Hypoxic-ischemic encephalopathy (HIE) is a condition caused by a lack of oxygen in the brain. Newborn HIE may involve a lack of oxygen in the baby’s blood (hypoxemia/hypoxia) or a lack of blood flow in the baby’s brain (ischemia) (1). Babies can become deprived of oxygen during labor and delivery, shortly before labor, or shortly after birth. When a baby is oxygen-deprived, immediate delivery is needed in most cases. This is because the physician must get the baby out of the oxygen-depriving conditions in the womb. Furthermore, the physician cannot directly help the baby with oxygenation, circulation, or ventilation while the baby is in the womb. Often, the fastest and safest way to deliver a baby is by an emergency C-section. When a baby is left in oxygen-depriving conditions because the physician spends too much time trying to deliver the baby vaginally and a C-section is delayed, the oxygen deprivation can cause HIE and other permanent brain injuries, such as cerebral palsy (CP) and intellectual and developmental disabilities (I/DD).
Preventing hypoxic-ischemic encephalopathy: monitoring fetal heart rate during labor
When a baby is still in the womb, the best way to tell if it is being deprived of sufficient oxygen is to pay close attention to the electronic fetal heart rate monitor. The fetal monitor is the only tool to tell whether the baby is getting enough oxygen. The fetal heart rate, shows up as a tracing on a graph. The fetal heart rate monitor tracks the baby’s heart rate in response to the mother’s contractions. Clinicians must be skilled in fetal heart tracing interpretation. They must closely watch and interpret the tracings during labor and delivery, especially if the pregnancy or labor is high risk. When a baby becomes oxygen-deprived, the fetal heart tracing will be abnormal or “nonreassuring,” and this information is usually the only indication that a baby is in distress and not getting enough oxygen (2). When this is the case, the plan must change to emergency delivery, usual by c-section.
Conditions that increase the risk of HIE
There are numerous conditions that can increase the risk of HIE. These include:
Fetal malpresentation and HIE
Malpresentation: Fetal malpresentation is a situation in which the baby is not in the normal head-first position for delivery and is instead presenting face-first, brow-first, breech, or in another unusual way. Malpresentation is associated with prolonged labor, as well as umbilical cord problems, which can be especially concerning as the umbilical cord is the baby’s connection to oxygen-rich blood from the mother. Face presentation is associated with multiple nuchal cords (when the cord is wrapped around the baby’s neck more than once). This can cause cord compression, thereby reducing or entirely cutting off oxygen-rich blood flow to the baby. A nuchal cord can also be so tight that it pushes on the vessels in the baby’s neck, restricting blood flow to the brain. Breech presentation is associated with nuchal cord and prolapsed umbilical cord (when the cord exits the birth
canal in front of the baby and is compressed by the baby’s body). When the baby’s cord becomes compressed, immediate delivery is needed to avoid oxygen deprivation, HIE, and death (3).
The physician should be closely monitoring the mother and baby and have the skill to notice when a baby is in an abnormal position. During any delivery (but especially one in which the baby is abnormally positioned), it is imperative to have the capacity to quickly move on to an emergency C-section.
Cephalopelvic disproportion and HIE
Cephalopelvic disproportion (CPD) is when the baby’s head is too large for the size of the mother’s pelvis. The physician should measure the mother’s pelvis at her first prenatal visit. Then, the physician must pay close attention to the baby, so the medical team can determine if the baby will be too large to fit through the birth canal (4). If the mother’s pelvis is small, an average-sized baby may not fit. Sometimes, the baby becomes macrosomic (large) due to gestational diabetes or other factors. Whatever the reason, if the baby cannot or is not likely to fit through the birth canal, the physician must change the plan and deliver by C-section.
It is crucial for the physician to be aware of the presence of CPD. It can be very dangerous for the physician to attempt vaginal delivery when CPD is present. Trying to vaginally deliver a baby that cannot fit through the birth canal can prolong labor, fetal distress and traumatic birth brain injury. When labor is prolonged, physicians may be tempted to use risky delivery methods (including using forceps or vacuum extractors) which greatly increases the chance of the baby suffering from an intracranial hemorrhage (brain bleed) and resultant HIE. Oftentimes, physicians spend too much time trying to use these risky instruments instead of quickly moving on to an emergency C-section.
