Fetal distress is an emergency pregnancy, labor, and delivery complication in which a baby experiences oxygen deprivation (birth asphyxia). This may include changes in the baby’s heart rate (as seen on a fetal heart rate monitor), decreased fetal movement, and meconium in the amniotic fluid, among other signs. Medical professionals must immediately address and manage fetal distress to avoid hypoxic-ischemic encephalopathy (HIE) and permanent injury. Expectant mothers aren’t always with their physician when signs of fetal distress occur, so it is important to know the following signs that indicate a baby is in trouble. Often, the only way to stop fetal distress is to deliver a baby, allowing doctors and nurses to administer medical care. This frequently is accomplished by C-section delivery.
Signs of fetal distress
1. Signs of fetal distress: decreased fetal movement in the womb
Fetal movement within the mother’s womb is one of the most exciting parts of pregnancy. Beyond bringing joy to the family, movement within the womb is an important indicator of the baby’s health. Some regular pauses in movement are normal because babies sleep in the womb. However, if the baby becomes less active or completely ceases to move, this may be a cause for concern. Physicians should ask expectant mothers about fetal movement and conduct additional testing if patterns are abnormal (1).
2. Signs of fetal distress: abnormal fetal heart rate
Some fetal heart rate patterns indicate distress. To observe an unborn baby’s heart rate, medical professionals can use either an external or internal fetal monitoring device. External monitoring is done through a belt-like device that can be strapped around a mother’s abdomen, while internal monitoring involves attaching an electrode to the baby’s scalp. In a healthy labor and delivery, the baby’s heart rate will drop slightly during a contraction, and then quickly return to normal once the contraction is over (2). Therefore, some variability in heart rate is to be expected: this shows as a jagged line on the monitor. The following fetal heart rate patterns are examples of nonreassuring patterns and warrant further investigation and medical intervention (3):
- An abnormally fast heart rate (tachycardia)
- An abnormally slow heart rate (bradycardia)
- Abrupt decreases in heart rate (variable decelerations)
- Late returns to the baseline heart rate after a contraction (late decelerations)
In addition to fetal monitoring, an abnormal fetal heart rate may be recognized in a non-stress test (NST) or a contraction stress test (CST).
During an NST, a medical professional looks at how the baby’s heart rate changes when the the fetus moves. A normal NST is called “reactive,” meaning that the baby’s heart rate went up and down as expected. “Non-reactive” means that the baby’s heart rate did not increase enough at times. Physicians may also classify NST results into categories:
- Requiring further testing and possibly delivery
- An emergency C-section is necessary
A CST helps to predict how the baby will cope during the labor process, and determine whether it is safe to proceed with a vaginal delivery. Uterine contractions temporarily restrict oxygen flow; this is something a healthy baby can tolerate, but it may be very dangerous for a baby in distress. During a CST, physicians record the baby’s heart rate in response to contractions. If conducting a CST on a woman not yet in labor, the physician may give her Pitocin (synthetic oxytocin), to make the uterus contract (4). It is important to note that there are certain risks associated with this. Pitocin can cause uterine tachysystole (excessively strong, frequent, or long contractions); this can severely restrict oxygen flow to the baby and sometimes leads to uterine rupture.
3. Signs of fetal distress: abnormal amniotic fluid level
The amount of amniotic fluid can be determined using a variety of ultrasound methods, including a qualitative assessment, the single deepest pocket (SDP), and the amniotic fluid index (AFI). The qualitative assessment is fairly subjective. The ultrasonographer scans the uterus and reports whether the amniotic fluid volume appears to be low, normal, or high, based on their own experience. THE SDP, sometimes called the maximum vertical pocket (MVP), is the vertical measurement (in centimeters) of the largest pocket of amniotic fluid that doesn’t contain parts of the fetal body or umbilical cord. The AFI is calculated by measuring the depth of the amniotic fluid in four sections of the womb and adding the numbers together (5).
If there is abnormally low amniotic fluid, this is a condition called oligohydramnios, which can lead to oxygen deprivation and birth injuries like HIE and cerebral palsy (CP). A trending decrease in amniotic fluid may also warn of oligohydramnios, and should be watched closely. If there is an abnormally high amniotic fluid volume, this is known as polyhydramnios. Polyhydramnios can also cause oxygen deprivation and subsequent birth injuries.
