Improper Use of Forceps During Twin Delivery Causes Brain Bleeds, Brain Damage & Cerebral Palsy

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During birth of a second twin, the obstetrician used forceps to facilitate delivery. Sadly, the forceps were used improperly, causing the baby to have a major brain hemorrhage (severe bleeding), subdural hematomas and pronounced respiratory failure at birth. This negligence, coupled with improper care after birth, caused the baby to have severe brain damage and cerebral palsy.

Forceps are a medical instrument used to help move the baby out of the birth canal. The device looks like salad tongs, with the tongs applied to each side of the baby’s head. Forceps are very risky and thus require a lot of skill. If they are applied unevenly to the baby’s head, used for too long, or used with too much force, the baby can experience severe bleeding in the brain, which can cause hypoxic ischemic encephalopathy (HIE), seizures, brain damage, cerebral palsy and other birth injuries.

The mother in this case had a relatively uncomplicated pregnancy until she began having contractions and pooling of blood at 32 weeks of gestation. At the labor and delivery unit, the obstetrician did not discuss her delivery options, such as a C-section to deliver the twins. Instead, without informing her of the risks of and alternatives to a forceps delivery, the obstetrician delivered the second twin with forceps.

Immediately after birth, the second twin had a good Apgar score (9), which is an indication that he may not need medical intervention. But shortly after the score was taken, nurses noticed indentation marks on his head starting to take shape. The baby turned pale and limp. Within hours, the little boy was diagnosed with subdural hematomas, major hemorrhages and pronounced respiratory failure. Despite his dangerous brain bleeds and severe respiratory failure, the newborn was not admitted to the neonatal intensive care unit (NICU). Instead, he was placed in a NICU step-down unit. After four days, he was diagnosed with severe brain damage.


Forceps are not commonly used. As such, many obstetricians lack skill in their use, and this includes being unfamiliar with the standards of care that must be followed. In this case, multiple areas of negligence occurred. Firstly, the mother did not give informed consent to having forceps used for delivery of her twin. Obstetricians must inform patients of the risks and benefits of – as well as the alternatives to – all procedures and medications. The mother was not given the choice of having a C-section delivery, which is a safe alternative to forceps use. In addition, the risks, such as head trauma and brain bleeds, were not explained to her.

Secondly, delivery by forceps was actually contraindicated in this case, which means it was against the standard of care for the physician to deliver the twin using forceps. Forceps are contraindicated in babies who are less than 34 weeks of gestational age due to the risk of intraventricular hemorrhage, a dangerous type of brain bleed. Other contraindications to forceps use include:

  • Cephalopelvic disproportion (CPD), which occurs when the baby’s head is too large for the size of the birth canal.
  • Vacuum extractors have been used. An obstetrician may not use forceps after delivery has been attempted with a vacuum extractor.
  • Fetal demineralization disease, connective tissue disorders and fetal bleeding diathesis.

There are numerous prerequisites that must be met before an obstetrician may use forceps. If any of these prerequisites are not met, use of forceps is contraindicated. The prerequisites are:

  • The baby’s head must be engaged.
  • The cervix must be fully dilated.
  • The membranes must be ruptured.
  • The baby’s presentation, position, lie and any asynclitism (tilted head) must be known. If any of these are uncertain, an ultrasound should be performed. If ultrasound is not available, no more than one-fifth of the baby’s head should be palpable abdominally if the vertex is engaged.
  • The baby’s size must have been estimated with clinical pelvimetry, showing adequate dimensions.
  • The mother’s anesthesia must be satisfactory.
  • The mother’s bladder must be empty.
  • The risks of the procedure must have been fully explained to the mother.
  • The obstetrician must be willing to abandon attempts if the forceps are not working / labor is prolonged.
  • The obstetrician must have experience with and be skilled in use of forceps.

