Birth Asphyxia and HIE: Definitions
Birth asphyxia occurs when a baby experiences a lack of oxygen to his or her brain during or near the time of birth. Hypoxic ischemic encephalopathy (HIE) is a brain injury caused by insufficient oxygen in the blood and decreased blood flow in the brain. Birth asphyxia and HIE can cause a baby to have permanent brain damage that may result in long-term conditions such as cerebral palsy, seizure disorders, developmental delays and learning disabilities. Birth asphyxia and HIE can often be prevented by closely monitoring the baby and quickly delivering her at the first signs of distress or impending distress. Skilled members of the medical team will be aware of distress if they continuously review the baby’s heart tracings on the fetal heart rate monitor. In addition, certain conditions make distress likely, and the medical team should monitor the mother and baby for these risky situations. For example, a breech presentation makes a prolapsed umbilical cord more likely, and cephalopelvic disproportion (baby is too large for the size of the mother’s pelvis) increases the baby’s risk of birth trauma and asphyxia. A C-section delivery is required for CPD and most types of breech presentation.
A speaker at the launch of the “Helping Babies Breathe Training Program” (which partners with the American Academy of Pediatrics) noted that severe birth injuries caused by birth asphyxia and HIE, prolonged labor and obstructed labor often occur because health professionals lack the skills to prevent the injuries.
How Does Prolonged Labor Cause Birth Asphyxia and HIE (Hypoxic Ischemic Encephalopathy)?
Labor is usually considered prolonged when the first and second stages of labor combined are greater than 20 hours for a first pregnancy and greater than 14 hours for women with prior births. Prolonged and arrested labor basically have 2 causes: inadequate contractions and/or mechanical impediments such as the baby being in an abnormal presentation.
Abnormal presentations include the following:
- A breech presentation in which the baby’s legs or buttocks present first
- A face presentation in which the baby’s face is in position to exit the birth canal first
- A deflexed position of the head in which the neck of the baby is less flexed, straight or extended
- The position of a baby in the uterus is such that the head of the baby is presenting first and is tilted to the shoulder, causing the baby’s head to no longer be in line with the birth canal (asynclitism).
Cephalopelvic disproportion (CPD) is another condition that can cause labor to be prolonged or arrested. CPD occurs when the size of the baby’s head is larger than the size of the mother’s birth canal or the baby presents in a position that will not allow her to travel through the birth canal.
Abnormal presentations and CPD increase the risk of numerous complications, such as umbilical cord prolapse / compression, which can cause severe birth asphyxia and HIE. In addition, some of these events increase the likelihood that the physician will attempt to speed up delivery by using the risky labor drugs Pitocin and Cytotec, or dangerous delivery devices such as forceps and vacuum extractors. Often, these drugs and devices actually prolong labor and delivery because the physician relies on them instead of moving on to a prompt C-section delivery. Indeed, it is very dangerous to try and force a vaginal delivery, especially when CPD and certain breech positions that require C-section delivery exist. Babies the experience a prolonged or arrested labor may start to experience birth asphyxia and HIE due to umbilical cord problems or the stress of too many contractions.
Inadequate uterine activity is the most common cause of prolonged and arrested labor. It refers to uterine activity that is either not strong enough or not appropriately coordinated to dilate the cervix and expel the baby. The uterine muscle may fail to properly contract when it is grossly stretched, as in twin pregnancy and hydramnios (excess amniotic fluid). The presence of tumors in the uterine musculature can also affect uterine contraction.
Inadequate contractions are usually treated with uterine stimulation. This is generally accomplished with Cytotec or Pitocin. These drugs can cause excessive contractions, called hyperstimulation, which can injure the baby. When contractions are too fast and strong, the placenta, which helps carry oxygen-rich blood to the baby, often cannot recharge with an adequate supply of this blood for the baby. As hyperstimulation continues, the baby’s oxygen deprivation gets progressively worse. Indeed, use of Pitocin or Cytotec requires very close monitoring of the baby’s heart rate, and the baby must be quickly delivered at the first signs of distress.
