Can a delayed C-section cause hypoxic-ischemic encephalopathy (HIE)?

Yes. 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).  Babies can become oxygen deprived 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 mother’s womb, the best way to tell if the baby is being deprived of sufficient oxygen is to pay close attention to fetal heart rate, which shows up as a tracing on a graph.  The fetal heart rate monitor monitors the baby’s heart rate in response to the mother’s contractions.  Clinicians skilled in fetal heart tracing interpretation must be present during labor and delivery to watch and interpret the tracings, 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 not getting enough oxygen.

The physician and medical team must closely monitor the mother and baby during labor and delivery and should notice dangerous conditions before they become so severe that the oxygen deprivation causes a change in the baby’s heart rate, which is called fetal distress.

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: A 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 (which is associated with oxygen deprivation and fetal distress), 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

Cesarean Delivery (C-Section)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.

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. In fact, in most cases of face presentation, the baby must be delivered by C-section.  When a baby is in a breech position, the physician can attempt to rotate the baby into a normal position, but these time-consuming maneuvers require a lot of skill; it often is safer to deliver the baby by C-section because prolonged labor is associated with oxygen deprivation and fetal distress.

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.  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 discuss the option of a scheduled C-section with the mother; the risks and benefits of all delivery options must be thoroughly discussed.

It is crucial for the physician to be aware of the presence of CPD.  Indeed, 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 causes prolonged labor, which can cause fetal distress.  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.  Abruption is dangerous because the placenta connects the baby to the uterus.  If the placenta separately 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.

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.  This can cause the baby to be oxygen deprived 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 (the “cervical os”).  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.

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.

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.  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 (or “show up”) 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 associated with placenta abruption.  As discussed earlier, if an emergency C-section isn’t performed when a severe abruption occurs, the baby can develop HIE.

Any condition that causes the baby to have a nonreassuring heart tone requires urgent delivery, often by emergency C-section.  Other conditions that may require an emergency C-section in order to avoid HIE include shoulder dystocia (baby’s shoulder gets stuck on the mother’s pelvic bone), oligohydramnios (low fluid in the womb), prolonged and arrested labor, and premature rupture of the membranes (PROM), especially if the baby hasn’t been delivered within 12 hours of the membranes rupturing, or if the cord has become compressed.

Physicians and the medical team must skillfully and continuously review the fetal heart tracings throughout labor and delivery to ensure that fetal heart tones are reassuring and the baby is receiving sufficient oxygen.  If nonreassuring fetal heart tracings occur, prompt and appropriate actions must be taken.  These actions may include the administration of oxygen, fluids, and medication to the mother.  More often, however, an emergency C-section is required in order to quickly remove the baby from the conditions causing the oxygen deprivation.  An emergency C-section should be performed within 10 – 18 minutes, depending on the circumstances, and sometimes sooner.

Hypoxic-Ischemic Encephalopathy (HIE) and Medical Malpractice

Physicians must continuously monitor the mother and baby and be aware of any problems that may necessitate emergent 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 AttorneysBirth Injury Attorneys | Reiter & Walsh, PC | HIE, Birth Asphyxia, Cerebral Palsy, Birth Injury Attorneys

At Reiter & Walsh ABC Law Centers, we have extensive experience handling birth injury cases involving hypoxic-ischemic encephalopathy (HIE). If your child experienced a lack of oxygen during birth or did not receive brain cooling treatment (hypothermia therapy) in a timely manner, you may be entitled to compensation for negligence or pediatric malpractice.

Our lawyers 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). We charge nothing unless your lawsuit is successful. Please reach out today for a free case review.

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Related Resources on Hypoxic Ischemic Encephalopathy (HIE)

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.