Misuse of forceps can cause the following types of brain bleeds:

  • Cephalohematoma. This is a collection of blood between the skull and its covering caused by ruptured vessels. Cephalohematomas are most commonly associated with forceps and vacuum extraction delivery. The swelling does not cross suture lines, which are bands of tissue that connect the bones of the skull. Also, there typically isn’t significant blood loss when a baby has a cephalohematoma. However, untreated cephalohematomas can cause severe infection in the baby, which can lead to pus-filled formations and death of parts of the skull. Infections causes by cephalohematomas can also cause meningitis.
  • Subdural hemorrhage or subdural hematoma. This is a ruptured blood vessel in the subdural space (the area between the surface of the brain and the thin layer of tissue that separates the brain from the skull). This type of brain bleed is usually accompanied by seizures, high levels of bilirubin in the blood, rapid swelling of the head, and retinal hemorrhages.
  • Subarachnoid hemorrhage. This is bleeding below the innermost of the two membranes that cover the brain. A subarachnoid hemorrhage can cause a baby to have seizures, lethargy, and apnea.
  • Cerebral hemorrhage. This is bleeding within the brain tissue itself.
  • Intraventricular hemorrhage (IVH). This is the most serious of all intracranial bleeds and it primarily occurs in premature babies since their blood vessels are weak. The bleeding occurs in the brain’s ventricular system, where spinal fluid is produced.


When a baby has a brain bleed, he should be admitted to the NICU for close observation and treatment. Brain bleeds put a baby at a high risk of suffering from seizures. Bleeds and hemorrhages must be diagnosed very quickly and EEG monitoring for seizures must take place. Treatment for brain bleeds includes making sure the baby’s blood pressure is normal and that the baby is getting help breathing if he needs it. Frequent measurements of red blood cells should be done, and in most cases, measurement of head size should be performed. Head imaging and blood clotting studies are also essential.

Treatment for blood loss includes giving the baby blood and other therapies to increase blood volume and blood pressure. This includes packed red blood cells, fresh frozen plasma, and normal saline administration. When the baby has a subdural hematoma, surgery to remove excess fluid and blood may need to be performed to decrease pressure inside the brain, and emergency surgery is needed when there is brain stem compression.


Another reason babies need to be admitted to the NICU is so they can get help breathing. Brain injury caused by brain bleeds and birth asphyxia can cause respiratory depression and difficulty breathing. Breathing problems include a decreased drive to breathe, apnea, a lot of secretions caused by meconium inhalation, and respiratory distress syndrome (RDS). In more severe cases of brain injury, the baby may be in respiratory failure.

RDS is associated with a difficult delivery and birth asphyxia. RDS is also common in premature babies and it is usually caused by a deficiency of surfactant in the baby’s lungs due to premature birth. Surfactant is a lipoprotein produced by the lungs to help the lungs be more compliant and able to easily expand and retract. When a baby has insufficient surfactant, his lungs will be stiff and there can be a lot of collapsed airways (alveoli). This can make it very difficult for the baby to breathe, even if he is on a ventilator (breathing machine). Stiff lungs on a vent can become seriously injured. In addition, babies with stiff lungs and respiratory distress are prone to getting lung infections and pneumonia. Stiff lungs, collapsed airways and infection can cause the baby to suffer from a lack of oxygen to his brain, which can cause hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia (PVL) and cerebral palsy. Thus, surfactant is very important for the baby. If the baby is born before 35 weeks – and especially if he is born before 30 weeks – he will likely require surfactant therapy.

Respiratory failure can be caused a brain injury that hinders the baby’s ability to breathe and decreases the baby’s drive to breathe. It can also be caused by mismanaged respiratory distress.

If a baby’s vent settings are not properly managed, the baby may receive breaths that are too large and fast, which can cause overventilation injuries such as hypocarbia and a pneumothorax (hole in the lung). Overventilation injuries can cause the baby to have PVL, cerebral palsy and hypoxic ischemic encephalopathy (HIE).

When a baby is on a vent, the medical team must carefully monitor the vent settings and the baby’s response to these settings. The baby will be slowly weaned off the machine so he can start breathing on his own.


When a baby is not getting enough oxygen to his brain, a progression of brain injury can occur that can cause permanent brain damage and lifelong conditions such as cerebral palsy. Oxygen deprivation that occurs during or near the time of birth is called birth asphyxia or hypoxia. After birth, oxygenation problems are usually referred to as hypoxia. Ischemia (insufficient blood flow) in the brain can be caused by birth asphyxia, hypoxia, stroke, blood pressure problems, brain bleeds and numerous other medical problems. Ischemia can also cause brain damage, cerebral palsy and other long-term problems.

Listed below are birth injuries that can be caused by birth asphyxia, hypoxia and ischemia:


If you are seeking the help of a birth injury 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 with birth injuries for almost 3 decades.

birth injury attorneysBirth injury lawyer Jesse Reiter, president of 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. Partners Jesse Reiter and Rebecca Walsh are currently recognized as being two of the best medical malpractice lawyers in America by U.S. News and World Report 2015, 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 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.

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