An abnormal heart rate is often the only indication that a baby is in distress and being deprived of oxygen. If a baby’s heart rate is not being continuously monitored during labor and delivery, the baby could be experiencing oxygen deprivation without anybody noticing. It is very important to notice oxygen deprivation because if it goes on for too long, the baby’s brain cells start to die and a form of brain injury called hypoxic-ischemic encephalopathy (HIE) can occur. A baby’s brain can be deprived of oxygen when there is not enough oxygen in the blood (hypoxemia/hypoxia) and when there is insufficient flow of blood in the brain (ischemia). HIE can cause lifelong problems such as cerebral palsy, seizures, and developmental delays.
Why is Fetal Monitoring Needed?
Fetal distress is a term that means the baby’s heart rate is abnormal due to oxygen deprivation. When a baby in the womb is in distress, it is very serious because physicians do not have instant access to the baby. Instead, the process of delivery (often via emergency C-section) has to take place before physicians are able to directly help the baby with oxygenation. In many cases, simply delivering the baby is the main action that needs to occur because it removes the baby from the oxygen-depriving conditions. However, the medical team may not be aware that a baby is in distress if the baby is not being monitored with a fetal heart monitor, or if data on the fetal monitor is being ignored or misinterpreted.
Fetal monitoring can be performed with internal or external fetal monitoring devices. When a baby is being monitored with an external monitor, belt-like straps are placed around the mother’s abdomen. One belt uses ultrasound pressure to measure the baby’s heart rate, and the other is a pressure transducer used to measure contractions. The information is recorded on a computer, and is printed onto a sheet of paper as a graphical representation of the baby’s heart rate in response to contractions. When the mother has a contraction, the baby’s heartbeat drops slightly but returns to normal once the contraction stops. The fetal monitoring graphs show if anything is wrong with this pattern. A more accurate method of fetal monitoring is an internal fetal monitor, which works in a similar manner, except an electrode is placed on the baby’s scalp, and this relays the baby’s heart rate to the computer. Fetal distress is shown as an abnormal (usually slow) heart rate on the fetal monitor. Abnormal heart rates/heart tracings are called nonreassuring tracings.
Fetal Heart Monitoring Errors
Fetal heart rate monitoring is often necessary, and there are specific guidelines regarding the use of fetal heart rate monitors.
Failure to Use a Fetal Heart Rate Monitor
In many cases, failure to use continuous fetal heart monitoring is negligence. Monitoring of the baby must take place if the pregnancy is high-risk or if delivery of the baby is a high-risk delivery. A baby’s heart rate must also be monitored if risky procedures are used during labor and delivery.
The following are high-risk situations that require continuous fetal heart rate monitoring:
- The mother is under the age of 20 or over the age of 35 at the time of delivery
- The mother had a medical condition before pregnancy, such as high blood pressure, breathing problems, kidney or heart problems, diabetes, autoimmune diseases, or a sexually transmitted disease such as herpes simplex virus
- The mother has a history of miscarriage, problems with a previous pregnancy, or risk factors for a high risk pregnancy
- The baby has an umbilical cord problem, such as a nuchal cord or prolapsed cord
- The mother is given labor induction drugs, such as Pitocin or Cytotec
- Physicians use forceps or vacuum extractors to help with delivery
- The mother is given any kind of anesthesia or an epidural
- Gestational diabetes
- Premature labor
- Multiple births (twins, triplets, etc.)
