Anesthesia Errors and Birth Injuries
It is very popular to use epidural anesthesia for childbirth, but there are associated risks that are not always adequately communicated to expectant mothers, resulting in the absence of informed consent. Epidurals can interfere with the second stage of labor, increasing the incidence of instrument use during delivery, which in turn increases the risks of brain bleeding and birth injuries due to improper instrument use. The health risks that can come with some pain relief medications include exceptionally low blood pressure (resulting in decreased blood flow to the baby), fetal heart decelerations, altered rhythm and sustainment of uterine contractions (resulting in fetal oxygen deprivation), acidemia (low blood pH) in newborns, increased incidence of postpartum hemorrhage, bradycardia (decreased heart rate), respiratory arrest in the mother, and other issues such as hypoxic ischemic encephalopathy (HIE) and cerebral palsy.
In the context of labor and delivery pain, the term “regional analgesia” refers to the inhibition of labor pain. The term “regional anesthesia” means use of a greater concentration of local anesthetic, which results in removal of all sensation. Local anesthetic is typically used to facilitate instrumental (use of forceps or vacuum extractor) or C-section delivery. However, the two terms are sometimes used interchangeably and there is considerable overlap between them. As an example, in some patients, epidural analgesia may provide sufficient pain relief for instrumental delivery, thereby negating the need for more potent anesthesia.
Regional techniques (epidural and spinal) provide unparalleled pain relief. A regional technique is one in which the drugs are administered into a specific region, the lower neuraxis (part of the central nervous system). Analgesics may be administered via epidural, spinal, or a combination of both routes. The epidural approach requires longer time to take effect compared to the spinal approach in which drugs are deposited directly into the cerebral spinal fluid (CSF).
Local anesthetics used for regional techniques during labor and delivery include bupivacaine, lidocaine, ropivacaine, procaine, 2-chloroprocaine and tetracaine.
Complications Associated with Anesthesia and Analgesia Use
Low Blood Pressure (Hypotensive Crisis) and Anesthesia Errors
Significant low blood pressure (hypotension) is a complication of analgesia / anesthesia. The way in which epiduralized mothers must lie accentuates this. The mother’s position is limited since she is essentially paralyzed for the duration of the epidural. Hypotension occurs among almost 1/3 of patients, with serious hypotension occurring approximately 12% of the time.
Maternal hypotension is a major risk for the baby. The epidural blocks the nerves which regulate blood pressure. It causes the blood in the baby to pool, keeping it from being pumped around the body in the proper manner. The mother’s arteries dilate and relax their usual, necessary level of tension, making it difficult for the heart to pump blood to the baby. These changes lead to a decrease in the blood output of the mother’s heart, which causes a decrease in oxygen-rich blood going to the placenta and baby.
The baby is completely dependent on the mother’s heart to pump blood to the placenta to satisfy her needs. All of her oxygen comes from across the placenta and through the umbilical cord. All of the food for the baby’s brain and other organs comes across the placenta. Without the proper supply of glucose and oxygen, a baby’s brain can become damaged.
All women receiving analgesia / anesthesia during delivery must have their babies monitored with a fetal heart monitor up until the point of abdominal prepping. Further monitoring is required after prepping depending on the circumstances. Monitoring is performed with a device that tracks the baby’s heart rate in response to contractions. Fetal distress will be evident on the fetal heart monitor, in most cases, and the staff must pay close attention to and properly interpret the fetal heart tracings.
Severely low blood pressure can also result from compression of the mother’s blood vessels (aorta and vena cava) since she is essentially lying flat on her back after epidural administration.
Fetal Distress and Anesthesia Errors
Fetal heart rate decelerations can be a sign of fetal distress and can occur following the use of epidurals. Babies can develop distress after epidural analgesia / anesthesia when the mother’s blood pressure becomes so low that blood cannot be adequately pumped into the uterus and placenta to deliver oxygen to the baby. The ability of the heart to respond to changing needs of the body is impaired.
Research suggests that analgesia / anesthesia may also transiently alter the balance between factors encouraging and discouraging uterine contraction. A temporary increase in the uterotonic effects (constantly contracted uterus) of either naturally occurring oxytocin or oxytocin (Pitocin) given by the physician (which is common during analgesia / anesthesia use) may then produce a tetanic contraction (the strongest possible constant contraction) with subsequent decrease in oxygen delivery to the baby and resultant fetal bradycardia.
