Macrosomia and HIE in the News
A child now has hypoxic ischemic encephalopathy (HIE), intellectual (cognitive) disabilities, learning disabilities, developmental delays and Erb’s palsy because the obstetrician failed to perform an emergency C-section when the baby was experiencing birth asphyxia and shoulder dystocia.
A new mother who had diabetes and pregnancy-induced hypertension was admitted to the hospital at 37 weeks gestation for delivery of her baby. Her primary obstetrician had told her that her baby was becoming too large (macrosomic) and that shoulder dystocia could be a problem. At the labor and delivery unit, the mother had a new obstetrician caring for her. She told him about her primary doctor’s concerns regarding shoulder dystocia. The obstetrician assured her that delivery would be fine; the baby’s head was in the normal, head-first position with normal fetal movement.
During the last few hours of delivery, however, there were several complications, including abnormal fetal heart rates, which showed up on the fetal heart monitor as nonreassuring heart tracings. Nonreassuring tracings mean the baby is in distress and not getting enough oxygen to her brain (birth asphyxia). In addition to the birth asphyxia, the mother’s second stage of labor was prolonged and the baby’s arm was stuck on the mother’s pelvis (shoulder dystocia). Despite these obstetrical emergencies, the obstetrician continued to force a vaginal delivery, even though an emergency C-section was clearly indicated. The doctor pulled too hard on the baby’s head in an attempt to deliver her. At birth, the baby’s arm hung limply at her side because the force the doctor applied to her head caused important nerves to be stretched and torn. The newborn was also blue and floppy. The prolonged birth asphyxia caused her to develop a brain injury called hypoxic ischemic encephalopathy (HIE). This resulted in permanent brain damage and the child being diagnosed with intellectual (cognitive) disabilities, learning disabilities and developmental delays.
What Are the Risks of Macrosomia?
When a mother has diabetes, her glucose (blood sugar) levels are elevated, which causes the unborn baby to have excess glucose. The high levels of glucose can cause the baby to grow very large, which is a condition called macrosomia. Macrosomia, also known as large for gestational age, is a condition in which a fetus or newborn weighs more than 4000 grams, although the risk increases greatly at 4500 grams. A C-section delivery is usually the safest way to deliver a baby who is macrosomic because macrsomia can cause numerous risky problems during labor and delivery. In this section, we’ll discuss some of the problems that can occur if a baby is macrocosmic.
Macrosomia and Prolonged Labor
Prolonged labor is associated with the baby not getting enough oxygen (hypoxia) and fetal distress. In addition, when the second stage of labor is prolonged or arrested, the baby is at an increased risk of getting an infection that travels from the mother to the baby at birth. These infections can cause the baby to develop sepsis and meningitis. When labor is prolonged, the baby is also at an increased risk of the doctor using forceps or vacuum extractors to assist with vaginal delivery. These dangerous delivery devices can cause brain bleeds and hemorrhages. Prolonged labor is indeed very risky and it can cause the baby to have hypoxic ischemic encephalopathy (HIE), cerebral palsy, seizures, developmental delays and other lifelong problems.
Macrosomia and Shoulder Dystocia
Shoulder dystocia is when the baby’s shoulder becomes stuck on the mother’s pelvis during the process of labor and delivery. Large babies have a significant risk of thisoccurring. When shoulder dystocia occurs, the doctor may use forceps or vacuum extractors to help deliver the baby, which can cause brain bleeds. Another very serious risk associated with macrosomia and shoulder dystocia is the baby’s umbilical cord becoming compressed between the baby and mother (usually the mother’s pelvis). When the cord is compressed, impinged upon or occluded, the baby can be severely deprived of oxygen-rich blood, causing birth asphyxia. When umbilical cord compression / occlusion occurs, the baby must be delivered right away by an emergency C-section. In fact, the risks associated with shoulder dystocia and macrosomia are so great that a C-section delivery is usually the safest way to deliver the baby.
Macrosomia and Erb’s Palsy
Erb’s palsy is another serious risk of forcing a vaginal delivery when shoulder dystocia is present. Sometimes when the shoulder is stuck in the birth canal, the doctor will pull too hard on the baby’s head. This excessive force can cause the brachial plexus nerves, which are nerves in the shoulder and neck area, to become stretched and torn. The stretching and tearing can cause arm weakness and paralysis, causing the baby’s arm to hang limply at her side, which is called Erb’s palsy. Macrosomia and shoulder dystocia are very serious conditions that can cause birth asphyxia, hypoxic ischemic encephalopathy (HIE), cerebral palsy and Erb’s palsy.
Macrosomia and Uterine Rupture
Uterine rupture. Macrosomic babies are also at risk of experiencing a ruptured uterus (womb), which is when there is a complete tear through all layers of the uterus. A uterine rupture can cause the baby to be deprived of oxygen in multiple ways. When a rupture occurs, the mother usually loses so much blood that there is a severe reduction in oxygen-rich blood being delivered to the baby, which can cause the baby to have birth asphyxia. A ruptured uterus is an obstetrical emergency that requires the baby to be delivered right away by emergency C-section to prevent birth asphyxia and hypoxic ischemic encephalopathy (HIE).