4. Signs of fetal distress: abnormal results of biophysical profile (BPP)
A baby’s biophysical profile (BPP) is also often taken if the results of an NST are nonreassuring. In addition to taking into account NST results, the BPP includes an ultrasound to assess fetal movement, breathing, tone, and amniotic fluid volume. The nonstress test and each of the four ultrasound parameters are assigned a score of either zero or two points (there is no one point). A total score of eight or higher is considered normal, unless the zero score relates to low amniotic fluid. A score of four or lower indicates fetal distress and requires immediate action (6).
5. Signs of fetal distress: vaginal bleeding
Small amounts of vaginal bleeding are fairly common during pregnancy. However, bleeding can be an indication that something is wrong with the pregnancy. One particularly dangerous example is placental abruption, which occurs when the placenta tears away from the womb. This causes the baby to be deprived of oxygen. Depending on the location and size of the abruption, it may not initially cause fetal distress, but the health of both mother and baby could still be in jeopardy.
Likewise, it is important to note that a placental abruption can be present with no vaginal bleeding (bleeding can be retained behind the placenta), but may still pose a serious risk.
A placental abruption and other placental problems that cause bleeding require very close monitoring, and in many cases, the mother should be admitted to the hospital and given an emergency C-section (7).
6. Signs of fetal distress: cramping
Some cramping is relatively normal during pregnancy. This is because as the baby grows, the uterus needs to expand. However, in some cases cramping is an indication of something more serious, such as miscarriage, placental abruption, preeclampsia, a urinary tract infection, or preterm labor. For more information on cramping during pregnancy, and the circumstances under which it is advisable to consult a doctor, click here (8). It is crucial that physicians appreciate cramping and perform proper tests to ensure the health of the mother and baby.
7. Signs of fetal distress: insufficient or excessive maternal weight gain
Experts believe that for women with a healthy pre-pregnancy weight, a weight gain of anywhere between 25 and 35 pounds is normal during pregnancy (the ranges are different for women who were under or overweight before becoming pregnant, as well as for those who are carrying twins or multiples; click here for more detailed information) (9).
If a mother gains much less than what is typical, the fetus may be in distress and have a condition called intrauterine growth restriction (IUGR), which means they are smaller than is developmentally appropriate (among other problems). IUGR requires careful physician monitoring and testing, and often early delivery prior to labor (10). A mother should have regular prenatal visits, and her physician should know that abnormal weight changes may necessitate additional fetal monitoring.
Excessive maternal weight gain is associated with giving birth to a baby that is abnormally large, which is a condition known as macrosomia. Macrosomia can be very dangerous for a baby. Macrosomia can create a risky birth situation, such as cephalopelvic disproportion (CPD), wherein the mother’s pelvis is too small to accommodate the size of the baby’s head, or shoulder dystocia, which is when the baby’s shoulder gets stuck on the mother’s pelvic bone during delivery (11). Macrosomia is especially dangerous if the physician is unaware of the condition. A physician in this situation may try to deliver the baby vaginally, and when delivery doesn’t progress the way it should (and it won’t if CPD or shoulder dystocia are present), the physician may use dangerous delivery devices. These may include birth-assisting tools like forceps and vacuum extractors, or labor induction drugs, such as Pitocin and Cytotec. Forceps and vacuum extractors can cause head trauma and brain bleeds, and labor induction drugs can cause contractions to be so strong, long, and frequent that the baby becomes deprived of oxygen. These issues can cause permanent brain damage in a baby, such as hypoxic-ischemic encephalopathy, cerebral palsy, and periventricular leukomalacia (PVL). Often, the best way to deliver a macrosomic baby is by C-section.
A note on terminology
The American College of Obstetricians and Gynecologists (ACOG) cautions that the term fetal distress is “imprecise and nonspecific.” Instead, they recommend that “fetal distress” be replaced with “nonreassuring fetal status” (12), and that a baby’s status should be further categorized into three separate groups that describe the extent to which the baby is affected (13).
