A midwife in Utah who presented herself as an expert in vaginal birth after C-section (VBAC) grossly mishandled a delivery and left a baby in tragic condition. The midwife, Valerie El Halta, gave the mother a labor induction drug (Pitocin or Cytotec). The mother’s contractions increased each time El Halta administered the drug. The contractions continued to intensify and the mother became physically ill. El Halta ordered the mother to push, and at one point, the baby appeared to be crowning, but he slipped back into the birth canal. El Halta stepped out of the room for a few minutes, and when she returned, she could not detect any fetal heart tones on the heart monitor.
At this point, El Halta panicked and grabbed a vacuum extractor, which she was not licensed to use. She removed the baby from the womb, but his umbilical cord was wrapped tightly around his body and he was not breathing.
While someone called 911, El Halta tried to resuscitate the baby, performing CPR. Emergency responders transported the baby boy to the hospital. At the hospital, the baby was given treatments, but his brain was too damaged from the severe oxygen deprivation he experienced. This type of brain damage is called hypoxic ischemic encephalopathy (HIE). The baby passed away less than a week later.
During labor, the mother also suffered severe trauma. Her uterus (womb) ruptured and she experienced placental abruption, which caused severe bleeding. The bleeding would have led to death had treatment been delayed any longer, according to physicians.
PROPER FETAL MONITORING AND ABILITY TO PERFORM EMERGENCY C-SECTION
This very tragic case emphasizes the importance of properly monitoring a mother and baby during labor and delivery, which means the baby’s heart tracings on the fetal heart monitor must be closely watched and accurately interpreted. If there are any signs of distress, a baby should be delivered immediately, usually by emergency C-section. In this case, the baby’s cord was compressed and he was inside a ruptured womb; both events have the capacity to completely cut off the baby’s oxygen supply, and both require immediate delivery. Physicians and midwives must appreciate signs of distress and should never be dismissive of an abnormal tracing or a tracing that could be a sign of distress. If a baby’s fetal heart tracing is abnormal, or the monitor appears not to be picking up the baby’s heart rate, clinicians should err on the side of caution and should never gamble that a baby will be fine inside the womb. There is no excuse for failure to properly monitor a baby or failure to promptly deliver a baby when the baby is in distress. If vaginal delivery cannot quickly occur, the baby should be delivered by emergency C-section.
A delivery should not occur in a place that does not have the capacity to perform an emergency C-section, especially when the delivery is a high risk one, as was the case with this mother from Utah, who was attempting a VBAC.
Experts state that a C-section should occur within 30 minutes of the time a decision to perform the surgery is made. In fact, most experts state that a C-section should take place within 10 – 18 minutes or less, and in some cases, the baby must be delivered as soon as possible, such as when there is a loss of fetal heart rate, very low heart rate, uterine rupture and umbilical cord compression.
VBAC AND UTERINE RUPTURE
A ruptured uterus can be life threatening for both the mother and baby. Uterine rupture refers to complete disruption of all uterine layers, which typically occurs when the forces of uterine contractions associated with attempted vaginal delivery cause the uterus to tear open, which can cause the unborn baby to spill into the mother’s abdomen. When rupture occurs, there often is hemorrhaging (severe and rapid bleeding) that can cause the baby to be severely deprived of oxygen (hypoxia).
A uterine rupture is most commonly associated with a trial of labor after C-section. In this case, the separation of the C-section scar during labor causes the rupture. It is further recognized that the induction or augmentation of labor in patients who are attempting a VBAC puts patients at an increased risk for uterine rupture. Thus, most physicians will not use agents such as Pitocin or Cytotec to induce or augment the labor of a patient who had a previous C-section. In fact, due to the serious risk of uterine rupture during a VBAC, the American College of Obstetrics and Gynecology (ACOG) only recommends VBAC in very low risk cases where patients are carefully chosen and given informed consent.
Due to the potentially devastating consequences of a rupture, physicians and midwives should be thoroughly aware of a woman’s history and know if she has any of the risk factors for a uterine rupture. Risk factors include VBAC and use of vacuum extractors.