- Placenta previa
- Cephalopelvic disproportion (CPD)
- The baby is macrosomic (large)
- Group B Strep (GBS)
- Incompetent cervix
- Placental abruption
- Post-term pregnancy
- Prolonged or arrested labor
- VBAC (vaginal birth after cesarean)
- Urinary tract infection or bacterial vaginosis
- Uterine (womb) rupture
- The baby is in an abnormal position, such as face or breech presentation
Errors Made During Fetal Heart Rate Monitoring
There are many errors that can occur when a baby actually is being monitored by a fetal heart rate monitor. The most common fetal monitoring errors are related to the following:
- Members of the medical team lack knowledge in fetal heart tracing interpretation and do not notice an abnormal heart rate and nonreassuring heart tracings
- The medical team fails to properly evaluate and treat nonreassuring fetal heart rate patterns
- The medical team fails to effectively talk to each other about the fetal heart rate tracings
- The medical team does not respond appropriately to abnormal fetal heart tracings and problems with the heart monitoring devices
- Failure of the medical team to use the chain of command to resolve disagreements regarding medical decisions
There is no doubt that medical errors frequently occur with fetal heart rate monitoring. Researchers have tried to identify the reasons for the errors, because the results of these errors can be devastating to babies. In one case study of a mother whose baby had severe brain damage, the errors occurred in the following way:
- The nurse and nurse’s assistant failed to notice an ongoing abnormal or nonreassuring fetal heart rate tracing;
- The medical team failed to correctly manage and treat the ongoing abnormal heart rate;
- Once the nurses noticed the abnormal heart tracing, they failed to use the chain of command in an appropriate way to get a physician into the mother’s room;
- Once contacted, the physician waited too long to go to the mother’s room to evaluate the abnormal heart tracing.
In the above case, once the physician saw the tracing, there was no argument that the baby had to be immediately delivered by an emergency C-section. However, the decision was made too late; the baby had been deprived of oxygen for too long and developed HIE and a severe seizure disorder.
In this case, the nurse and nurse’s assistant were not knowledgeable enough to recognize the abnormal heart rate as soon as it started. Since the tracing wasn’t noticed, the baby’s distress and oxygen deprivation were not managed. Once the team noticed the nonreassuring tracings, they did not go through the proper channels to immediately get a physician into the room to either deliver or treat the baby. The physician failed by trusting a medical team that lacked knowledge in fetal heart rate monitoring. The physician also made a critical mistake by not responding quickly when notified about the abnormal tracing.
Indeed, research indicates that lack of knowledge, fear of conflict, and poor communication are three errors that greatly contribute to medical mismanagement of a baby near the time of and during labor. Every single member of the medical team that is using electronic fetal heart rate monitoring must have an adequate knowledge base, and the hospital must have policies in place that help prevent fetal monitoring errors from occurring.
Hypoxic-Ischemic Encephalopathy (HIE) from Fetal Heart Monitoring Errors
Interpreting a fetal heart tracing requires skill. Often, a nonreassuring fetal heart tracing is the only indication that a baby is being deprived of oxygen. If a physician or nurse fails to monitor the baby, properly interpret the tracings, or react appropriately to abnormal tracings, an emergent situation that requires intervention may be missed. The baby may be left in oxygen-depriving conditions that cause HIE and other brain injuries.
Conditions that can cause oxygen deprivation, a non-reassuring FHR, and HIE include the following:
- Uterine rupture: The uterus can tear open during labor. The tearing often is caused by the force of uterine contractions or because a scar from a previous C-section ruptured. A rupture can cause a baby to be deprived of oxygen through the following mechanisms: 1.) The rupture causes the mother to lose so much blood that the blood flow going to the baby through the umbilical cord is significantly decreased, and/or 2.) The rupture causes the placenta to be either partially or fully cut off from the mother’s circulation. This means that there will be either no or low flow of oxygen-rich blood to the baby through the umbilical cord.
- Umbilical cord problems: The umbilical cord is the baby’s lifeline; it is the vessel by which oxygen-rich blood is delivered from the mother to the baby. If something is pressing against the cord or if the cord is in a knot, blood may be unable to properly flow through the cord, and the baby can become deprived of oxygen.
- Hyperstimulation of the uterus: This can be caused by improper use of Pitocin or Cytotec. These drugs can cause the uterus (womb) to have strong and frequent contractions, which can cause the uterus to be hypertonic. This means that the contractions are so intense that the uterus is in a state of almost constant contraction, and the vessels that carry blood to the baby are compressed or impinged upon. Since the contractions are almost continuous, there is not sufficient relaxation of the uterus to allow the placenta and its vessels to go back to normal and recharge with a fresh supply of oxygen. When there is insufficient flow of oxygen-rich blood, the baby can become severely deprived of oxygen.