Regardless of what terminology they prefer, it is important that medical professionals be very familiar with specific warning signs of fetal oxygen deprivation in order to prevent permanent harm.
Causes of fetal distress
The following are just a few underlying causes of fetal distress:
- Abnormal fetal presentation
- Forceps and vacuum extractor misuse
- Placental abruption
- Prolonged and arrested labor
- Umbilical cord problems
- Uterine rupture
Treating fetal distress
The medical team must skillfully and continuously monitor fetal well-being throughout pregnancy, labor, and delivery. They are responsible for recognizing and responding to signs of fetal distress. If a baby is in distress, appropriate interventions may include the administration of oxygen, fluids, and medication to the mother, or a change in the mother’s position. Often, an emergency C-section is required in order to remove the baby from the conditions causing the fetal distress, especially if earlier interventions did not cause fetal heart tones to become reassuring. An emergency C-section should be performed within 3 to 18 minutes, depending on the circumstances, and sometimes a lot sooner.
Mismanaged fetal distress, birth injury, and medical malpractice
Signs of fetal distress should always be taken seriously. It is critical that medical professionals promptly recognize and address these signs (which may include interventions such as an emergency C-section) in order to prevent permanent injury and disability in a newborn baby. They must be especially careful in assessing maternal and fetal health in high-risk pregnancies. If physicians dismiss signs of fetal distress or fail to follow standards of care for high-risk pregnancies, this constitutes medical negligence. If this negligence leads to injury, it is medical malpractice.
Reiter & Walsh, P.C. | Michigan birth injury attorneys helping children since 1997
Birth injury is a challenging area of law to pursue due to the complex nature of the medical records. The award-winning birth injury attorneys at Reiter & Walsh ABC Law Centers have decades of joint experience with birth injury, hypoxic-ischemic encephalopathy (HIE), and cerebral palsy cases. To find out if you have a case, contact our firm to speak with one of our birth trauma attorneys. We have 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. We give personal attention to each child and family we help, and are available 24/7 to speak with you.
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- Hofmeyr, G. J., & Novikova, N. (2012). Management of reported decreased fetal movements for improving pregnancy outcomes. The Cochrane database of systematic reviews, 4, CD009148.
- Fetal Heart Monitoring: What’s Normal, What’s Not?. (2018, January). Retrieved from https://www.healthline.com/health/pregnancy/abnormal-fetal-heart-tracings#decelerations
- Fetal Distress: Diagnosis, Conditions & Treatment. (2016, May 19). Retrieved from http://americanpregnancy.org/labor-and-birth/fetal-distress/
- Monitoring your baby before labor: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved from https://medlineplus.gov/ency/patientinstructions/000485.htm
- (n.d.). Retrieved from https://www.uptodate.com/contents/assessment-of-amniotic-fluid-volume
- (n.d.). Retrieved from https://www.uptodate.com/contents/the-fetal-biophysical-profile
- Cramping During Pregnancy: Causes, Treatment & Prevention. (2017, February 21). Retrieved from http://americanpregnancy.org/your-pregnancy/cramping-during-pregnancy/
- Reproductive Health. (2018, May 17). Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-weight-gain.htm
- Default – Stanford Children’s Health. (n.d.). Retrieved from https://www.stanfordchildrens.org/en/topic/default?id=intrauterine-growth-restriction-iugr-90-P02462
- (n.d.). Retrieved from https://www.uptodate.com/contents/fetal-macrosomia
- Committee on Obstetric Practice. (2005). ACOG Committee Opinion. Number 326, December 2005. Inappropriate use of the terms fetal distress and birth asphyxia. Obstetrics and gynecology, 106(6), 1469.
- (n.d.). Retrieved from https://www.uptodate.com/contents/management-of-intrapartum-category-i-ii-and-iii-fetal-heart-rate-tracings
Video: attorneys discuss mismanaged fetal distress, delayed delivery, and birth injuries
In this video, Michigan birth injury attorneys Jesse Reiter and Rebecca Walsh discuss how a lack of oxygen to a baby’s brain (asphyxia) can cause birth injuries such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy. When a baby is in distress and experiencing birth asphyxia, they must be delivered right away to prevent brain injury.