’s technique to pull the baby out is equally important – there should be no twisting of the head or neck, no excessive pulling, and no pulling for more than 10 to 15 minutes.  Also, if the vacuum extractor comes off 3 times during use, or if 3 consecutive pulls do not result in delivery of the baby, the physician must move on to a C-section delivery.  Vacuum extractors are a high-risk instrument, and incorrect use can result in severe injuries, such as skull fractures, brain hemorrhages and hematomas, brachial plexus injuries / Erb’s palsy, cerebral palsy and seizures.
  • Sentinel event.  A sentinel event is an unexpected occurrence involving death or serious injury.  Serious injury specifically includes loss of limb or function thereof; Erb’s palsy is an example of a sentinel event.  Such events are called “sentinel” because they signal the need for immediate investigation.

The purpose of this study was to determine whether antepartum factors alone, intrapartum factors alone, or both in combination, are associated with term neonatal HIE.  Though this was a strong case-controlled study due to the number of babies studied, the report is limited by the use of case and control groups from different populations.  Additionally, placental abnormalities, infection and trauma, all of which can be potential causes of HIE, were not included in the study.  Nonetheless, this study emphasizes the critical role that events occurring during delivery can play in the development of HIE.

Indeed, there are many events that can occur during delivery that can severely deprive a baby of oxygen and cause HIE.  It therefore is crucial that physicians follow standards of care during delivery.  A baby must be closely monitored, and if the baby shows signs of distress on the fetal heart rate monitor, she must be delivered immediately, usually by emergency C-section.  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. Failure to properly monitor a baby during delivery and failure to follow standards of care when risky events occur during delivery constitute negligence.  If this negligence causes HIE in the baby, it is medical malpractice.

birth asphyxia and hypoxic ischemic encephalopathy (HIE) attorneysHELP FOR FAMILIES WITH CHILDREN WHO HAVE HIE

If your child has been diagnosed with HIE, a review of medical records can determine whether negligence played a role in causing the injury. The nationally recognized birth injury attorneys at Reiter & Walsh ABC Law Centers have experience in handling HIE cases throughout the nation.  We understand the complex issues involved with HIE and will help you obtain the compensation you deserve.  Contact Reiter & Walsh ABC Law Centers for a free review of your case:  (888) 419 – BABY.

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