Most babies of mothers receiving epidural anesthesia / analgesia develop episodes of slow heart rate (bradycardia). While this does not typically affect the healthy baby, it can be disastrous for the baby that is already compromised from some other problem.
The transient low blood pressure that typically occurs after epidural analgesia / anesthesia administration has been found to lower the baby’s blood pH. This is called acidemia, which is acidic blood. When a baby has acidemia at birth, it usually means that the baby was not getting enough oxygen in the womb. Much of the time, babies recover from oxygen deprivation and acidemia. But if the baby was deprived of oxygen for too long, permanent brain damage can result. Indeed, many researchers think that epidurals significantly worsen the condition of already compromised babies, and this may lead to C-section births when the babies might otherwise have tolerated vaginal births.
Given the numerous risks to the baby when the mother receives an epidural / anesthesia, it is imperative for the medical team to closely watch the fetal heart tracings on the fetal monitor. Fetal monitoring from the start of labor until the baby is delivered. This means that close fetal heart monitoring must take place before AND after administration of anesthesia. At the first signs of fetal distress, preparations should be made for a prompt C-section delivery. Delay of a necessary C-section delivery when a baby is being deprived of oxygen and in distress can cause brain injury such as hypoxic ischemic encephalopathy (HIE).
Abnormal Uterine Contractions and Anesthesia Errors
Uterine contractions can become weaker and less frequent during analgesia / anesthesia epidural use. An oxytocin infusion is then necessary to improve labor and produce stronger contractions. Mothers given epidurals have longer labors and have a higher incidence of the use of oxytocin than mothers having non-medicated deliveries. There are important risks of giving oxytocin.
Administration of oxytocin during labor can cause:
- Sustained uterine contractions (hypertonic or tetanic contractions) which are too strong and frequent and result in the baby going into distress from lack of oxygen. When this is too severe, the uterus can rupture. The epidural can mask the strength of the uterine contractions so that no one knows that how strong they are, making uterine rupture more possible.
- Dangerously high blood pressure
- Abnormal heart rhythms
- Nausea and vomiting
- Hemorrhage around the brain
- Retention of water leading to convulsions and coma
- Bleeding in the pelvis and increased incidence of postpartum hemorrhage
- Death of the baby
- Jaundice of the baby
Heart Problems and Anesthesia Errors
During anesthesia / analgesia usage, mothers can experience bradycardia, heart block in which the electrical activity of the chambers of the heart become dissociated, and sometimes even cardiac arrest.
Respiratory Arrests and Anesthesia Errors
Mothers can stop breathing (respiratory arrest) and can experience other breathing difficulties when anesthesia / analgesia is used.
Second Stage of Labor Effects
With large doses of anesthesia / analgesia, the mother may lose the desire and ability to bear down and push. This results in increased use of forceps and vacuum extractors during delivery as compared to mothers having unmedicated deliveries. Forceps and vacuum extractors put a baby at risk for head trauma and brain bleeds, which can cause brain damage. Prolonged labor also has risks, such as oxygen deprivation and brain bleeds.
Anesthesia Use in Vaginal Birth After Cesarean Section (VBAC) Deliveries
Anesthesia / analgesia is sometimes used with mothers desiring a vaginal birth after having a C-section (VBAC). One group of researchers studied the maternal and fetal consequences of uterine rupture during VBAC and concluded that significant neonatal morbidity (injury to the baby) occurred when 18 or more minutes elapsed between the onset of prolonged decelerations and delivery. Uterine rupture refers to complete disruption of all uterine layers, which typically occurs when the forces of uterine contractions associated with attempted vaginal delivery cause the uterus to tear open, potentially causing the unborn baby to spill into the mother’s abdomen. When this occurs, there often is hemorrhaging (rapid, uncontrolled bleeding) that can cause the baby to be severely deprived of oxygen. A uterine rupture can be caused by a preexisting injury or trauma, but a rupture is most commonly associated with a trial of labor after C-section.
Other Complications Associated with Anesthesia Use
- Motor Block. Epidural anesthesia / analgesia can cause motor block, resulting in temporary paralysis, even of respiratory muscles.
- Accidental Spinal Anesthesia. When an epidural accidentally turns into a spinal anesthetic, many complications can occur:
- Postspinal headaches.
- Dysfunction of the bladder is frequent
- Occasionally numbness and tingling (paresthesias) of the lower limbs and abdomen develop, and sometimes there is a temporary loss or diminution of sensation in these areas.
- Unilateral footdrop (paralysis of the muscle that lifts the foot) has occurred.
