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When To Worry: From Difficult Labor To Birth Injuries In Ohio
Because each labor and delivery experience is unique, new moms are often caught sharing birth stories. For mother and baby, the onset of contractions through baby’s arrival are some of the most dangerous and life-altering moments.
And frustratingly, even the perfect birth plan can quickly go awry. With the pain and potential panic of intense contractions that seem to never let up, your plan may go out the window. How labor progresses and the decisions of your ob-gyn or the ob-gyn on call can make the difference between a healthy baby and a serious birth injury.
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Examples Of Birth Injuries
The terms and the jargon used by medical professionals can be difficult to understand. Deceleration and variability relate to the fetal monitoring during labor and can indicate whether intervention is necessary. Once a baby arrives, an APGAR test (Activity, Pulse, Grimace, Activity and Respiration, each scored on a scale of 0 to 2) can help identify possible complications or injuries. These tools are several used to prevent and/or diagnose damage to the brain and nerves.
A diagnosis itself may include terms nearly incomprehensible:
- Hypoxic-ischemic encephalopathy (HIE) requires translation: Hypoxic is lack of oxygen, ischemic means restricted blood flow, which causes encephalopathy or damage to the brain. This is also called acute perinatal asphyxia. Moderate encephalopathy carries a 10 percent risk of death, and 30 percent of those who survive suffer disabilities.[1] Infants who suffer severe encephalopathy only have a 40 percent chance of survival and most are left handicapped.[2] The part of brain affected and immediate efforts such as brain cooling can affect the severity of the injury.[3]
- Cerebral Palsy is one that most recognized injuries that can occur at birth. It may be spastic (affecting one arm or leg) or dyskinetic (affect ability to control movement in arms, legs, face or tongue). Learning difficulties along with vision and hearing impairment can occur as a result.
- Shoulder dystocia is when a baby’s shoulder(s) will not come through the pelvis. Intervention can damage nerves. These brachial plexus injuries include Erb’s palsy and Klumpke’s palsy.
- A skull fracture can occur with vacuum extraction and other types of intervention. You generally cannot see this injury, but over time your baby’s behavior may indicate that an injury occurred.
Sometimes these injuries can be immediately apparent. In other cases, it may take six months to several years before you realize an injury occurred or understand the true severity of the injury.
[1] Shankaran, S, M.D., Laptook, A, M.D. et al, “Whole-Body Hypothermia for Neonates with Hypoxic-Ischemic Encephalopathy,” New England Journal of Medicine, Oct. 2005, accessed at https://www.nejm.org/doi/full/10.1056/NEJMcps050929
[2] Id.
[3] Id.
A Referral To A Pediatric Neurologist
Medicine has become so specialized that a pediatrician may refer to you a specialist if concerns arise at a checkup. A pediatric neurologist treats children who are having problems with their nervous system. Symptoms can range from headaches and muscle problems to seizures and developmental delays.
Common tests that child neurologists rely upon to diagnose include:
- Electroencephalogram (EEG) compares electrical activity in the brain with what would be expected in a child at a developmental stage. This is often ordered if a child is struggling with seizures.
- Magnetic resonance imaging (MRI) and CT scans are imaging tests that take pictures of the brain and spine. These tests can be difficult for children, and resources exist to prepare parents when they are required.
Child neurologists become part of a care team. In complex cases of cerebral palsy or brain injury, they often work closely with occupational and speech therapists as well as physical therapists to help a child develop to the best of their potential.
If referred to one of these specialists, find out whether an injury suffered at birth might have been an underlying cause. An experienced birth injury attorney can go back and review electronic fetal monitoring strips, APGAR scores and blood gases to determine whether something went wrong during delivery.
What Is An Electronic Fetal Monitor?
It is one tool used to monitor contractions and how your baby responds to them. The strip that the machine prints out provides physicians, nurse-midwives and nurses with continuous information on your baby’s heart rate along with your contraction pattern.
Once admitted to the hospital, a first step is for a nurse to place two bands above and around your belly to establish a baseline. Some hospitals have a mobile device allowing birthing mothers to pace the halls and move while in labor, but most do not.
The machine displays two lines:
- The top is the baby’s heart rate (normal is between 110 to 160 beats per minute)
- The bottom records your contractions
A baby’s heart rate will vary during delivery, but when and why a baby’s heart rate decreases can inform physicians or midwives that something may be wrong. It can also indicate when an emergency cesarean section is necessary.
Four Types Of Decelerations
Spontaneous heart rate decreases are not linked to a contraction. Usually this is not a significant concern.
Early decelerations normally appear during active labor. A gradual decrease in the baby’s heart rate mirrors your contraction. (This is thought to be related to pressure on baby’s head). If these periods are not prolonged, this is generally harmless.
The next two can be cause for concern and may require immediate intervention or an emergency C-section.[4]
Variable deceleration does not follow a mirrored pattern. Big dips in the baby’s heart rate start to look like V’s. The umbilical cord could be compromised and not carrying sufficient blood and oxygen to the baby. If the baby’s overall heart rate rises or variability decreases, intervention options include changing position, infusing extra fluid through an IV and putting an oxygen mask over the mother’s face.
If these do not work, metabolic acidosis can occur within an hour and a half.[5] Early recognition of the variable deceleration and immediate intervention are crucial because waiting can lead to asphyxia (lack of oxygen) and brain damage.