Physicians may also use the labor induction drugs Pitocin or Cytotec to speed up delivery. These drugs can cause contractions to be so strong and fast the baby becomes deprived of oxygen. Like with forceps and vacuum extractor use, if the baby is not going to fit through the birth canal, attempting to speed up labor will not help, and will only delay the correct delivery method (C-section). Indeed, if labor induction drugs cause a hypertonic uterus (when the uterus is in a nearly constant state of contraction), the baby must immediately be delivered by C-section because hypertonic uterine contractions can cause oxygen deprivation in a baby to become progressively worse.
Placental abruption and HIE
Placental abruption is a condition in which the placenta becomes either partially or completely separated from the uterus (5). Abruption is dangerous because the placenta connects the baby to the uterus. If the placenta separates from the womb completely, the baby will be totally cut off from the mother’s blood vessels. This means there is no way for oxygen-rich blood to pass through the umbilical cord to the baby. In the case of a complete abruption, the baby must be delivered by emergency C-section in a matter of minutes (5).
In the case of a partial abruption, the physician should be prepared to perform an emergency C-section because partial abruptions can turn complete or severe very quickly. The urgency of the delivery depends on multiple factors: the location of the placental separation, the length of time of the separation, the age of the baby, and the amount of reserve the baby has. The mother and baby must be closely monitored when any type of abruption is present; the fetal heart monitor can notify the physician of fetal distress. Failure to quickly deliver a baby when placental abruption is severe can cause oxygen deprivation and HIE.
Uterine rupture and HIE
Uterine rupture is a condition in which the wall of the uterus tears open. This can occur due to the forces of labor (especially if a woman has a scar from a previous C-section). When the uterus ruptures, the baby and placenta can move into the mother’s abdomen (6). This can cause the baby to be deprived of oxygen in two different ways: uterine ruptures can cause the mother to lose so much blood that not enough oxygen-carrying blood can be delivered from her to the baby through the umbilical cord, or the rupture causes the placenta to be cut off from circulation. When uterine rupture occurs, complete oxygen-deprivation is common, as well as fetal or neonatal death. An emergency C-section is mandatory in cases of rupture due to the potentially devastating consequences of the condition.
Placenta previa and HIE
Placenta previa is a condition in which the placenta either partially or totally covers the cervical opening . A placenta previa is typically characterized as either: 1.) a complete placenta previa – in which the placental tissue completely covers the cervical opening; or, 2.) a partial or marginal placenta previa in which the placenta only partially covers the cervical opening (7).
Hemorrhagic placenta previa is typically characterized by painless third trimester bleeding. Often, bleeding occurs with the cervical changes and related uterine contractions that occur as the pregnancy advances through the third trimester. As a result, when the cervical opening becomes wider and/or uterine activity occurs, the placenta previa can become hemorrhagic, causing the mother – and sometimes the baby – to hemorrhage (bleed suddenly and profusely). Because of this, the physician must closely monitor a mother diagnosed with complete placenta previa; delivery via C-section is often necessary well before the time when any uterine activity or related cervical changes are likely to occur.
Since a complete placenta previa covers the cervical opening, vaginal delivery is never safe. It has long been recognized that placenta previa may cause life-threatening hemorrhage in less than fifteen minutes, and that the amount or extent of hemorrhage associated with placenta previa is often unpredictable. Furthermore, because a baby’s circulating blood volume is so low, fetal hemorrhage associated with placenta previa is particularly dangerous, and may lead to the baby’s death or HIE and severe brain damage if not properly managed (7).
Preeclampsia and HIE
Preeclampsia is a disease which occurs during pregnancy, characterized by high blood pressure and protein in the urine. Preeclampsia is generally classified as being mild, moderate, or severe. In many cases, a mother with mild preeclampsia can rapidly progress to a more severe form. When preeclampsia is undiagnosed or untreated, there are significant risks to the baby (8). Preeclampsia causes blood vessel problems in the placenta, which can cause a decrease in the flow of oxygen-rich blood from the placenta to the baby.
