In a recent study published in Health Affairs, hospitals classified by researchers as being “low-performing” had a 23% obstetrical complication rate for women who delivered vaginally, and hospitals classified as being “high-performing” had an obstetrical complication rate for vaginal delivery of 10%. The gap in complication rates was even larger among women who delivered by C-section: low-performing hospitals had a complication rate of 21% and high-performing hospitals had a 4% rate of complication. Hospitals were classified as being high, average or low performing based on the relative risk a patient would suffer a complication at that particular hospital.
Laurent Glance, the lead author of this study said, “[t]he key finding is that there is significant variability in maternal outcomes across U.S. hospitals. This presents us with an opportunity to identify ‘best practices’ at hospitals with low rates of maternal complications in order to improve outcomes for patients at all hospitals.”
High-risk obstetrician J. Christopher Glantz iterated the value of the study, stating that it underscores the importance of examining variations in obstetrical practices and how these variations impact complication rates. Glantz pointed out that in the field of obstetrics, individual practice styles, experience and training shape how physicians practice, but none of the researchers in the study expected to see such large differences in complication rates among hospitals.
The study discussed previous research that found that the institution in which an obstetrician completed her residency training made a substantial difference in that particular obstetrician’s rate of complications.
Given the wide variation in complication rates and the fact that 13% of all women who give birth in the U.S. experience a labor and delivery complication, it is very important for pregnant women to carefully choose their obstetrician.
HOW TO CHOOSE AN OBSTETRICIAN FOR PREGNANCY AND DELIVERY
Given the prior research on residency training and obstetrical complication rates, determining where your potential obstetrician did her residency can be an important factor. A residency program is the hospital in which a physician does her initial training after graduating from medical school. Residents work under attending physicians, and residency programs last approximately 3 – 5 years, depending on the specialty. After residency, many physicians do further specialized training programs called fellowships. One way to determine the quality of the residency program your obstetrician attended is to see how the program ranks in U.S. News and World Reports, which recently conducted a survey on the top residency programs. Of course, all ranking systems have some limitations, so it is important to determine what factors were used in the ranking system or survey.
It is important to ask your potential obstetrician certain questions to make sure that if something does go wrong during labor and delivery, the medical team will notice the complication and be able to quickly act so that the baby stays safe. Most babies are born healthy. But this does not mean an obstetrician or hospital can take shortcuts that can cause serious harm to the baby if a complication occurs. Listed below are some questions to ask your potential obstetrician.
Questions to Ask Potential Obstetricians
- How many deliveries have you performed?
- Are you skilled at interpreting fetal heart rate tracings?
- Will you be continuously monitoring my baby’s heart rate when I go into labor?
- Will someone skilled in fetal heart rate interpretation be with me at all times while I’m in labor?
- If my baby shows signs of distress on the heart monitor and I cannot quickly deliver her, do you and the hospital have the capability to quickly deliver my baby by C-section? Will I be in or next to a room where a C- section can promptly be performed?
- Will there be a second physician immediately available so that if both my baby and I are in distress, there is one physician focusing on me and one focusing on my baby?
- Will you please fully explain the risks and benefits of – and alternatives to – any drugs (Pitocin or Cytotec to induce or speed up labor) or delivery instruments you are going to use (forceps or vacuum extractors)?
- *If an obstetrician decides to use drugs or delivery instruments, it is important to ask the obstetrician how much experience she has with using the drugs or forceps / vacuum extractors. C-section risks and benefits must also be thoroughly discussed.
If the obstetrician leaves the room during labor, the mother should not hesitate to ask the staff members present if they are skilled at fetal heart rate interpretation and if they have taken a proficiency exam. Research shows that a lot of malpractice occurs when abnormal (non-reassuring) fetal heart tracings are not recognized, or if they are recognized, there is a breakdown in communication among the staff. An example of this is when the staff fails to communicate abnormal heart tracings to the obstetrician, and then the baby is not quickly delivered and is instead left in oxygen depriving conditions, which can cause brain damage such as hypoxic ischemic encephalopathy (HIE) and cerebral palsy.
