Delayed C-section deliveries can cause forms of brain injury, such as hypoxic-ischemic encephalopathy (HIE) or cerebral palsy in a baby. The American College of Obstetricians and Gynecologists (ACOG) has established a decision-to-incision time (time within which a cesarean delivery should take place after an emergency sign presents) of 30 minutes or faster (1). In the Guidelines for Perinatal Care, ACOG and the American Academy of Pediatrics (AAP) state that 30 minutes is too long in many instances. In the textbook, they recognized that there are certain situations in which delivery should occur much faster than 30 minutes. Some examples include cases of uterine rupture, umbilical cord prolapse, placenta previa, and placental abruption (2). In their November 2010 Practice Bulletin, ACOG states that “when a decision for operative delivery in the setting of a category III EFM (severe electronic fetal monitoring) tracing is made, it should be accomplished as expeditiously as feasible” (3). Such instances require a much faster delivery time than 30 minutes to protect the baby from oxygen deprivation and hypoxia. According to one study, in order to avoid irreversible hypoxic injury, C-sections should be achieved within 10-18 minutes or faster when a serious complication is identified (4).
When medical personnel spend too much time attempting to deliver vaginally, babies are often do not get enough oxygen. This can cause permanent brain injuries. Medical professionals must act quickly upon signs of fetal oxygen deprivation because physicians cannot directly help babies with oxygenation, ventilation, or circulation when the baby is inside the womb. Often, the fastest and safest way to deliver a baby is by ordering and performing an emergency C-section.
The only way to tell whether a baby is getting enough oxygen inside the mother’s womb is to closely monitor the fetal heart rate (5). The fetal heart rate tones show up on a graph and are known as fetal heart tracings. The fetal heart rate monitor shows the baby’s heart rate in response to the mother’s contractions (6). Clinicians skilled in fetal heart tracing interpretation must be present 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 not receiving enough oxygen.
The physician and medical team must closely monitor the mother and baby during labor and delivery in order to notice dangerous conditions before they become so severe that the oxygen deprivation causes a change in the baby’s heart rate. These changes to the baby’s heart rate are known as fetal distress.
Oxygen-depriving conditions necessitating emergency C-section delivery
A number of conditions, complications, and situations can result in fetal oxygen deprivation and necessitate an emergency C-section delivery. In this section, we’ll discuss some of the pregnancy, labor, and delivery situations that often require planned or emergency C-section delivery.
Malpresentation and C-section delivery
When a baby is in an abnormal position (malpresentation or out of position) when labor begins, it can be very dangerous (7). Malpresentation can cause prolonged labor, which is associated with oxygen deprivation and fetal distress (8). In addition, malpresentation is associated with umbilical cord problems (see below for more information on this).
The physician must closely monitor the mother and baby and have the skill to notice when a baby is in an abnormal position. During any delivery, it is imperative to have the capacity to quickly move on to an emergency C-section. When the baby is malpositioned, everything must be in place for the physician to quickly perform a C-section (7, 9). When a baby is in a breech presentation, the physician can attempt to rotate the baby into a normal position, but these maneuvers require a lot of skill, and they are time-consuming. Thus, when breech presentation occurs, it often is safer to deliver the baby by C-section. It is important to remember that prolonged labor is associated with oxygen deprivation and fetal distress.
Umbilical cord problems and C-section delivery
The umbilical cord is the baby’s connection to oxygen-rich blood coming from the mother (10). A nuchal cord, when the umbilical cord is wrapped around the baby’s neck, can be so tight that it pushes on the vessels in the baby’s neck, restricting blood flow to the baby’s brain. Cord prolapse, when the cord exits the birth canal in front of the baby, can become compressed and severely or completely cut off the flow of oxygen-rich blood to the baby. When umbilical cords become compressed, babies must be delivered immediately to avoid hypoxic-ischemic encephalopathy (HIE) and death.
