A mother whose baby went past the due date was given Cytotec to induce labor. When the mother’s labor stopped, she was given Pitocin. The medical team did not continuously monitor the baby’s heart rate with the fetal heart monitor; the monitor was taken off at various times during delivery. At birth, which was 13 hours after the mother arrived at the delivery unit, the baby needed resuscitation because she wasn’t breathing, but this was delayed for 20 minutes because the attending physician was not present. The newborn’s Apgar scores were low and her umbilical cord blood gas values showed that her blood was acidic (low pH). Low Apgar scores can mean the baby is in poor health at birth, and an acidic pH typically means the baby was being significantly deprived of oxygen.
Sadly, the oxygen deprivation during labor and delivery and the delayed resuscitation caused the newborn to have hypoxic ischemic encephalopathy (HIE), cerebral palsy and intellectual disabilities (cognitive deficits). The little girl requires 24-hour assistance.
The use of Pitocin was excessive, causing hyperstimulation of the uterus, which caused oxygen deprivation (birth asphyxia) in the baby. The baby’s heart rate was not continuously monitored, and when it was monitored, the mother’s heart rate was mistakenly recorded as the baby’s. The medical team therefore was not aware of the fact that the baby was experiencing birth asphyxia and in distress. The baby should have been delivered a lot sooner by emergency C-section, and at birth, a proper team should have been available to perform resuscitation maneuvers. Failure to follow standards of care with respect to these issues caused the baby’s brain to be deprived of oxygen for too long, which caused HIE, permanent brain damage and lifelong problems for the little girl.
Pitocin and Cytotec Can Cause Birth Asphyxia and HIE (Hypoxic Ischemic Encephalopathy)
Cytotec and Pitocin are drugs used to start or speed up labor, although Cytotec is not approved for this type of use. Cytotec is a pill that is inserted into the vagina to cause contractions and ripening of the cervix. Pitocin is typically given by IV during the birthing process to initiate contractions and to increase the frequency and strength of contractions.
The use of these labor drugs is risky, especially if they are used together. Some of the serious risks associated with them include hyperstimulation and hypertonicity of the uterus, as well as uterine rupture.
Hyperstimulation (tachysystole) is a side effect of Cytotec and Pitocin, and it can seriously hinder the flow of blood through the placenta and umbilical cord, thereby causing oxygen deprivation in the baby. As hyperstimulation continues, oxygen deprivation in the baby gets progressively worse. Hypertonicity occurs where there is no rest in between contractions, which severely interferes with oxygen delivery to the baby.
Hyperstimulation and hypertonicity cause oxygen deprivation because in between contractions, the placenta fills with the mother’s blood and is relayed to the baby through the umbilical cord. When the uterus contracts, the flow of blood in or out of the placenta slows or stops. Between contractions, the placenta is at rest and blood flows freely. For the placenta to function properly, there must be sufficient time between contractions for the placenta to recharge with a fresh supply of oxygen-rich blood. Hyperstimulation and hypertonicity induced by Pitocin or Cytotec can cause contractions that occur less than 2-3 minutes apart, which limits the placenta’s ability to recharge with a fresh supply of oxygen-rich blood.
When the baby’s brain is deprived of oxygen for too long, a cascade of cellular events occur that cause cell injury and death, which can lead to the baby having hypoxic ischemic encephalopathy and other types of brain injury. On an MRI, HIE can be seen as damage to the white and/or gray matter of the brain, and sometimes fluid in the brain (edema) can also be seen. HIE is one of the most common causes of cerebral palsy and other types of brain damage, including periventricular leukomalacia (PVL).
When a mother is experiencing hyperstimulation or hypertonicity, the medical team must stop the administration of Pitocin. Cytotec, on the other hand, cannot be easily stopped because the pill is absorbed by vessels in the mother’s vagina. Both drugs are risky because there is no way to predict how a mother will tolerate them.
Oxygen deprivation and fetal distress often manifest on the fetal heart monitor as decelerations (decrease in heart rate below the baby’s baseline) and tachycardia (fast heart rate), which are nonreassuring heart tracings. Fetal distress is a sign that the baby is being deprived of oxygen. When distress occurs, an emergency C-section must usually take place to prevent HIE, brain damage and cerebral palsy.
Hyperstimulation can cause one of the most serious pregnancy conditions, uterine rupture. A ruptured uterus occurs when excessive contractions associated with hyperstimulation cause the uterus to tear, either partially or completely. This is dangerous because it can cause birth asphyxia in the baby by either causing the mother to lose so much blood that she is unable to supply enough to the baby, or by causing the umbilical cord or placenta to tear away from the uterus, thereby cutting off the baby’s connection to oxygen-rich blood from the mother. When uterine rupture occurs, the baby is at risk for HIE and brain damage.