A physician caring for a mother with preeclampsia must conduct thorough maternal evaluations to continually assess the extent of the disease. In addition, the physician must initiate a regimen of fetal surveillance to determine what effects the preeclampsia may be having on the baby. Due to the extreme risks associated with even mild to moderate preeclampsia, many physicians deliver the baby prior to term. Preeclampsia can sometimes occur during labor and delivery. Thus, it is crucial that physicians closely and skillfully watch the fetal heart monitor so that the baby can be quickly delivered by emergency C-section at the first signs of oxygen deprivation and fetal distress. Physicians must also pay close attention to the mother’s blood pressure during labor and delivery, especially if she has risk factors for preeclampsia. Preeclampsia is also associated with placental abruption. As discussed earlier, if an emergency C-section isn’t performed when a severe abruption occurs, the baby can develop HIE.
Hypoxic-ischemic encephalopathy (HIE) and medical malpractice
Physicians must continuously monitor the mother and baby and be aware of any problems that may necessitate emergency delivery by C-section. Physicians should quickly deliver a baby before there is severe oxygen deprivation, and this means they must be able to promptly diagnose the conditions listed above. It is crucial for physicians to avoid vaginal delivery when it is not possible or when it is very dangerous. This requires skill and very close assessment of the mother and baby. Not only must physicians be prepared for a C-section delivery, but they must also closely monitor the baby’s heart rate. If a physician or team member ignores the fetal monitor tracings, misinterprets the tracings, or fails to quickly deliver the baby by C-section and the baby develops HIE, it is medical malpractice.
Award-winning hypoxic-ischemic encephalopathy attorneys
At ABC Law Centers (Reiter & Walsh, P.C.), we have extensive experience handling birth injury cases involving hypoxic-ischemic encephalopathy (HIE). If your child experienced a lack of oxygen during birth, a delayed C-section, or did not receive brain cooling treatment (hypothermia therapy) in a timely manner, you may be entitled to compensation for negligence or malpractice.
Our lawyers have won numerous awards for their work in birth injury law. We charge nothing unless your lawsuit is successful. Contact us today for a free case review.
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Video: Hypoxic Ischemic Encephalopathy Attorney Jesse Reiter Discusses Birth Asphyxia
In this video, hypoxic ischemic encephalopathy lawyers Jesse Reiter and Rebecca Walsh discuss the causes of and treatments for HIE. Negligence by the medical team is often the cause of HIE and birth asphyxia.
- Hypoxic-Ischemic Encephalopathy (HIE): Legal Help for Birth Injuries. www.abclawcenters.com/practice-areas/prenatal-birth-injuries/fetus-or-newborn-medical-problems/hypoxic-ischemic-encephalopathy/.
- Reiter, Jesse. “Signs of Fetal Distress and Oxygen Deprivation: FAQs.” Michigan Birth Injury & HIE Attorneys, 14 Nov. 2014, www.abclawcenters.com/frequently-asked-questions/what-are-some-signs-that-my-baby-is-in-distress/.
- “Abnormal Fetal Position/Presentation and Birth Injury.” Michigan Birth Injury & HIE Attorneys, www.abclawcenters.com/practice-areas/prenatal-birth-injuries/abnormal-position-or-presentation/.
- “Cephalopelvic Disproportion (CPD): Birth Injury Lawyers.” Michigan Birth Injury & HIE Attorneys, www.abclawcenters.com/practice-areas/prenatal-birth-injuries/traumatic-birth-injuries/cephalopelvic-disproportion/.
- “Placental Abruption: Danger to Mothers and Babies.” Michigan Birth Injury & HIE Attorneys, www.abclawcenters.com/practice-areas/prenatal-birth-injuries/labor-and-delivery-complications-and-errors/placental-abruption/.
- “Uterine Rupture and Birth Injuries: Legal Help.” Michigan Birth Injury & HIE Attorneys, www.abclawcenters.com/practice-areas/prenatal-birth-injuries/labor-and-delivery-complications-and-errors/uterine-rupture-and-hie/.
- “Placenta Previa and Medical Malpractice: Birth Injury Attorneys.” Michigan Birth Injury & HIE Attorneys, www.abclawcenters.com/practice-areas/prenatal-birth-injuries/labor-and-delivery-complications-and-errors/placenta-previa/.
- “Birth Injury Attorneys: Mismanaged Preeclampsia.” Michigan Birth Injury & HIE Attorneys, www.abclawcenters.com/practice-areas/prenatal-birth-injuries/maternal-medical-conditions/preeclampsia-and-eclampsia/.