Cephalopelvic disproportion and C-section delivery
Cephalopelvic disproportion (CPD) is a pregnancy complication in which the fetus’s head is too large to easily pass through the mother’s pelvis. Medical personnel must 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 (11). If the mother’s pelvis is small, an average-sized baby may not fit. Sometimes the baby becomes macrosomic (abnormally 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 delivery 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 because it can be very dangerous to attempt vaginal delivery when CPD is present. First, trying to vaginally deliver a baby that cannot fit through the birth canal causes labor to be prolonged, which can cause fetal distress. Second, when labor is prolonged, physicians may be tempted to use risky delivery techniques, such as the use of forceps or vacuum extractors, which greatly increases the chance of the baby suffering from an intracranial hemorrhage (brain bleed) and resultant hypoxic-ischemic encephalopathy (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 that the baby becomes deprived of oxygen. Like forceps and vacuum extractors, if the baby is not going to fit through the birth canal, using devices to speed up labor will many times delay the ordering and performance of a C-section delivery.
Placental abruption and C-section delivery
Placental abruption is a pregnancy complication in which the placenta becomes either partially or completely separated from the uterus. Placental abruption is dangerous because the placenta connects the fetus to the womb (uterus). If the placenta becomes becomes partially or completely separated from the womb, the baby will be cut off from the mother’s blood vessels, which means no oxygen-rich blood from the mother will be able to travel to the baby (12). In the case of an abruption where the baby is not getting enough oxygen, the baby must be delivered by emergency C-section in a matter of minutes. 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 hypoxic-ischemic encephalopathy (HIE) (12).
Uterine rupture and C-section delivery
Uterine rupture is a dangerous obstetrical complication in which the wall of the womb tears open during delivery. Uterine rupture often occurs due to the forces of labor, especially if a woman has a scar from a previous C-section (13). When the uterus ruptures, the baby and the placenta can spill into the mother’s abdomen. A rupture can cause the baby to be oxygen deprived by the following mechanisms:
- The mother loses so much blood (low blood volume and blood pressure) that not enough oxygen-carrying blood can be delivered from her to the baby through the umbilical cord.
- The rupture causes the placenta to be cut off from circulation, which means the umbilical cord cannot deliver oxygen to the baby.
Complete deprivation of oxygen is common in cases of uterine rupture, and fetal or neonatal death occur quite often in cases of a complete rupture. An emergency C-section within 10 minutes is mandatory when rupture occurs due to the potentially devastating consequences of the condition (14).
Placenta previa and C-section delivery
Placenta previa is a condition in which the placenta either partially or totally covers the cervical opening (the “cervical os”). Placenta previa is typically characterized as either of the following (15):
- Complete placenta previa, in which the placental tissue completely covers the cervical opening
- 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 (15). Often, bleeding occurs with the cervical changes and related uterine contractions that naturally 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. Because of this, the physician must closely monitor a mother diagnosed with complete placenta previa and the physician usually must deliver the baby by C-section well before the time when any uterine activity or related cervical changes are likely to occur (15).
Preeclampsia and C-section delivery
Preeclampsia is a maternal health condition occurring during pregnancy that is characterized by high blood pressure and protein in the urine. Preeclampsia can be classified as being mild, moderate, or severe (16). In many cases, a case of mild preeclampsia can rapidly progress to a more severe form. When preeclampsia is undiagnosed or untreated, there are significant risks to both the mother and 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 (16). 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 placental abruption (16). As discussed earlier, if an emergency C-section isn’t performed when a severe abruption occurs, the baby can develop HIE.
Other indications for C-section delivery
Any condition that causes the baby to have a non-reassuring heart tones 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
- 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 non-reassuring fetal heart tracings occur, prompt and appropriate actions must be taken (15). 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 as soon as possible (2).
Delayed C-section, hypoxic-ischemic encephalopathy (HIE), and medical malpractice
Physicians must continuously monitor the mother and baby and be aware of any problems that may necessitate delivery via emergency C-section. Medical professionals should quickly deliver a baby before there is 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 dangerous to the mother and/or baby. This requires skill and very close assessment of the mother and baby. 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.
If your child has hypoxic-ischemic encephalopathy or any other birth injury, contact ABC Law Centers. Our award-winning attorneys will review the medical records and determine if negligence occurred. If your child was injured due to medical malpractice, we will fight to win the money they deserve for medical care and a secure future. We serve clients throughout the nation and never charge any fees until we win your case.
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Video: Michigan delayed C-Section lawyers discuss birth injuries
View our video library to see Michigan delayed C-section lawyers Jesse Reiter & Rebecca Walsh discuss causes of and treatments for cerebral palsy and other birth injuries.
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