A case from New Zealand is a tragic reminder of how critically important it is to quickly deliver a baby by emergency C-section when fetal distress is present. A mother experienced a concealed placental abruption during labor, which caused her baby’s heart rate to drop. This non-reassuring heart tracing was recognized right away, but instead of acting quickly to deliver the baby, the physician ordered blood tests on the mother. Precious minutes were wasted while the mother’s blood was drawn, sent to the lab and analyzed. The placental abruption caused the baby boy to suffer a lack of oxygen to his brain, which lasted for far too long. The little boy developed hypoxic ischemic encephalopathy (HIE), a brain injury caused by oxygen deprivation. When a C-section was finally performed, the baby was pale and unresponsive. The team tried to resuscitate him, but a heart rate was never established. The baby boy was pronounced dead after 19 minutes. This case is extremely tragic because the death could have been prevented if the baby had been delivered as soon as the non-reassuring heart rate was recognized. The mother was already in the delivery room and a C-section could have been performed immediately. A placental abruption is very dangerous for both the mother and baby. If a baby is near term and an abruption occurs, physicians should quickly deliver the baby to prevent permanent brain damage, HIE, cerebral palsy and death.The mother is also very sad and upset because the physician never even gave her a choice about having a C-section. He failed to explain what was happening with her baby and did not get her consent on doing the slow blood tests–or about delaying a necessary C-section. Failing to get informed consent is negligence. Physicians are supposed to explain the risks, benefits and alternatives to all medical procedures. This mother did not receive adequate information from the physician and she never had a chance to make an informed decision, a decision that would have affect the life of her baby.Not only did the physician fail to inform the mother of what was occurring and what her options were, he was actually very rude and abrupt with her, not even allowing her to ask questions. The physician was disciplined by the hospital, forced to apologize to the devastated mother, and is required to attend a sensitivity training class to improve his communication skills. The physician’s actions are under investigation by the Medical Council of New Zealand.
What Is Placental Abruption?
When the placenta tears away from the uterus (womb), it is called a placental abruption. The placenta plays a crucial role in providing oxygen and nutrients to the baby. Thus, when something affects the functioning of the placenta, it can cause the baby to be deprived of some or all of his oxygen.
The placenta is a sac-like formation that is attached to the uterus. The uterus is on one side of the placenta and the umbilical cord is on the other. The baby’s only source of oxygen is the oxygen-rich blood that travels from the mother to the baby. The blood flows from the mother through vessels in the uterus to the placenta. From the placenta, blood travels through the umbilical cord to the baby.
Sometimes only part of the placenta tears away from the uterus, called a partial placental abruption. Other times, there is a complete tear, called a complete placental abruption. When a complete abruption occurs, the baby will be completely deprived of oxygen and will need to be delivered immediately. Partial placental abruptions are also worrisome because they can turn severe very quickly. Thus, if the baby is at or close to term, it is the standard of care to immediately deliver the baby when a partial abruption is present.
Indeed, if a baby is greater than 36 weeks of gestation, delivery is the standard of care, even when there is only mild placental abruption. If the baby is at or less than 36 weeks of gestation and the abruption is not severe, the mother must be admitted to the hospital for very close monitoring of her and the baby. The baby’s heart rate will be continuously monitored and if the baby becomes distressed, he will be delivered immediately. The mother will also be closely monitored, and continuous tests will be performed so the medical team will know if the abruption gets worse. If it does, the baby will be delivered immediately by emergency C-section, in most cases.
What Are The Risk Factors For Placental Abruption?
The risk factors for placental abruption include the following:
- Mother over the age of 35 or younger than 20
- Women who have given birth before
- Accidental puncture of the placenta (e.g., during amniocentesis)
- Chorioamnionitis (infection of the two membranes of the placenta and the amniotic fluid)
- Previous placental abruption
- Abnormal uterine blood vessels
- Nutritional deficiency, especially folic acid (a B vitamin)
- High levels of a protein called alph-fetoprotein
- The baby is male
- Uterine fibroid tumors
- Cigarette smoking. When this is coupled with high blood pressure/preeclampsia, the risk of abruption is greatly increased.
- Mothers with long-term high blood pressure (hypertension/preeclampsia). This is the most common cause of placental abruption, and it occurs in approximately 44% of cases.
- Trauma to the abdomen (e.g., from a car accident). The effect of trauma may not be immediately obvious, but over the course of 24 hours, even mild trauma may progress to severe abruption.
- Sudden decompression of the uterus from events such as the delivery of the first child in a multiples birth, artificial rupture of the membranes (physician breaks the mother’s water), or premature rupture of the membranes (PROM). This is particularly threatening in cases of polyhydramnios (abnormally high amniotic fluid).
What Are The Signs And Symptoms Of Placental Abruption?