THE IMPORTANCE OF A C-SECTION DELIVERY WHEN THE BABY IS IN DISTRESS
When a baby has a non-reassuring heart tracing and is in distress it almost always means her brain is not getting enough oxygen. When a baby is deprived of sufficient oxygen, she needs to be delivered right away to get her out of the injurious situation and breathing on her own, and outside of the womb where the medical team can give her direct help. Indeed, obstetrical complications sound very frightening. However, if the baby is promptly delivered at the first sign of distress, she will usually have no permanent injuries. This is why an emergency C-section is so important and can be life-saving.
LABOR AND DELIVERY COMPLICATIONS
When the baby is in the womb, she receives her oxygen from oxygen-rich blood delivered to her from her mother. It travels through the womb and through the placenta and then through the umbilical cord into the baby’s circulation. Complications affecting the womb (uterus), placenta and umbilical cord can cause oxygen deprivation in the baby. In addition hyperstimulation caused by Pitocin and Cytotec can cause problems with blood flow in the placenta, and traumatic events, such as the baby being in an abnormal position and the use of forceps or vacuum extractors can cause brain bleeds and permanent nerve damage in the baby.
Listed below are some complications that, if not properly managed, can cause the baby to have permanent injuries, such as hypoxic ischemic encephalopathy (HIE), cerebral palsy, seizure disorders, periventricular leukomalacia (PVL), and intellectual disabilities.
Complications That Can Cause Birth Injuries
Brain Bleeds and Hemorrhages
Brain hemorrhages and bleeds can cause brain injury, cerebral palsy and seizure disorders. Some bleeds are within the skull (intracranial) and some are located between the skull and the skull’s covering (extracranial). Listed below are common causes of brain bleeds during delivery.
- Vacuum extraction delivery. A vacuum extractor is a small cup that is placed on the baby’s head so the physician can apply traction to help maneuver the baby through the birth canal. This is a risky device and specific criteria must be met before a physician uses it. The pressure of the suction cup can cause a serious bleed called a subgaleal hemorrhage. This occurs when the vacuum ruptures a vein and the vein bleeds into the space between the scalp and the skull. This can cause severe lack of oxygen in the baby’s brain. If the bleed is not properly managed, almost half of the baby’s blood volume can end up in the subgaleal space.
- Forceps delivery. Forceps look like salad tongs and are applied to each side of the baby’s head. Forceps must be precisely placed on the head, and it is critical that the physician not apply too much force. Forceps can cause trauma to the skull and spinal cord, as well as brain bleeds and hemorrhages.
- Hypoxic ischemic encephalopathy (HIE). Hypoxia (lack of oxygen in tissue) and ischemia (restricted blood flow), specifically an ischemia reperfusion injury, can cause the baby to have a brain bleed. An ischemia reperfusion injury is when something, such as a clot / stroke, causes a restriction of blood flow in the brain. When blood flow is restored in this area, there is a series of events that end up damaging blood vessels, making brain bleeds more likely.
Forceps and vacuum extractors can cause clots and strokes, thereby causing reperfusion injuries and brain bleeds.
Lack of Oxygen in the Baby’s Brain
Brain damage caused by a lack of oxygen in the baby’s brain is called hypoxic ischemic encephalopathy (HIE). HIE is caused by a lack of oxygen in the baby’s blood and / or a restriction of blood flow in the baby’s brain. Listed below are some conditions that can cause HIE and other conditions, such as cerebral palsy and seizures.
- Umbilical cord problems, such as a prolapsed umbilical cord, the cord being wrapped around the baby’s neck (nuchal cord), a short umbilical cord, and the cord being in a true knot can cause partial or complete oxygen deprivation in the baby.
- Uterine rupture. This occurs when there is a tear through all the layers of the womb. A ruptured uterus can cause severe hemorrhaging in the mother, and the baby may even spill into the mother’s abdomen.
- Oligohydramnios. This is a condition characterized by low amniotic fluid. Oligohydramnios puts the baby at a significant risk of having a prolapsed or compressed umbilical cord. It can also lead to meconium aspiration, which is when the baby inhales a mixture of amniotic fluid and stool into her lungs. This can cause respiratory distress and oxygenation problems.
- Premature rupture of the membranes (PROM). PROM occurs when the water breaks before the mother goes into labor. PROM can cause umbilical cord compression, premature birth and being born before the lungs are fully developed, which can cause a lack of oxygen to the baby’s brain. PROM also increases the chances of the baby getting an infection, which can lead to sepsis and meningitis.