Late deceleration occurs when the decrease in heart rate follows the contraction. This can also indicate that the baby is not getting enough oxygen. Turning the mother on her side or reducing Pitocin are common intervention methods. If linked to a drop in the mother’s blood pressure after an epidural, medication can be used to raise her blood pressure to a normal range. Continued late deceleration and reduced variability are cause for a C-section.
[4] Fahey, JO, “The Recognition and Management of Intrapartum Fetal Heart Rate Emergencies: Beyond Definitions and Classifications,” Journal of Midwifery & Women’s Health, Nov-Dec. 2014, 616-23. accessed at https://www.ncbi.nlm.nih.gov/pubmed/25389019.
[5] Parer, J, King, et al., “Fetal Acidemia and Electronic Fetal Heart Rate Patters: Is There Evidence of an Association?” The Journal of Maternal-Fetal and Neonatal Medicine 19(5), 289-94. accessed at: https://www.ncbi.nlm.nih.gov/pubmed/16753769.
Related Heart Rate Classifications
These categories range from I to III and are determined by looking at baseline heart rate and interpretation of the fetal monitoring strips:
- Category I – Baseline heart rate of 110 to 160 beats per minute. Moderate variability. No variable or late decelerations. Normal acid-base balance in baby’s body.
- Category II – Some variable or late decelerations, but the baby’s heart rate remains normal. Heart rate that is too high. Deceleration lasts more than 10 minutes. Problems may be developing, intervention is needed with closer monitoring.
- Category III – Frequent variable or late deceleration. Little variability. Slow baseline heart rate. Immediate intervention, extra fluid through an IV, oxygen mask, stop Pitocin infusion and change of position. If the pattern does not improve, the OB needs to deliver the baby.
These monitoring tests work together but also require subjective interpretation by a physician or midwife.
The Dangers Of Improper Or Delayed Monitoring
When a care provider fails to identify non-reassuring fetal heart rate patterns, the danger is that hypoxia can occur. Without adequate oxygen, a baby’s brain cells start to die, which is a process called ischemia. Once delivered, the baby may need resuscitation and assistance breathing.
Symptoms of HIE follow a continuum with some of the most severe cases including seizures. Poor muscle tone is another than can interfere with feeding when a baby cannot properly coordinate sucking and swallowing. As a baby grows developmental delays may become apparent.
Prevention of HIE is often possible with appropriate care and timely monitoring.
Was A Birth Injury Caused By A Mistake?
A physician may be negligent if he or she fails to do what a reasonable, prudent physician in the same specialty would have done in the same or similar circumstances. Negligence is not a deviation from perfection but from what other reasonable physicians in Ohio and the region would have done.
An attorney may be able to spot red flags that this standard of care was breached with years of experience. Further investigation may uncover altered records or a pattern of staffing shortages that caused monitoring gaps. Expert review is another step in the process to seek a remedy.
Before Speaking To An Attorney, Ask Questions
Does the firm they have registered nurses on staff or attorneys with medical backgrounds? Have they handled similar cases? Has an attorney obtained verdicts?
The team at Crandall & Pera Law has registered nurses on staff. The firm’s attorneys combine for more than 40 years of experience handling medical malpractice and birth injury cases. Having attorneys who started their careers working for the defense allows us to anticipate and counter the other side’s arguments. Our attorneys are not afraid to take to cases to trial and limit the number of cases they take to give your matter the attention it deserves.
You have enough on your hands caring for your child, assembling a medical care team and getting to all the appointments. What will the future hold? While we cannot predict exactly, we can share our experience from working with similarly affected families. During one of the most difficult times of your life, let us handle the legal issues and ensure your family has the financial protections in place to cover lifelong care needs.
Attorney Profiles
Here are some of the things that set our founding attorneys apart from the crowd:
Steve Crandall
A founding partner of Crandall & Pera Law, attorney Steve Crandall has been practicing law for more than 25 years. He started his career defending insurance companies. In 2001, he switched his focus to helping injured individuals and their families. Licensed in Ohio and Kentucky, he has obtained significant verdicts and settlements in each state.
He has spoken extensively on medical malpractice and personal injury claims at conventions and conferences. In addition to being selected for inclusion in Ohio Super Lawyers for more than a decade, Mr. Crandall has been recognized among the National Trial Lawyers’ Top 100 Trial Lawyers. He has earned a “pre-eminent lawyer” rating of 5.0/5.0 on Martindale-Hubbell and a “superb” rating on Avvo with a 10/10.
Together with the attorneys at his firm, Steve Crandall has taken more than 100 cases to verdict and recovered tens of millions for injury victims.
Marc Pera
After graduating from The Ohio State University Michael E. Moritz College of Law school in 1996, attorney Marc Pera gained valuable experience defending insurance companies and large corporations. In 2002, he joined Steve Crandall in fighting for victims who had suffered serious injuries because of someone else’s negligence.
Mr. Pera is frequently asked to present on medical malpractice and personal injury topics to other attorneys through state and local bar associations. He has been included in the Ohio Super Lawyers list since 2012, selected for membership in the National Trial Lawyers’ Top 100 Trial Lawyers since 2014, and named to the Top 25 Medical Malpractice Attorneys by the same organization. Mr. Pera has a “superb” rating through Avvo with a 10/10 ranking.
His service to the profession includes serving as the Medical Negligence Committee Chair (2009 – 2010) & Board of Trustees Representative At Large (2014 – 2016) for the Ohio Association for Justice and Solo/Small Firm Committee Chair for the Cincinnati Bar Association (2006 – 2008). He manages the firm’s Cincinnati office.