The signs and symptoms of placental abruption can include:
- Internal bleeding (occurs roughly 30-40% of the time)
- Low blood pressure
- Placental abruption progression
- Bleeding during the second half of pregnancy or excessive bleeding during labor
- Intense abdominal pain
- Uterine contractions during labor that last longer than normal
- Uterus that becomes hard to the touch during labor
- Fetal distress
- Uterine irritability
If any of these signs occur, it is very important for the mother to go to the hospital right away and make sure the medical team immediately starts to monitor the baby’s heart rate. Proper tests should be performed on the mother to check for placental abruption or any other serious condition that can affect the baby. Sadly, we have seen numerous cases in which a mother arrives at the emergency room complaining of vaginal bleeding and/or other symptoms listed above and the medical personnel tell her it is normal, send her home, and the baby ends up with permanent brain damage from a lack of oxygen to the brain. This type of brain damage (hypoxic ischemic encephalopathy) often leads to cerebral palsy, which causes lifelong problems.
Placental Abruption, Hypoxic Ischemic Encephalopathy, IUGR, and Cerebral Palsy
Placental abruption must be recognized and appreciated by the medical team. Even a minor abruption can become serious very quickly. When there is a concealed abruption (retained retroplacental hemorrhage), the actual blood loss may be a lot more than what is observed. Abruptions can cause the baby to be deprived of adequate oxygen. The amount of injury to a baby depends on the degree of the abruption, the age of the baby and the amount of reserves the baby has. If the baby is greater than 36 weeks, delivery should occur even if the abruption is minor. If the abruption is moderate to severe, a baby that is 36 weeks or less also should be delivered, in most cases.
Sometimes mothers have placental abruption that lasts for a good portion of the pregnancy. This long-term abruption can cause the baby to be chronically deprived of adequate oxygen and nutrients, resulting in intrauterine growth restriction (IUGR). IUGR means the baby is experiencing poor growth in the womb.
Whether the placental abruption is sudden or chronic, compromise of the baby can be detected by astute fetal heart rate monitoring, which is very easy to do. Heart rate monitoring should be performed as soon as the mother presents to the hospital in labor, any time the mother presents to the hospital with signs of abruption, and during all prenatal testing. Prenatal tests consist of heart rate monitoring in conjunction with ultrasounds. Ultrasounds are part of the diagnostic work-up for placental abruption, and during prenatal testing, an ultrasound will be indicative of IUGR in a baby. When IUGR is present, physicians must determine the cause.
If placental abruption is present, the mother should be admitted to the hospital for close monitoring or emergency delivery, depending on the age of the baby and severity of the abruption. As this New Zealand case illustrates, there are certain instances in which tests should be delayed and delivery must occur immediately to protect the health of the baby. Placental abruption requires that the medical team act with an extreme sense of urgency. Tests can be performed while preparations for emergency C-section are being made. The mother should be thoroughly informed of all her options, possible outcomes for the baby, reasons for performing certain tests, and risks and alternatives for all possible procedures.
Sudden placental abruption and chronic abruption both can cause hypoxic ischemic encephalopathy (HIE) in the baby. This type of brain injury often leads to cerebral palsy in the child. Cerebral palsy occurs when there is damage to the motor centers of the brain, resulting in problems with signals between the brain, nerves and muscles. This causes children to struggle with movement, posture, balance and coordination. Cerebral palsy can be severe, affecting all four limbs and relegating a child to a wheelchair, or it may be mild, affecting one or two limbs. The condition is different in each child.
Early Detection And Treatment Of HIE Can Help Prevent Cerebral Palsy
If a baby suffered an oxygen-depriving event (asphyxia) during or near the time of delivery, it is critical for the physician to assess the baby for hypoxic ischemic encephalopathy (HIE). If a baby has HIE and is given hypothermia (brain cooling) treatment within 6 hours of the oxygen-depriving insult (in this case, within 6 hours of the placental abruption), her chances of developing cerebral palsy are greatly reduced. This is because after an insult, hypothermia treatment halts almost every injurious process that starts to occur in the brain after asphyxia.
Reiter & Walsh: Three Decades Of Advocacy For Children With Birth Injuries, HIE, & Cerebral Palsy
Jesse Reiter, president of Reiter & Walsh ABC Law Centers, is the only attorney in Michigan who has spent his entire 28+ year career focusing on birth injury cases, and most of his cases involve helping children who have hypoxic ischemic encephalopathy and cerebral palsy. When Jesse and his team of attorneys take a case, they spend a lot of time getting to know the child and family they are helping so they can fully understand the child’s needs.
Jesse and his team have won many awards for their advocacy of children. Jesse is currently recognized as being one of the best medical malpractice lawyers in America by U.S. News and World Report 2014, as well as one of the 10 Best Attorneys in Michigan by Super Lawyers magazine. Reiter & Walsh ABC Law Centers is also recognized as being one of the best medical malpractice law firms in the country by U.S. News and World Report 2014.
Cerebral palsy, hypoxic ischemic encephalopathy (HIE) and birth injury cases are difficult areas of law to pursue due to the complex nature of the medical records. The award winning lawyers at ABC Law Centers have decades of experience with cerebral palsy and HIE cases. We handle cases in Michigan, Ohio, Washington, D.C. and throughout the nation and we give personal attention to each child and family we help. We have numerous multi-million dollar verdicts and settlements that attest to our success, and no fees are ever paid to our firm until we win your case. Email or call us at 888-419-2229. Our firm’s lawyers are available 24/7 to speak with you.