Excessive use of painkillers or anesthesia can cause inefficient uterine activity and may prevent voluntary effort by the mother to deliver the baby during the second stage of labor. Research shows that anesthesia can increase the length of the second stage of labor, and that it increases the use of Pitocin, as well as the frequency of forceps and vacuum extractor use.
Cervical Dystocia or Stenosis
The term cervical dystocia is used when the cervix fails to dilate properly and remains at the same position for more than 2 hours after the latent phase of labor. The cervix may fail to dilate when it is fibrosed due to previous operations, such as cone biopsy (type of cervical biopsy where a cone-shaped piece of tissue is removed), or due to the presence of tumors. Physicians should be aware of these problems in a mother and should expect the possibility of a prolonged or arrested labor and the need for a prompt C-section delivery.
Shoulder dystocia is another very risky situation. It occurs when the baby’s shoulder gets stuck on the mother’s pelvic bone during delivery. There are certain maneuvers that the physician can do to try and free the shoulder so the baby can be delivered. However, this can lead to head trauma and other injuries. Physicians may sometimes pull too hard on the baby’s head in an attempt to get the baby out of the birth canal. This is against the standard of care because excessive force can cause nerves in the baby’s neck and shoulder to stretch and tear, which can cause arm paralysis, or Erb’s palsy. Shoulder dystocia also increases the baby’s risk of experiencing umbilical cord compression and resultant birth asphyxia and HIE. Due to the risks that shoulder dystocia poses, a C-section delivery is the safest way to deliver a baby in this situation.
Indeed, prolonged, arrested and obstructed labor increase numerous risks for the baby. Being involved in labor for a long time is traumatic. In addition, many conditions associated with prolonged and obstructed labor make it more likely that that baby will be exposed to Pitocin, Cytotec, forceps and/or vacuum extractors. All of these issues can cause the baby to have birth asphyxia and brain bleeds, which can cause hypoxic ischemic encephalopathy (HIE). Shoulder dystocia poses the additional risk of Erb’s palsy.
Preventing Birth Asphyxia and HIE (Hypoxic-Ischemic Encephalopathy)
Prevention of birth asphyxia and HIE (hypoxic ischemic encephalopathy) boils down to two major factors:
- Closely monitoring the mother and baby so that fetal distress or impending distress is recognized
- Quickly delivering the baby when fetal distress or impending distress are present.
During pregnancy, the mother and baby should have regular prenatal tests to help ensure fetal health. If the pregnancy is high risk, more frequent prenatal testing is required and the mother should be referred to a maternal-fetal specialist. As soon as the mother is admitted to the labor and delivery unit, a fetal heart monitor should be attached to her body and the baby’s heart rate should be continuously monitored.
In addition, the mother should be monitored for any signs of a pregnancy complication, such as a nuchal cord or placental abruption. If these or other complications exist, preparation for a C-section delivery should be made, in most cases. The point of a fetal heart monitor is to alert the medical team of fetal distress. If the baby is experiencing a lack of oxygen to her brain, this will result in nonreassuring heart tracings on the fetal monitor. When nonreassuring tracings occur, the medical team may try resuscitative maneuvers which are aimed at increasing blood flow and oxygen to the baby. These maneuvers may include IV fluids or giving oxygen to the mother. However, there is no guarantee that resuscitative maneuvers will relieve fetal distress. In fact, distress caused by certain obstetrical conditions, such as a complete cord compression or complete placental abruption will not be affected by in-utero resuscitation; babies experiencing these conditions must be delivered within a matter of minutes.
