Undiagnosed Macrosomia Leads to Birth Injury
A baby girl recently born in an Alabama hospital has a paralyzed arm, called Erb’s palsy, because her physician did not perform proper fetal assessment prior to delivery and engaged in risky procedures during delivery.
The lawsuit brought against the physician argued that the doctor did not prepare for the possibility that the baby girl would be very large at the time of delivery, a condition called macrosomia. The girl weighed more than 9 pounds at birth, but her mother was not offered the option of a C-section delivery. During the attempt at vaginal delivery, the baby’s arm got stuck on the mother’s pelvis, which prevented her from being able to progress through the birth canal. To try and move the baby through the canal, the physician applied force to the baby’s head, which included use of a delivery device called a vacuum extractor. A vacuum extractor uses a suction cup that is placed on the baby’s head. A pump provides suction, which helps to pull the baby out during delivery.
The cup popped off of the baby’s head multiple times and the vacuum extractor failed to move the baby through the birth canal. The physician finally pushed the baby back into the womb and ordered a C-section.
When the little girl was born, her right arm was hanging limply at her side. Her arm is essentially non-functional, with no strength. The force applied to the baby’s head during delivery caused her to sustain a brachial plexus injury, which is an injury that occurs when the network of nerves that run from the spinal column to the shoulder, arm and hand get stretched or torn. The little girl was later diagnosed with Erb’s palsy.
After the little girl was born, her parents were confused and sad about how such a serious injury could have occurred when everything seemed to be going well during pregnancy. The mother was not told she had a large baby and that her delivery would be a risky one.
Diagnosing and Managing Fetal Macrosomia
Macrosomia is a condition in which a baby weighs more than 8 pounds, 14 ounces (4,000 grams) at birth. The condition usually develops when a baby receives too many nutrients. This can occur when the mother is obese or suffers from diabetes, particularly gestational diabetes.
There are many factors that increase the risk of a mother having a macrosomic baby. Physicians should closely observe the mother during her pregnancy. If any risk factors for the condition are present, the physician should discuss the risks and benefits of all the different delivery options with the mother. As with any delivery, the physician should be prepared to perform an emergency C-section. When macrosomia is suspected, it is often necessary to plan to deliver the baby early. Sometimes, a C-section is the planned choice for delivery after the mother and physician discuss the risks, benefits and alternatives. If a C-section is recommended before week 39 of pregnancy, the physician should test the amniotic fluid to determine whether the baby’s lungs are mature enough for birth.
Instances in which a C-section delivery almost always is recommended include the following:
- When the mother’s previous pregnancy was complicated by shoulder dystocia, especially when a brachial plexus injury occurred;
- When it has been determined that the baby weighs more than 4500 grams.
Physicians can assess the size of a baby in the womb and determine if the baby is likely to be large at birth by performing the following procedures:
- Ultrasound: If the baby is large enough, an ultrasound can be used to determine her size, although ultrasounds can be up to 15% inaccurate. In the third trimester, the physician should take measurements of parts of the baby’s body, such as the head, abdomen and leg bone. These measurements are entered into a formula to estimate the baby’s weight.
- Abdominal circumference (AC) is the most reliable method used to assess the risk of macrosomia. An enlarged AC on ultrasound should prompt reevaluation of fetal growth in three to four weeks, especially in women with diabetes.
- Leopold maneuver: The baby’s weight can be estimated by the physician with simple palpation (pushing on the mother’s stomach).
- Measurement of fundal height: This is an inaccurate way of estimating the baby’s size. The measurements are influenced by maternal size, the amount of amniotic fluid, the status of the bladder, the presence of pelvic masses (e.g., fibroids), fetal position, and many other factors. In general, though, a fundal height that is 3-4 centimeters larger than the gestational age of the pregnancy in the third trimester necessitates further testing to determine the cause.
Brachial Plexus Injury, Erb’s Palsy, and Vacuum Extraction
The most common cause of brachial plexus injuries and Erb’s palsy is dystocia, an abnormal or difficult childbirth or labor. Brachial plexus injuries occur when downward lateral traction (force) is applied by the physician to the baby’s head and neck when the baby gets stuck in the birth canal. Initially, the physician might use her hands to try and pull the baby out. The physician might then use vacuum extractors if manual traction doesn’t work. Applying too much force to a baby’s head is very risky. Vacuum extractors have numerous risks in addition to those associated with excessive traction.
Indeed, shoulder dystocia is an obstetrical emergency due to the potential for the umbilical cord to become compressed within the birth canal, which can deprive the baby of oxygen and cause permanent brain damage, such as hypoxic ischemic encephalopathy (HIE) and cerebral palsy. When this type of dystocia occurs, urgent C-section delivery is often the safest way to deliver the baby. Valuable time can be wasted on maneuvers to try and deliver the baby vaginally. A vacuum extractor not only takes time to use, but it adds many risks. In addition to the risk of brachial plexus injury, vacuum extractor use increases risks of the following:
- Skull fractures
- Retinal hemorrhages (eye bleeds)
- Brain hemorrhages or bleeds. A serious complication of a vacuum extraction is a subgaleal brain hemorrhage. In this case, the vacuum ruptures a vein which bleeds into a space between the scalp and skull. This condition is life threatening. About 90% of all subgaleal hemorrhages are related to vacuum extraction. This type of bleeding is most likely to occur with excessive force and prolonged cup application.
- Cerebral palsy, seizures and other forms of brain damage
Erb’s palsy is often caused by a physician’s mistake, such as improperly using a vacuum extractor, applying too much traction or pressure to the baby’s head and neck during delivery, or simply failing to identify and treat risk factors for shoulder dystocia, such as macrosomia. Due to the potential for severe injury when shoulder dystocia is present, a prompt C-section may be the safest method of delivery. The mother must be given informed consent regarding risks and alternatives of all delivery method options, including those pertaining to vacuum extractor and C-section deliveries.
Help For Families With Birth Injured Children
Erb’s palsy is a devastating condition that can require costly treatment and therapy. If your child has been diagnosed with Erb’s palsy, 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 decades of experience in handling macrosomia and Erb’s palsy cases throughout the nation, and we have numerous multi-million dollar verdicts that attest to our success. We understand the complex issues involved with the conditions and will help you obtain the compensation you deserve. Contact Reiter & Walsh ABC Law Centers for a free review of your case: 888-419-2229.