A young woman’s obstetrician decided to induce labor at 32 weeks because the woman had preeclampsia and it was posing serious risks to the baby. Instead of performing a C-section, the doctor induced labor with Pitocin. During labor, the baby’s heart rate became nonreassuring, indicating that the baby was experiencing birth asphyxia. Instead of performing an emergency C-section, the doctor allowed labor to progress for 3 more hours. When the baby was finally born, it was discovered that her umbilical cord was wrapped around her neck, which is called a nuchal cord. The nuchal cord had caused the birth asphyxia and the premature baby was soon diagnosed with a brain injury called periventricular leukomalacia (PVL). The PVL caused permanent brain damage and the little girl now has cerebral palsy.
Nuchal Cord (Cord Wrapped Around Baby’s Neck) and Birth Asphyxia
When the baby is in the womb, she receives all her oxygen from oxygen-rich blood delivered to her from her mother. Blood flows from the mother, through the placenta, and then into the baby through the umbilical cord. The placenta is an organ that acts similarly to the lungs. Oxygen diffuses through vessels in the uterus and placenta and is then carried to the baby through a vein in the umbilical cord. Anything that affects the uterus, placenta and umbilical cord can cause the baby to receive insufficient oxygen.
When the cord is wrapped around the baby’s neck, the baby can experience birth asphyxia in a number of ways. The cord can become compressed, restricting blood flow in the cord. The umbilical cord can also impede blood flow in arteries in the baby’s neck. Both of these conditions can cause congestion of blood in the baby, meaning less blood is involved in circulation. Sometimes a true knot forms in the nuchal cord, further increasing the risk of cord compression.
Birth asphyxia is a daunting condition, but the medical team is supposed to be continuously monitoring the baby’s heart rate during labor and delivery. With proper monitoring and interpretation of the fetal heart rate strips, birth asphyxia will be detected. This is because oxygen deprivation causes nonreassuring heart tracings. Once the tracings become nonreassuring, the medical team must act quickly. This usually entails quickly delivering the baby by C-section in order to get her out of the oxygen-depriving conditions. Indeed, it is not only the standard of care for hospitals to continuously monitor the baby’s heart rate during labor, but hospitals that hold themselves out as labor and delivery units must have the capacity to quickly perform an emergency C-section if the baby becomes distressed.
Periventricular Leukomalacia, Hypoxic-Ischemic Encephalopathy, and Cerebral Palsy
Prolonged birth asphyxia can cause brain injury, usually in the form of periventricular leukomalacia (PVL) and hypoxic ischemic encephalopathy (HIE). Due to the stages of development of a baby’s brain, premature babies are more susceptible to periventricular leukomalacia and term babies are more likely to experience hypoxic ischemic encephalopathy, although both conditions can occur in term and preterm babies. HIE usually involves damage to the basal ganglia, cerebral cortex or watershed regions of the brain, but it sometimes includes periventricular leukomalacia (PVL).
Periventricular leukomalacia (PVL) refers to white matter brain injury characterized by the softening and death of white matter near the brain’s lateral ventricles, which are located in the top section of the brain and provide pathways for cerebral spinal fluid. When white matter tissue dies or becomes severely damaged, fluid-filled cysts may be left behind.
Periventricular leukomalacia and hypoxic ischemic encephalopathy can cause permanent brain damage and lifelong conditions such as the following:
- Cerebral palsy
- Seizure disorders
- Motor disorders
- Developmental delays & disabilities
- Intellectual (cognitive) disabilities
- Learning disabilities
In this case, the mismanaged nuchal cord caused the premature baby to experience birth asphyxia for too long, which caused periventricular leukomalacia. The PVL led to permanent brain damage, resulting in the child having cerebral palsy.
Periventricular leukomalacia (PVL) is the most common ischemic (reduced blood flow) brain injury in premature infants and it frequently causes cerebral palsy, especially spastic cerebral palsy.
High-Risk Conditions and Scheduled Early Delivery
Although the obstetrician in this case violated standards of care by failing to quickly deliver the baby when she became oxygen-deprived and distressed, the doctor does appear to have followed standards of care by scheduling an early delivery when the mother had a high risk condition such as preeclampsia. Preeclampsia can become so risky that it is safer to deliver the baby early than to continue the pregnancy.
Preeclampsia is a condition characterized by high blood pressure and dysfunction of some major organs in the mother. It can cause a reduced flow of blood to the baby, which can cause the baby to have long-term nutrient and oxygen deprivation (hypoxia). Preeclampsia must be very closely monitored and managed. Even mild forms can progress to severe forms of the disease, causing the baby to experience a sudden (acute), severe form of hypoxia. In addition to long-term hypoxia as well as acute hypoxia, preeclampsia poses the risk of the mother developing eclampsia, which is when the mom experiences a seizure. This requires prompt treatment of the mother and immediate delivery of the baby to prevent permanent brain damage and even death of the mom and infant.
Preeclampsia often causes a baby to experience intrauterine growth restriction (IUGR), also called fetal growth restriction (FGR). Intrauterine growth restriction increases a baby’s risk of birth injuries such as hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia (PVL) and resultant cerebral palsy. In addition, babies experiencing IUGR often do not tolerate labor well, which is why an early C-section delivery is often scheduled when IUGR is present.
Other complications associated with preeclampsia include placental abruption and premature birth, which increase a baby’s risk of experiencing birth asphyxia, periventricular leukomalacia, hypoxic ischemic encephalopathy and cerebral palsy.