Birth Asphyxia, HIE and Neonatal Brain Damage
Birth asphyxia occurs when the baby receives inadequate oxygen to her brain. This can be caused by anything that affects blood flow to the baby. In the womb, the baby receives all her oxygen from oxygen-rich blood delivered to her from the mother. The blood travels from the mother through the uterus and placenta and then into the baby via the umbilical cord. Blood flow to the baby takes the following path: maternal circulation –> uteroplacental blood vessels –> umbilical cord vein –> fetal cardiopulmonary system.
Birth asphyxia can lead to hypoxia (a lack of oxygen) and hypercarbia (high carbon dioxide levels) in the blood. Severe hypoxia causes lactic acid production in the baby’s muscle and heart tissues and then in the brain, which is a major cause of acidic umbilical cord blood (a low pH). The extent of brain injury caused by hypoxia is determined by the length of time and severity of the hypoxia as well as the fetal reserves. Treatment of the baby after birth also affects the extent of the brain damage; if proper management of the baby’s oxygenation, ventilation, and cardiopulmonary/vascular status doesn’t occur, brain damage can get worse.
Hypoxic ischemic encephalopathy (HIE) is a brain injury caused by hypoxia and ischemia. HIE usually involves damage to the basal ganglia and watershed regions of the brain, but sometimes also includes periventricular leukomalacia (PVL).
HIE often causes permanent brain damage and lifelong conditions such as the following:
- Cerebral palsy
- Seizure disorders
- Intellectual disabilities
- Developmental delays
- Motor disorders and low muscle tone
Continuous Fetal Heart Rate Monitoring to Prevent Prolonged Birth Asphyxia, HIE and Brain Damage
When a mother is admitted to the labor and delivery unit, it is the standard of care to continuously monitor the baby’s heart rate. If the medical team lacks skill in fetal heart rate interpretation, nonreassuring heart tracings can be missed, which is what occurred in the case discussed earlier; the team mistook the mother’s heart tracings for the baby’s. When nonreassuring heart tracings are not recognized, it is likely that nobody on the medical team will be aware that the baby is experiencing birth asphyxia. Indeed, nonreassuring heart tracings during labor and delivery are often the only sign that a baby is being deprived of oxygen, which is why it is the standard of care to continuously monitor a baby’s heart rate throughout labor and delivery. When the baby is experiencing birth asphyxia and fetal distress, she must be delivered right away in order to get her out of the oxygen-depriving conditions and breathing on her own. In addition, a baby cannot be directly helped when in the womb.
The longer a baby goes without oxygen and the more severe the oxygen deprivation, the more extensive the brain injury. This is why it is of critical importance to recognize fetal distress and act on it by quickly delivering the baby, which usually must occur by an emergency C-section.
Delayed Resuscitation at Birth Can Cause HIE and Permanent Brain Damage
When a baby is having heart, blood pressure or breathing problems at birth, a delay in performing resuscitative maneuvers can cause the baby to be deprived of oxygen for too long, which can cause damage to the baby’s organs, including the heart and brain. It is the standard of care for hospitals to have a resuscitation team immediately available for all babies being delivered.
Respiratory distress, low blood pressure and other newborn cardiopulmonary / vascular issues can cause a baby to go into full cardiac arrest if there is a delay in resuscitation. The progression to a full code in a baby is as follows: 1.) respiratory distress, 2.) respiratory failure / shock, 3.) cardiopulmonary failure, and finally, 4.) cardiopulmonary arrest.
The resuscitation team often has to use medications and maneuvers, such as chest compressions and “bagging” the baby, to help the baby breathe and have adequate cardiovascular function. Bagging is when a mask that is attached to a bag goes over the baby’s face and gentle breaths are forced into the baby’s airway. The baby may also need to be intubated, which is when a tube is placed in the baby’s upper airway so a breathing machine can help her breathe. If a baby’s heart stops or is in a dangerous rhythm, the physician may use a defibrillator to send an electric shock to the heart to restore normal rhythm.
Another important part of resuscitation is restoring blood volume and pressure if the baby lost a lot of blood during delivery, which can occur with conditions such as vasa previa. When vasa previa or any other condition occurs that causes the baby to lose blood, someone from the medical team should quickly order blood so it is ready for transfusion right away if the baby needs it. Treatments to increase blood volume include IV fluids and colloids (such as blood).
In the case discussed above, resuscitation of the baby was delayed for 20 minutes because the attending physician was not present. This is a major violation of the standard of care. Firstly, all members of the medical team assisting in delivery should be trained to initiate neonatal resuscitation. Secondly, a resuscitation team is supposed to arrive within minutes of being called. Thirdly, an attending physician is supposed to be immediately available in all labor and delivery units. Delayed resuscitation can cause a baby to have hypoxic ischemic encephalopathy, periventricular leukomalacia, seizures, permanent brain damage and lifelong conditions such as cerebral palsy.
Birth Injury Attorneys Helping Children Who Have Hypoxic Ischemic Encephalopathy, Brain Damage and Cerebral Palsy
If your child was diagnosed with a birth injury, such as cerebral palsy, a seizure disorder or hypoxic ischemic encephalopathy (HIE), the award winning birth injury 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.