Macrosomia, Fetal Distress and Hypoxic Ischemic Encephalopathy (HIE)
It is the standard of care to continuously monitor the unborn baby during labor and delivery with a fetal heart rate monitor. When the baby begins to experience oxygen deprivation and distress, the fetal heart tracings will become nonreassuring. When this occurs, the baby must be delivered right away, usually by an emergency C-section. Failure to quickly deliver a baby being deprived of oxygen can result in permanent brain damage caused by prolonged birth asphyxia. The more severe the birth asphyxia and the longer it lasts, the more severe the brain damage will likely be.
The consensus among most experts is that that when nonreassuring heart tracings first appear and are indicative of an obstetrical emergency requiring quick delivery, a C-section must occur within 30 minutes, and in many cases, the C-section should occur within 18 minutes. In some cases, such as when the mother experiences cardiac arrest, or there is complete umbilical cord occlusion, complete placental abruption, massive blood loss or slow fetal heart rate, the baby should be delivered within 5 minutes; delivery taking longer than 15 minutes could cause severe brain damage and death of the baby.
What Causes HIE?
Conditions that can cause birth asphyxia and hypoxic ischemic encephalopathy are listed below:
- Umbilical cord problems, such as a nuchal cord (cord wrapped around baby’s neck), umbilical cord prolapse, short umbilical cord and cord in a true knot
- Ruptured uterus
- Preeclampsia / eclampsia
- Placental abruption
- Placenta previa
- Anesthesia mistakes, which can cause blood pressure problems in the mother, including a hypotensive crisis. This can greatly decreases the supply of oxygen-rich blood going to the baby, causing birth asphyxia.
- Oligohydramnios (low amniotic fluid)
- Premature rupture of the membranes (PROM) / premature birth
- Prolonged and arrested labor
- Intracranial hemorrhages (brain bleeds), which can be caused by a traumatic delivery. Forceps and vacuum extractors can cause brain bleeds. Sometimes intense contractions (hyperstimulation) caused by labor induction drugs (Pitocin and Cytotec) can cause head trauma. Mismanagement of cephalopelvic disproportion (CPD), abnormal presentations (face or breech presentation), and shoulder dystocia also put the baby at risk of experiencing birth trauma and birth asphyxia.
- Hyperstimulation caused by Pitocin and Cytotec can also cause oxygen deprivation that gets progressively worse.
- Fetal stroke
- Postmaturity syndrome
- Placental insufficiency and intrauterine growth restriction (IUGR)
- Fetal stroke
- Postmaturity syndrome
Some high risk pregnancy conditions can deprive a baby or oxygen long-term. In these instances, doctors will usually recommend a planned, early delivery. Early delivery is usually scheduled for a time in which the baby’s lungs and other body systems are mature enough to minimize premature birth complications. Early delivery typically occurs at a time in which the risks of remaining in the womb are greater than the risks of being born early. Early deliveries are often scheduled when the mother has hypertension, preeclampsia, diabetes, gestational diabetes, IUGR, oligohydramnios, a twin pregnancy, vasa previa, placenta previa, and placental abruption. Of course, sometimes these conditions cause problems that require an unplanned, emergency C-section delivery.
Does Hypoxic Ischemic Encephalopathy (HIE) Always Cause Brain Damage, Intellectual Disabilities, Learning Disabilities, Developmental Delays, or Cerebral Palsy?
Hypoxic ischemic encephalopathy (HIE) is a brain injury caused by insufficient oxygen in the baby (hypoxia) and reduced blood flow to the baby’s brain (ischemia). HIE is often caused by the baby not getting enough oxygen during or near the time of labor and delivery. If the HIE is mild and properly treated, that baby may have no permanent brain injury and lifelong problems. Often, however, babies with hypoxic ischemic encephalopathy (HIE) develop permanent brain damage.
Brain injury, including HIE, is an evolving process. Thus, brain scans need to be taken at regular intervals to see how the brain damage is progressing and to see the extent of the injury. Brain damage can evolve over many weeks.
There is a treatment for hypoxic ischemic encephalopathy that halts almost every injurious process that starts to occur when the brain experiences an oxygen-depriving insult. This treatment is called hypothermia (brain cooling) treatment and it must be given within 6 hours of the time the baby experienced oxygen deprivation. This usually means the treatment must be given within 6 hours of labor and delivery. Hypothermia treatment can prevent the brain injury from becoming severe enough to cause cerebral palsy and other motor disorders, or the treatment may reduce the severity of the CP.
Below are some conditions that can be caused by birth asphyxia and hypoxic ischemic encephalopathy (HIE):
- Permanent brain damage
- Seizure disorders
- Cerebral palsy (CP)
- Intellectual disabilities
- Developmental delays
- Learning Disabilities
- Motor disorders
When a premature baby experiences birth asphyxia, she is more likely to develop a brain injury called periventricular leukomalacia (PVL), although premature babies can also develop HIE. And while term babies are more likely to develop hypoxic ischemic encephalopathy as a result of birth asphyxia, they can also develop PVL. Hypoxic ischemic encephalopathy usually involves damage to the basal ganglia, cerebral cortex or watershed regions of the brain, but it sometimes includes PVL.
Reiter & Walsh, P.C. | Award-Winning Birth Injury and Hypoxic Ischemic Encephalopathy Lawyers
If you are seeking the help of a birth injury or hypoxic ischemic encephalopathy 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.
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.