- Permanent nerve damage (conditions called chronic, progressive adhesive arachnoiditis or transverse myelitis) can occur. These lead to paralysis of the lower parts of the body.
- Deaths have been reported
- Difficult breathing
- Increased incidence of forceps deliveries
- Medication interactions. A hidden danger of epidural anesthesia / analgesia is its interaction with medications (prostaglandins) commonly used to soften the cervix and start labor. The use of prostaglandins is common at hospitals and creates a potentially dangerous situation in which the usual medications used to treat low blood pressure will no longer work.
- IV Cannulation. Accidental injection of the anesthetic solution into the blood stream can occur and cause the mother to twitch, have convulsions, or lose consciousness. Seizures can occur from the toxic effects of the anesthetic agent entering the blood stream.
- Trauma to the blood vessels near the spinal column
- Punctured dura (a covering of the brain)
- Infection at the site of injection
C-Section Delivery and Anesthesia Use
Operative anesthesia requires a more intense block because the pain and stimulation from surgery is different and more intense than the pain of labor. Relatively dilute concentrations of local anesthesia are administered for labor analgesia to avoid motor block and to minimize interference with second stage pushing efforts. However, motor block is desirable for C-section delivery to obtain abdominal muscle relaxation. A more intense block is achieved by administering a high concentration of local anesthetic.
For scheduled C-section, the rapidity of anesthetic induction is less of a concern, so all anesthetic options are available. If the C-section must be performed urgently (e.g., nonreassuring fetal heart rate pattern), an anesthetic technique that can be performed expeditiously is preferred. If the C-section is a true emergency, the time required to achieve anesthesia and facilitate a rapid delivery may be of critical importance to the well-being of the baby and / or mother. This is one of the main reasons it is critical to have a skilled team readily available at all deliveries, and it is crucial the all team members – especially the obstetrician and anesthesiologist – communicate effectively when a C-section is about to take place.
Spinal anesthesia is more desirable than epidural if time is of the essence because the onset of the block is faster with a spinal approach. However, if the mother already has an epidural catheter in place, operative anesthesia may be achieved within a few minutes in most cases by injecting a more concentrated local anesthetic.
In a mother is experiencing a sudden onset hemorrhage and / or her blood pressure or circulation is compromised, a regional anesthesia typically should not be used because it will produce dilated blood vessels, which will exacerbate an already low blood pressure. Significant bleeding diathesis (unusual susceptibility to bleeding) is another contraindication to general anesthesia.
Since anesthesia usually causes hypotension in the mother, and hypotension can cause a decrease (sometimes severe) in oxygenation of the baby, prophylactic strategies to help prevent hypotension are often utilized. These strategies include giving the mother extra fluids intravenously (fluid intake increases blood volume, which in turn, increases blood pressure), giving her colloid prehydration (a solution that contains particles that increase blood volume), and having the mother wear compression boots or leg wrappings. Medications such as phenylephrine and ephedrine, which increase blood pressure, may be given prophylactically. However, reactive hypertension (abnormally high blood pressure) can occur when these medications are given prophylactially, so prompt treatment at the first sign of hypotension may be a more cautious approach. It cannot be emphasized enough that close monitoring of the mother’s heart rate and blood pressure and the baby’s heart rate are essential, and the team administering the drugs must have detailed communication with each other.
A slow heart rate in the mother (bradycardia) can occur when ephedrine and phenylephrine are given, although this is more common with ephedrine.
For low risk mothers and babies undergoing scheduled C-section delivery, the presence of a normal fetal heart rate should be ascertained and documented before administration of anesthesia. When an emergency C-section is about to occur, continuous fetal heart rate monitoring should be maintained until the abdominal sterile preparation has begun, at which time the external monitor may be removed. If an internal monitor is being used, it may be removed when the abdominal sterile preparation is complete.
The introduction of a sterile field does not necessitate discontinuation of fetal heart rate monitoring. Indeed, there are certain instances in which monitoring should continue until the baby is delivered. Sterilizable probes are available for use with certain Doppler monitors. If a hospital does not have these types of probes, a condom can be placed over the probe to allow for fetal heart rate monitoring during a C-section.
Anesthesia Errors, Hypertensive Crisis and Hypotensive Crisis
A hypertensive crisis is defined as a persistently high blood pressure or a precipitous change in blood pressure, such as a slightly high blood pressure suddenly becoming extremely high. A hypotensive crisis is persistently low blood pressure, or a suddenly large decrease in blood pressure, such as a very high blood pressure that suddenly drops to normal. Both can occur during labor and delivery as result of anesthesia / analgesia use.