If a woman shows any signs of a uterine rupture, physicians must prepare for a very quick delivery. Urgent delivery is almost always indicated in patients with a uterine rupture because fetal heart rate changes become nonreassuring and / or there is instability of the blood pressure and circulation. Rupture should be suspected in women who are having a trial of labor after a prior C-section if one or more of the following signs and symptoms are present:
- Fetal heart rate abnormalities
- Sudden or worsening abdominal pain
- Decreasing uterine contractions
- Vaginal bleeding
- Blood pressure and circulatory instability
The classic signs, however, have been shown to be unreliable and frequently absent. Prolonged, late or variable decelerations and bradycardia (slow heart rate) seen on fetal heart rate monitoring are the most common and often the only manifestations of uterine rupture. In most cases, signs of fetal distress will appear before pain or bleeding. It therefore is crucial that physicians closely monitor the mother and baby, and be prepared to perform an emergency C-section. Furthermore, the time between diagnosis of a rupture and delivery should be very quick in order to avoid brain damage from HIE / asphyxia.
Uterine rupture can cause oxygen deprivation in the baby by the following mechanisms:
- The mother loses so much blood (low blood volume / blood pressure) that not enough oxygen-carrying blood can be delivered from her to the baby through the umbilical cord.
- The rupture causes the placenta to be cut off from circulation, which means the umbilical cord, which is the conduit by which blood flows from the placenta to the baby, cannot deliver oxygen to the baby.
- Complete deprivation of oxygen (anoxia) is common in cases of uterine rupture, and fetal or neonatal death occur quite often in cases of complete rupture.
VBAC, PITOCIN / CYTOTEC, VACUUM EXTRACTORS, FETAL DISTRESS AND NEGLIGENCE
In this case, the midwife violated multiple standards of care. Firstly, a VBAC puts a woman at great risk of having a ruptured uterus. When a ruptured uterus occurs, the baby usually must be delivered by emergency C-section. Thus, a VBAC should not be attempted if the midwife or physician delivering the baby do not have the capacity to perform a fast C-section. When a rupture occurs, there is no time to transport the mother to another facility.
Secondly, Pitocin or Cytotec should not be used during a VBAC. These drugs further increase the risk of a ruptured uterus as well as placental abruption. If placental abruption and uterine rupture both occur, the mother will likely loose a lot of blood and the baby will be severely oxygen-deprived.
Thirdly, a vacuum extractor should never be used when the practitioner does not have the capacity to quickly move on to a C-section. There is a high risk of trauma to the baby when vacuum extraction is performed. If a vacuum extractor does not lead to delivery of the baby, it is against the standard of care to keep attempting vacuum extraction (more than 3 attempts is contraindicated), and it also is against the standard of care to try and use a different delivery instrument, such as forceps. Therefore, C-section is usually the next required move when vacuum extraction fails to lead to birth.
Finally, during labor, a mother and baby must be closely and continuously monitored, especially when a high risk situation is present, as was the case with this mother. This means that the monitor must be closely watched, the tracings must be properly analyzed and interpreted, and the main practitioner should never leave the room and fail to watch the monitor, even for a few minutes. When distress is evident, the baby must be quickly delivered.
Attempting a VBAC, administering Pitocin or Cytotec, and use of a vacuum extractor require skill. Physicians and midwives should not perform any of these procedures without the requisite skills. Doing so is negligent. In addition, it is negligent to perform any of these procedures without having the capacity to move on to an emergency C-section.
HELP FOR BABIES INJURED AS A RESULT OF MEDICAL NEGLIGENCE
It is imperative that close monitoring of a mother and baby occur during delivery, especially if a mother has risk factors for uterine rupture. Continuous monitoring of the baby must take place, and it is essential that physicians pay close attention to the fetal heart rate and be prepared for an urgent C-section. Failure to properly monitor the mother and baby and to notice signs of a rupture is negligence. Failure to follow standards of care and to quickly and properly deliver the baby also constitutes negligence. If this negligence leads to permanent injury in the baby, it is medical malpractice.
The nationally recognized lawyers at Reiter & Walsh ABC Law Centers have many years of experience in birth injury cases, including HIE, uterine rupture, Pitocin / Cytotec and VBAC cases. If you experienced any of these complications during pregnancy and your child developed an injury, we can help you. Our skilled attorneys have decades of experience and will work tirelessly to obtain the compensation you and your family deserve. Call us at 888-419-2229 for a free consultation.