When fetal distress occurs, preparations should be made for a prompt C-section delivery while in-utero resuscitation maneuvers are being undertaken. It is very important to have skilled members of the health care team involved in labor and delivery. It takes skill to interpret fetal heart tracings, and these tracings are often the only indication that a baby is experiencing birth asphyxia and HIE. The team also must be well-coordinated so that preparations and execution of a C-section delivery are fast. A delay in performing a necessary C-section can cause hypoxic ischemic encephalopathy and permanent brain damage in the baby.
When prolonged and obstructed labor occur, the medical team should pay very close attention to the fetal heart monitor and be prepared for a quick C-section delivery. Other conditions that typically require a prompt C-section due to the risk of birth asphyxia and HIE (hypoxic ischemic encephalopathy) are listed below:
- Umbilical cord problems, such as a nuchal cord (cord wrapped around baby’s neck), umbilical cord prolapse, short umbilical cord and cord in a true knot
- Ruptured uterus
- Preeclampsia / eclampsia
- Placental abruption
- Placenta previa
- Anesthesia mistakes, which can cause blood pressure problems in the mother, including a hypotensive crisis. This can greatly decreases the supply of oxygen-rich blood going to the baby.
- Oligohydramnios (low amniotic fluid)
- Premature rupture of the membranes (PROM) / premature birth
- Prolonged and arrested labor
- Intracranial hemorrhages (brain bleeds), which can be caused by a traumatic delivery. Forceps and vacuum extractors can cause brain bleeds. Sometimes intense contractions (hyperstimulation) caused by labor induction drugs (Pitocin and Cytotec) can cause head trauma. Mismanagement of cephalopelvic disproportion (CPD), abnormal presentations (face or breech presentation), and shoulder dystocia also put a child at risk of having a brain bleed.
- Hyperstimulation caused by Pitocin and Cytotec can also cause oxygen deprivation that gets progressively worse.
- Fetal stroke
- Issues associated with postmaturity syndrome (macrosomia, oligohydramnios, placental insufficiency, etc.)
How Can Birth Asphyxia and HIE Cause Brain Damage, Cerebral Palsy, and Lifelong Disabilities?
When the brain goes without oxygen for too long, brain cells become injured and a cycle of injury starts to occur that can cause permanent brain damage. Birth asphyxia and HIE / hypoxic ischemic encephalopathy can cause the following conditions:
- Permanent brain damage
- Seizure disorders
- Cerebral palsy (CP)
- Intellectual disabilities
- Developmental delays
- Motor disorders
- Periventricular leukomalacia (PVL). HIE usually involves damage to the basal ganglia and watershed regions of the brain, but sometimes also includes periventricular leukomalacia (PVL)
Legal Help for Children with Birth Injuries, Birth Asphyxia and HIE | Michigan Hypoxic Ischemic Encephalopathy Lawyers
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Video: Michigan Birth Asphyxia Lawyer Jesse Reiter Discusses Birth Asphyxia and HIE
In this video, birth asphyxia and HIE lawyers Jesse Reiter and Rebecca Walsh discuss the causes of birth injury, birth asphyxia and HIE.
After the traumatic birth of my son, I was left confused, afraid, and seeking answers. We needed someone we could trust and depend on. ABC Law Centers was just that.
- Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy. Obstet Gynecol 2014; 123:896.
- Wu YW, Backstrand KH, Zhao S, et al. Declining diagnosis of birth asphyxia in California: 1991-2000. Pediatrics 2004; 114:1584.
- Graham EM, Ruis KA, Hartman AL, et al. A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy. Am J Obstet Gynecol 2008; 199:587.
- Thornberg E, Thiringer K, Odeback A, Milsom I. Birth asphyxia: incidence, clinical course and outcome in a Swedish population. Acta Paediatr 1995; 84:927.
- Lee AC, Kozuki N, Blencowe H, et al. Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990. Pediatr Res 2013; 74 Suppl 1:50.
- Chau V, Poskitt KJ, Miller SP. Advanced neuroimaging techniques for the term newborn with encephalopathy. Pediatr Neurol 2009; 40:181.