In these types of blood pressure crises, the baby can become severely compromised due to decreased flow of oxygen-rich blood. Fetal mortality and morbidity is often directly linked to the maternal condition, and therefore management is based on quick diagnosis and stabilization of the condition and prompt delivery of the baby.
In a hypertensive crisis, blood pressure must be lowered in a safe manner. The blood pressure should not exceed a drop of 25 – 30% in the first 60 minutes, and it should not drop below a certain point (usually 150/95). Every effort must be made to not overcorrect the hypertension. Too swift or too dramatic a reduction in blood pressure can have untoward consequences for both mother and baby, including sudden fetal distress secondary to decreased blood flow in the placenta, and the possibility of maternal myocardial or cerebral infarction (cessation of blood flow in vessels in the heart or brain, which can cause a heart attack or stroke). For these reasons, short-acting intravenous agents are recommended to treat hypertensive emergencies, and oral or sublingual compounds must be avoided because they are more likely to cause precipitous and erratic drops in blood pressure.
During the crisis, the mother should be in a delivery unit with critical care capabilities under the direction of physicians skilled in managing critically ill patients. Such management should include participation of anesthesiologists, maternal-fetal medicine specialists, and nurses with critical care experience. Continuous fetal heart rate monitoring is critical. Under such extreme circumstances, it is often not possible to prolong a pregnancy that is remote from term. Delivery decisions will need to balance prematurity risks against maternal risks, and oftentimes, and emergency C-section must be performed. Vaginal delivery can be less stressful with respect to maternal blood pressure and circulation, but it is not always practical. Indeed, C-section delivery may be preferable, especially if the baby is in an abnormal position, the cervix is unfavorable for induction, or a protracted attempt at labor induction is not prudent. Altered placental function – especially if combined with prematurity – often results in the baby being unable to tolerate labor for very long, necessitating an emergency C-section under potentially less controlled circumstances. The anesthesiologist and others on the critical care team must carefully review the optimal anesthesia technique.
In a hypertensive crisis, magnesium sulfate should be given to prevent eclampsia.
Epidurals, Informed Consent and Medical Malpractice
Women are frequently not given informed consent for epidurals during labor and delivery. Even reading the 2 paragraphs from the package insert that comes with the medication used for epidurals might make a woman think twice. The insert states that local anesthetics rapidly cross the placenta, and when used with an epidural, varying degrees of maternal, fetal and neonatal toxicity may occur. In addition, language on the insert states that adverse reactions in the mother, fetus and neonate involve alterations of the central nervous system, peripheral vascular tone and cardiac function, and there is an increase in the incidence of hypotension, slowing of labor, and forceps delivery.
Failure to inform the mother of the risks and benefits of and alternatives to anesthesia / analgesia use is negligence. Failure to properly administer the drugs and closely monitor the mother and baby, and failure to have a skilled team present during anesthesia / analgesia use also constitute negligence. It also is imperative for the team to have detailed communication with each other during labor and delivery. The baby’s heart rate must be continuously monitored with a fetal heart rate monitor. At the first signs of distress, the baby should be quickly delivered by emergency C-section. If these standards of care are not followed and the mother or baby suffer injury as a result, it is medical malpractice.
Birth Injury Attorneys Helping Children with Birth Injuries from Anesthesia Errors
A child’s birth injury diagnosis is one of the most devastating diagnoses that a parent can receive after a difficult birth. If your child has been diagnosed with cerebral palsy, HIE, or another birth injury from anesthesia misuse, we encourage you to reach our to the Reiter & Walsh, P.C. birth injury attorneys as soon as possible. During your free case review, our team will determine the cause of your child’s injuries and, should you have a case, help you obtain the compensation your family needs.
The Reiter & Walsh, P.C. team is based in Michigan, but we handle cases all over the United States. Should you live outside Michigan, our attorneys will travel to your hometown as necessary. Beyond Michigan, we’re able to handle cases in states such as Ohio, Texas, Arkansas, Mississippi, Tennessee, Pennsylvania, Washington D.C., Wisconsin, and all over the United States. We’re also equipped to handle FTCA cases involving military medical malpractice and federally funded clinics.
To begin your free birth injury case review, please contact the Reiter & Walsh ABC Law Centers team in whichever way best suits your needs:
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Video: Attorneys Discuss Anesthesia Errors and Birth Injuries
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