- Placental abruption: This is a serious condition in which the placenta separates either partially or completely from the uterus. Abruption can cause oxygen deprivation in the baby since the baby receives oxygen-rich blood from the mother through the placenta and umbilical cord. If there is a complete placental abruption, the baby will not be receiving any oxygen-rich blood. Partial abruptions may not be as severe; the severity depends on how much of the placenta has separated, the length of time and location of the separation, the age of the baby, and the amount of reserve the baby has.
- Uteroplacental insufficiency: Anything that causes insufficient blood flow to the placenta during pregnancy can cause the baby to be oxygen deprived. This can occur when there is an abnormally thin placenta or there are problems with vessels and capillaries in the placenta.
- Polyhydramnios (excessive amniotic fluid): When there is too much amniotic fluid, there is a risk of cord prolapse, placental abruption, and premature birth, all of which can lead to oxygen deprivation in the baby.
- Oligohydramnios (insufficient amniotic fluid): At about 20 weeks of age, the baby breathes and swallows amniotic fluid, which aids in nutrition, growth, lung maturation, and maintaining a constant temperature. If this fluid is insufficient, it typically means the placenta is not functioning properly. Oligohydramnios can cause cord compression, and is associated with intrauterine growth restriction (IUGR), meconium aspiration, preeclampsia, and placental abruption, all of which can cause a baby to be oxygen deprived.
- Cephalopelvic disproportion (CPD): This means that the baby’s head is too large to fit through the mother’s pelvis. If the baby can’t easily get through the birth canal (this can also be an issue with macrosomia), the baby is at risk of having a difficult and prolonged labor, which can cause trauma, brain bleeds, and umbilical cord prolapse and compression. All of these complications can cause severe oxygen deprivation in a baby.
- Breech presentation: If the feet or buttocks are positioned to come through the birth canal first, serious complications can arise, such as cord prolapse, nuchal cord, head trauma, and brain bleeds. These conditions can cause the baby to be severely oxygen deprived.
- Prolonged and arrested labor and maternal exhaustion: When labor takes too long or fails to progress (stops), the baby can become extremely distressed because firstly, contractions and the forces of labor can be stressful on the baby and on the placenta that supplies oxygen to the baby. In addition, when long labor occurs, there is an increased risk of delivery instrument use, such as use of forceps and vacuum extractors, which can cause trauma to the baby’s head and result in intracranial hemorrhages/brain bleeds. Furthermore, physicians may use the labor induction drugs Cytotec or Pitocin, which can cause uterine hyperstimulation. Oxygen deprivation in the baby can occur as a result of all these conditions.
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, or a change in the mother’s position. More often, however, an emergency C-section is required in order to remove the baby from the conditions causing the fetal distress. An emergency C-section should be performed within 18 minutes, depending on the circumstances, and sometimes a lot sooner.
The sole purpose of the fetal heart monitor is to allow the physicians and the medical team to identify signs of fetal distress and to take quick and appropriate action. If a physician or team member ignores the fetal monitor tracings, misinterprets the tracings, or fails to take appropriate action and the baby develops HIE, it is medical malpractice.
Reiter & Walsh, PC | Trusted Hypoxic-Ischemic Encephalopathy Attorneys
If your child has suffered HIE and you believe it was due to improper fetal monitoring, contact the birth injury lawyers from Reiter & Walsh ABC Law Centers. Our award-winning attorneys will review the medical records and determine if the fetal monitor tracings were ignored, misinterpreted, or not properly acted upon. If your child was injured due to medical malpractice, we will fight for you to win the money your child deserves for medical care and a secure future. Email or call us toll-free for a free consultation: 888-419-2229. We serve clients in Michigan and all 50 states, and never charge any fees until we win your case.
Free Case Review | Available 24/7 | No Fee Until We Win