Improper Fetal Monitoring and Birth Injury

In an unborn baby, heart rate can help indicate the baby’s relative health. If the baby’s heart rate is too high or too low, this can indicate fetal distress, which is a medical emergency and should be promptly addressed. Fetal distress can indicate that the baby’s body is trying to compensate for oxygen-depriving conditions (like in the case of uteroplacental dysfunction), or (if the mother is in labor) it can mean that the baby cannot tolerate labor contractions and may need to be delivered via emergency C-section. Tachycardia (high heart rate) or bradycardia (low heart rate) are both indicators of issues that need to be addressed during pregnancy, labor, and delivery.

During labor and delivery, medical staff must make sure that the baby tolerates the process well. This means making sure that the baby is receiving enough oxygen and is not showing signs of fetal distress. Staff use electronic fetal monitors to do this, interpreting the readouts to check progress. Staff can improperly interpret the readouts or use the monitors incorrectly. When this happens, they can miss signs that the baby is in distress, missing an important opportunity to avert injury.


brain injury in infantsUnderstanding Fetal Heart Rate

There are certain heart rate ranges in unborn babies that can indicate their health status:

  • Normal fetal heart rate (or ‘baseline’): approximately 120 – 160 beats per minute
  • Low fetal heart rate (bradycardia): under 100-110 beats per minute
  • High fetal heart rate (tachycardia): more than 160-180 beats per minute.

Depending on the baby’s gestational age, a baby’s heart rate can vary somewhat.

If a baby has an abnormal heart rate and is far away from being at term, medical professionals screen them for risk factors and intrauterine growth restriction, both of which can reduce oxygen flow to the baby, resulting in adverse outcomes. If abnormalities are suspected, medical professionals may suggest further testing, including:

  • Fetal electrocardiogram (when cardiac defect or conduction abnormality is suspected)
  • Maternal laboratory evaluations (for vascular disease and other underlying health conditions)
  • Umbilical artery Doppler imaging (in the case of fetal growth restriction)

What does it mean when fetal heart rate is high (tachycardia)?

When fetal heart rate is high (tachycardia), it can mean that the baby’s heart is working harder than normal to pump blood and oxygen to the rest of the body. This is a compensatory mechanism that can help offset low oxygen conditions (to some degree). However, this compensatory mechanism fails after a certain time period because babies are not capable of maintaining such a fast heart beat. When this mechanism fails, the baby’s heart rate can drop precipitously (bradycardia), allowing hypoxia (lack of oxygen) to set in. Medical professionals should promptly investigate and treat the cause(s) of fetal tachycardia. There are several underlying causes of fetal tachycardia, including poor placental perfusion, maternal fever, infections, maternal thyroid issues, and others.

What does it mean when fetal heart rate is low (bradycardia)?

When fetal heart rate is low (bradycardia), it can mean that the baby is not getting enough oxygen, or that the baby has an underlying health issue causing low heart rate. If the bradycardia is due to fetal distress (oxygen deprivation), the baby should be delivered right away, usually by emergency C-section.

Fetal Heart Rate During Labor

During labor, fetal heart rate is monitored using electronic fetal monitoring to see if the baby is tolerating labor well.

If the baby’s heart rate starts dropping or stays persistently high above baseline and continues rising, this could be a sign that the baby is in distressDespite its standard use in hospitals today, sometimes doctors and nurses still fail to monitor their patients or improperly interpret monitor tracings. This can lead to debilitating birth injuries for the baby.

Fetal heart rate can be influenced by a variety of factors, including:

During labor, the baby’s heart rate is ‘variable’ (it rises, falls, and fluctuates, varying constantly from baseline). Variability indicates a healthy cardiac and circulatory system.  Short-term variability is when the baby’s heart rate moves up and down by a range of about 5 to 10 beats per minute from beat to beat and shows on the fetal heart rate tracings as a somewhat jagged line. This is considered normal. Long-term variability is when the baby’s heart rate moves up and down by a range of 6 to 25 beats per minute over the course of a minute.  It also shows as a jagged line on fetal monitor tracings and is a good sign. A baby’s heart rate is said to be “reassuring” if the fetal heart rate pattern has normal variability with accelerations and normal baseline. This means that the baby is well oxygenated and is tolerating labor and delivery well.

If the baby’s heart rate does not rise and fall as expected or begins to flatten out, the underlying cause needs to be found. Babies whose heart rates aren’t variable (who have minimal or absent variability) are likely having issues with decreased oxygenation; this is an emergency. It is medical professionals’ job to ensure the baby’s heart rate never reaches minimal or absent variability, because at that point damage may occur.

There are some interventions that may be recommended depending to help the baby’s heart rate. There include:

  • Changing the mother’s position from side to side
  • Administering oxygen to the mother
  • Providing the mother with IV fluids
  • Digital or vibroacoustic scalp stimulation

However, C-section is often the best and fastest way to handle fetal heart rate abnormalities. In utero, there are limited options for helping treat a baby in distress. Once the baby is born, medical professionals can initiate resuscitation procedures and other medical interventions that can help remediate the in-utero conditions that caused the fetal distress.