- Prolonged and arrested labor. Contractions during labor are traumatic for the baby, and when it is prolonged, there can be a lack of oxygen to the baby’s brain that gets progressively worse, especially if Pitocin or Cytotec are used.
- Placental abruption. This is when the placental tears away from the uterus (womb).
- Placenta previa. This is when the placenta grows close to the opening of the uterus, which can partially or completely block the mother’s cervix (cervical os). The cervix is the opening to the birth canal. If the placenta remains close to or completely covers at the time of labor and delivery, delivery by C-section is required because cervical opening and uterine activity during vaginal delivery can cause hemorrhagic bleeding in the mother and even the baby. This can cause a severe lack of oxygen in the baby’s brain.
- Anesthesia mistakes can cause blood pressure problems and a hypotensive crisis in the mother. When a mother’s blood pressure drops too low, there will be a decreased supply of oxygen-rich blood going to the baby. When a mother hemorrhages, this will also cause her blood pressure to drop, thereby decreasing the oxygen supply to the baby.
- Fetal stroke. This is when blood vessels in the brain become blocked or restricted. Forceps and vacuum extractors can cause the baby to have a stroke, which can cause a severe lack of oxygen in the brain. Hypoxic ischemic encephalopathy (brain injury from oxygen deprivation) and stroke often occur together.
- Preeclampsia / eclampsia. This is when the mother has high blood pressure diagnosed during pregnancy. When hypertension occurs, there can be decreased flow of blood to the baby. There are a number of ways hypertension can cause this. One way is that the high blood pressure and factors associated with it cause damage to or constriction of the vessels in the placenta. When this happens, there is decreased flow of oxygen-rich blood to the baby through the placenta and umbilical cord.
- Preeclampsia also increases the risk of placental abruption. In addition, preeclampsia – or any long term pregnancy condition that can cause a baby to be deprived of oxygen – predisposes a baby to hypoxia during the stresses of labor.
Sometimes during delivery, the baby’s shoulder gets stuck behind the mother’s pelvic bone, thereby halting the progression of delivery. This is called shoulder dystocia. When dystocia occurs, the physician sometimes pulls too hard on the baby’s head, causing significant strain on nerves in the baby’s neck and shoulder. This strain can cause the nerves to tear or become severely damage, which is called a brachial plexus injury. Damaged and torn nerves can cause the baby’s arm to be paralyzed or extremely weak and dysfunctional, a condition called Erb’s palsy.
Babies who are macrosomic are at an increased risk of having shoulder dystocia. If a mother has gestational diabetes or is carrying her baby past the due date, the baby is at risk of being macrosomic and suffering shoulder dystocia. In these instances, a C-section delivery is often the safest method of delivery.
When shoulder dystocia is present and physicians do not move on to a C-section delivery, the baby will experience a prolonged labor and delivery, which can cause the baby to have hypoxia and develop HIE. In addition, physicians are more likely to use forceps and vacuum extractors in a shoulder dystocia situation, thereby increasing the baby’s risk of having a stroke and brain bleeds.
MICHIGAN BIRTH INJURY LAWYERS HELPING CHILDREN FOR ALMOST 3 DECADES
If you are seeking the help of a lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury cases. Reiter & Walsh ABC Law Centers is a national birth injury law firm that has been helping children for almost 3 decades.
Birth Injury lawyer Jesse Reiter, president of the Reiter & Walsh ABC Law Centers, has been focusing solely on birth injury cases for over 28 years, and most of his cases involve hypoxic ischemic encephalopathy (HIE) and cerebral palsy. Jesse is currently recognized as one of the best medical malpractice lawyers in America by U.S. News and World Report 2014, which also recognized ABC Law Centers as one of the best medical malpractice law firms in the nation. The lawyers at ABC Law Centers have won numerous awards for their advocacy of children and are members of the Birth Trauma Litigation Group (BTLG) and the Michigan Association for Justice (MAJ).
If your child was diagnosed with a birth injury, such as cerebral palsy, a seizure disorder or hypoxic ischemic encephalopathy (HIE), the award winning lawyers at ABC Law Centers can help. We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent. Our nationally recognized birth injury firm has 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 Reiter & Walsh ABC Law Centers at 888-419-2229 for a free case evaluation. Our firm’s award winning lawyers are available 24 / 7 to speak with you.