Fetal Monitoring and Birth Injury Prevention

There are two methods of fetal monitoring – external and internal. External monitoring is done by strapping a belt-like device around a mother’s abdomen.  The device records the mother’s contractions and baby’s heart rate. Internal monitoring involves attaching an electrode to the baby’s scalp once the mother’s cervix is dilated to 2-3 centimeters and the baby’s head is engaged. The internal fetal monitor may provide a more accurate measurement of the baby’s heart rate and the mother’s contractions than the external monitor. In both methods, the data is transferred through the wires on the monitors to a machine that records and prints the information on strips for doctors and nurses to read.

The typical fetal monitor strip consists of two rows of graphs. The top shows the fetal heart rate in beats per minute and the bottom graph charts the mother’s contractions. During labor, when a mother has a contraction, the baby’s heartbeat will drop slightly, but should return to normal once the contraction is over. The fetal monitoring strip shows any discrepancies in this pattern. For example, if the monitor shows that a baby’s heart rate does not recover immediately after the contraction or if there is a deceleration in the baby’s heart rate after the contraction (a “late” deceleration), there may be a problem with the baby.

Labor monitoring with an external monitor, intrauterine pressure catheter, pulse oximeter and fetal scalp monitor

Signs and Symptoms of Fetal Distress (Non-Reassuring Heart Tracings)

A heart rate greater than 160 (tachycardia), a heart rate lower than 110 to 120 for an extended period of time (bradycardia), a decrease in fetal heart rate variability, variable decelerations which become longer-lasting, or late returns to baseline heart rate after the contraction has ended are considered “non-reassuring” indications. This may signal that the baby is not getting enough oxygen and if not delivered soon, could suffer birth asphyxia (hypoxic-ischemic encephalopathy).

Fetal Distress and Birth Injuries: Causes

There are several serious conditions that can occur during labor and delivery that cause the fetal heart rate to become non-reassuring. These include:

  • Umbilical cord problems like umbilical cord compression, umbilical cord prolapse (umbilical cord precedes the baby’s exit from the uterus) or nuchal cord (cord wrapped around baby’s neck).
  • Placental abruption (placenta separates from uterine wall).
  • Uterine rupture (a tear in the wall of the uterus, usually at the site of a previous c-section incision).
  • Labor contractions are too strong, too long, or too frequent. Sometimes these problems can occur as a result of labor induction medications such as oxytocin (Pitocin) and Cytotec.
  • Uteroplacental insufficiency (insufficient amount of blood flowing to the placenta).
  • Polyhydramnios (excessive amniotic fluid) or oligohydramnios (insufficient amniotic fluid)
  • Cephalopelvic disproportion (baby’s head is too big to fit through mother’s pelvis), macrosomia (large baby), breech (baby is positioned in a buttocks first or foot-first position instead of head-down), or other delivery presentation that causes the baby to get caught in the birth canal.

Preventing Fetal Distress and Birth Injuries

Obstetricians and nurses must carefully review fetal monitor strips throughout labor and delivery to ensure fetal heart tones are reassuring and the baby is getting enough oxygen.  If non-reassuring conditions occur, appropriate and timely actions must be taken. Generally, nursing interventions are attempted first to restore normal oxygenation to the baby. These include the administration of supplemental oxygen, changes in maternal position, increasing intravenous fluids, and the administration of medications that subdue contractions and maximize placental blood flow. If fetal heart tones remain non-reassuring despite nursing interventions, the fetus should be delivered by emergency cesarean section.  Emergency cesarean section should be performed in 5 to 30 minutes, depending on the circumstances.

Classifying Normal and Abnormal Fetal Heart Rates in Labor and Delivery

During labor and delivery, electronic fetal monitoring (EFM) is used to:

  • Ensure the baby has enough oxygen, and
  • Reduce the risk of neonatal complications due to oxygen deprivation.

Professionals use electronic fetal heart rate monitoring to spot signs of fetal hypoxia and intervene appropriately to eliminate or reduce the risk of HIE and other birth injuries. Fetal heart rate monitoring helps medical professionals assess how well a baby is tolerating labor. If fetal heart rate tracings begin to be concerning, medical professionals should act to intervene.

In 2008, experts proposed a three category system for classifying fetal heart rate (FHR) tracings. The system divides fetal heart rate tracings into three categories:

  • Category I Fetal Heart Tracings: Category I fetal heart rate tracings are considered normal. These tracings include all of the following:
    • A baseline FHR between 110-160 beats per minute
    • A moderate level of baseline FHR variability (meaning that the FHR waivers only moderately from the baseline level)
    • Absence of late or variable decelerations (FHR does not decelerate after a contraction)
    • Presence or absence of both FHR accelerations, and early decelerations
  • Category II Fetal Heart Tracings: Category II fetal heart rate tracings are considered ‘indeterminate.’ The large majority of tracings fall into this category. Some characteristics of Category II tracings are considered benign, while others are more urgent and may require prompt interventions to avoid brain injury due to oxygen deprivation. Some qualities of category II fetal heart rate tracings are:
    • Bradycardia, or slow heart rate (when baseline FHR variability is also present)
    • Tachycardia, or fast heart rate
    • Minimal or marked baseline variability
    • Absent baseline variability with no recurrent FHR decelerations
    • Absence of induced accelerations in FHR after stimulation of the baby
  • Category III Fetal Heart Tracings: Category III fetal heart rate tracings are considered abnormal and require appropriate intervention, which often includes prompt delivery, often via emergency C-section. If Category III fetal heart rate tracings are allowed to continue without intervention, this will likely result in fetal brain injury. Category III tracings include the following:
    • Absent baseline variability and recurrent late decelerations
    • Absent baseline variability and recurrent variable decelerations
    • Absent baseline variability and bradycardia
    • Sinusoidal pattern (a pattern that is uniform but does not resemble a normal FHR pattern)

The Pitfalls of the Three-Category EFM Classification System

Because the three-category system of classification includes a broad Category II section, some researchers find that this system is less useful for providing medical professionals with guidelines for intervening when concerning heart rate tracings show up. Some researchers (such as Parer and Ikeda) have developed more granular 5-category systems for EFM classification that help subdivide Category II tracings into further divisions, providing medical professionals with more precise categories for various heart rate tracing patterns.

Electronic fetal heart rate monitoring is a critical tool for understanding how a baby is tolerating labor. If medical professionals do not act on concerning fetal heart rate tracings, they are putting the baby at risk for injury. During labor and delivery, a well-trained and experienced medical staff member should be watching the fetal monitoring strips for concerning signs, and they should notify other staff, conduct medical interventions, and intervene if the baby’s heart rate drops or worsens. If they do not, it is medical malpractice, because their actions increase the baby’s chances of being injured by oxygen deprivation.


Legal Help for Fetal Monitoring Errors, HIE, and Birth Injury

Birth Injury Attorneys | Reiter & Walsh, PC | HIE, Birth Asphyxia, Cerebral Palsy, Birth Injury AttorneysThe sole purpose of the fetal heart monitor is to allow medical staff to identify any signs of fetal distress and to take swift and appropriate action. If a healthcare provider ignores or misinterprets the fetal monitor strips, resulting in oxygen deprivation and brain damage, it is medical malpractice. Birth injury cases require specific, extensive knowledge of both law and medicine. In order to achieve the best results, our team believes it’s critical to specifically and exclusively handle birth injury cases. Reiter & Walsh ABC Law Centers is a national birth injury law firm that has been helping children with birth injuries since its inception in 1997.

Our firm, which is based in Detroit, Michigan, has helped families across the United States in cases involving fetal monitoring errors, delayed delivery, C-section mistakes, HIE (hypoxic-ischemic encephalopathy), premature birth, cerebral palsy, periventricular leukomalacia (PVL), and other birth injuries and complications. Our clients have hailed from all over the United States, including Michigan, Ohio, Texas, Wisconsin, Washington D.C., Pennsylvania, Tennessee, Arkansas, Mississippi, and other states. The Reiter & Walsh, P.C. birth trauma team has also handled FTCA (Federal Tort Claims Act) cases involving military medical malpractice and federally-funded clinics.

To begin your free birth trauma case review, simply contact us in any of the following ways:

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Video: Detroit, Michigan Birth Injury Attorneys Discuss Medical Malpractice and Fetal Monitoring Errors

In this video, Jesse and Rebecca discuss birth injuries and how improper fetal monitoring and delayed C-section delivery are frequently the cause of birth injuries such as cerebral palsy.


SOURCES:

  • Cahill AG, Caughey AB, Roehl KA, et al. Terminal fetal heart decelerations and neonatal outcomes. Obstet Gynecol 2013; 122:1070.
  • Chauhan SP, Klauser CK, Woodring TC, et al. Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: interobserver variability. Am J Obstet Gynecol 2008; 199:623.e1.
  • Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol 2008; 112:661.
  • Electronic fetal heart rate monitoring: research guidelines for interpretation. National Institute of Child Health and Human Development Research Planning Workshop. Am J Obstet Gynecol 1997; 177:1385.
  • Jackson M, Holmgren CM, Esplin MS, et al. Frequency of fetal heart rate categories and short-term neonatal outcome. Obstet Gynecol 2011; 118:803.
  • Berkus MD, Langer O, Samueloff A, et al. Electronic fetal monitoring: what’s reassuring? Acta Obstet Gynecol Scand 1999; 78:15.
  • Krebs HB, Petres RE, Dunn LJ, Smith PJ. Intrapartum fetal heart rate monitoring. VI. Prognostic significance of accelerations. Am J Obstet Gynecol 1982; 142:297.
  • Liston R, Sawchuck D, Young D, et al. Fetal health surveillance: antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can 2007; 29:S3.

For more information on fetal heart rate monitoring, please see the American Academy of Family Physicians’ Guide to EFM.

Further Reading: