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Brain Injury from Asphyxia
Asphyxia is the most common cause of brain injury at birth. Asphyxia in the birthing process occurs when the baby
does not receive enough oxygen through the unborn baby's lifeline: the umbilical cord, which is connected to the
placenta, which is attached to the mother's uterus.
During labor and delivery, doctors and nurses look to the electronic fetal monitor for changes that can provide warning
signs that a baby is at risk for asphyxia. If the fetal monitor shows a pattern of decelerations in the baby's heart
rate late in the contraction or variably during the contraction, this can be a sign of a problem.
Fetal Monitoring
The electronic fetal monitor puts out a strip of paper that shows the baby's heart rate, which should range from
about 120 to 160 beats per minute, in relation to the timing of the mother's uterus contraction. Here is an example:
The top bar graph is the baby's heart rate. Each horizontal box represents 10 seconds, and the slightly darker lines
show one minute. Each vertical box represents a change in heart rate of 10 beats per minute. This baby's heart rate
on this strip ranges from about 120 to 160 beats per minute, completely normal.
The bottom graph shows the strength of the mother's uterine contractions. When the line gets near the bottom,
the uterus is relaxed. In determining if a baby is under distress, it is important to look for drops in the baby's heart
rate - decelerations - in connection with the timing of the uterine contractions. There are three basic types of
decelerations: early, late and variable.
Early Decelerations: Early decelerations (decels) have a gradual drop in the baby's heart rate with the onset
of the drop occurring with the onset of a contraction. The U-shape of the early decel mirrors the upside-down-U shape
of the contraction. An early deceleration is entirely normal and is not associated with lack of oxygen to the baby.
Late Decelerations: Late decelerations have the same characteristics as early decels, but the onset occurs
after the onset of the contraction. Late decelerations can mean the baby is not getting enough oxygen from the
mother's placenta. The size and depth of a late decel is not the key, because even subtle late decels can be ominous.
As the contraction builds, blood flow through the placenta is diminished, leaving the fetus to rely on reserves. When
reserves are inadequate, the baby's heart rate decreases and a late decel occurs. After the contraction ends, normal
blood flow usually resumes and the heart rate recovers.
Variable Decelerations: Variable decels can occur before, during, or after a contraction, or when no contraction
is present (nonperiodic). It is characterized by an abrupt drop in FHR, followed by an abrupt return to baseline. Variable
decels can vary in size, timing, depth and duration. Also, atypical variable decelerations can occur, which are more
diagnostic of a fetus at risk.
Variable decelerations are associated with cord compression. Thus, the duration of the decel may be tied to the period of
time that the cord is compressed. When the umbilical cord is compressed, it causes an increase in fetal blood pressure,
reduces oxygen supply to the fetus, and activates responses in the brain which result in a decrease in heart rate and
the development of variable decelerations. As hypoxia becomes prolonged, the decelerations may become deeper and
last longer.
"Beat-to-beat" variability: Another important hallmark of baby well-being on a fetal monitor strip is the
"beat-to-beat variability" of the baby's heart rate. The fetal heart rate varies from one beat to the next, because two
branches of the nervous system control changes in the heart rate. The sympathetic branch is constantly trying to
speed up the heart, while the parasympathetic branch is trying to counteract this by slowing the heart. These
beat-to-beat changes are referred to as variability. Normally, the sympathetic and parasympathetic nervous systems
have equal opposite effects on the heart rate, resulting in a consistently variable heart rate pattern. When the equilibrium
is altered, accelerations and decelerations may occur. Further, the reduction or cessation of oxygen flow to the brain can
lead to a decrease or loss of variability. This shows on the fetal monitor strip by the baby's heart rate becoming less
"squiggly" and more flat or compressed, with little change from beat to beat.
The next slide shows a prolonged deceleration in the baby's heart rate, down to as low as 80 beats per minute, while at the
same time the mother's uterus is not completely relaxing between contractions. (This is also known as uterine hyperstimulation.)
The gaps show that the monitor is frequently failing to pick up the signal from the baby's heart. This baby went on to suffer
profound brain injury because the mother's uterus ruptured and all oxygen to the baby was lost for a number of minutes.
The nurse-midwife was trying to have the mother undergo a vaginal delivery after a prior caesarean section ("VBAC" - vaginal
birth after caesarean).
Prenatal testing late in pregnancy
Before a mother goes into labor, tests are available to determine if a baby can undergo the stresses of labor and delivery
safely. The standard of care calls for some type of fetal assessment when risk factors for uteroplacental insufficiency exist,
or other specific clinical situations develop, such as:
- decreased fetal movement,
- hypertensive disorders (Pregnancy-induced hypertension or pre-eclampsia),
- diabetes,
- oligohydramnios (reduced amniotic fluid, meaning the baby is not urinating normally in the uterus),
- intrauterine growth retardation, and
- post-dated pregnancy (baby is overdue).
There are several fetal tests that are available to assist the doctor in determining if a baby may be compromised. These include:
- fetal movement counting,
- the non-stress test ("NST"),
- the contraction stress test ("CST"),
- the oxytocin challenge test ("OCT")
- the biophysical profile ("BPP"),
- ultrasound, and
- doppler flow testing.
These tests are used to gather information about:
- whether the fetus has adequate reserves to withstand the stress of labor,
- whether the intrauterine environment is hostile and no longer capable of promoting normal fetal growth and development, and
- whether the fetus is under stress and would benefit from immediate delivery.
High blood pressure in Pregnancy
Clinical Signs and Symptoms
Hypertension (high blood pressure) occurs in almost one in ten pregnancies. Pregnancy may induce hypertension or
aggravate a woman's pre-existing hypertensive condition. When a woman develops pregnancy-induced or aggravated
hypertension, the pregnancy may continue to term. However, the risk of maternal or fetal death or injury increases in
pregnancies complicated by hypertension. The condition may lead to fetal growth retardation, premature birth, and
uteroplacental insufficiency (an insufficient environment for the baby because of loss of blood flow from the uterus to
the placenta), which can diminish the flow of oxygen and nutrients to the fetus and cause fetal distress.
An obstetrician may respond to these potential complications by checking the mother's blood pressure at more
frequent intervals, hospitalizing the mother for testing and observation, initiating drug therapy, ordering laboratory
tests, or terminating the pregnancy.
Clinical Signs
Hypertensive conditions of pregnancy are classified by when the hypertension is diagnosed and what other clinical
findings accompany it. For example, when the patient develops high blood pressure before becoming pregnant, or
is diagnosed before the 20th week, the condition is called chronic hypertension. This may be mild or severe, depending
on the blood pressure measurement. Patients who have chronic hypertension are at increased risk for developing
more serious complications at a later stage of the pregnancy.
If the patient develops hypertension after the 20th week, the condition is called pregnancy-induced hypertension.
If hypertension is accompanied by proteinuria (excess protein in the urine), or edema (swelling of extremities or the
face, caused by fluid retention), or both, obstetricians refer to it as pre-eclampsia. Proteinuria is usually detected by
a dipstick reading at the prenatal visit. Although it is not routinely done, a 24-hour total protein urine test can be
performed when the obstetrician desires a more reliable indicator of the problem. The obstetrician need not rely only
on the dipstick result, when time permits further evaluation.
Edema is the least significant indicator of a worsening hypertensive condition, because it is a normal finding in many
pregnancies. However, edema of the hands and face is significant when hypertension is present and accompanied
by excessive weight gain.
The signs of elevated blood pressure, proteinuria, and edema are important not only in diagnosing preeclampsia, but
also in determining the severity of the disease. Therefore, the patient's blood pressure, urine, and weight gain should
be checked at each prenatal visit. Other clinical findings that indicate a rapidly worsening situation are visual
disturbances, ranging from slight blurring to partial or complete blindness; severe headaches; and right upper
abdominal pain.
Preeclampsia is life-threatening when several factors combine to produce a condition known as the HELLP syndrome
(hemolysis, elevated liver enzymes, and low platelet count). Another life-threatening complication, called eclampsia,
arises when preeclampsia is accompanied by convulsions. Either of these may require the prompt delivery of the
baby, regardless of the stage of pregnancy, to protect the mother.
There is no cure for preeclampsia other than terminating the pregnancy. However, even though adverse maternal
consequences usually can be avoided by an early delivery, the baby may be compromised. The obstetrician must
balance the benefits to the baby of treating the preeclampsia and prolonging the pregnancy against the risks of
growth retardation and asphyxia, as well as the risks to the mother. Therefore, to implement a successful management
plan, the doctor must accurately determine the age of the fetus.
Obstetricians may consider using antihypertensive drugs to control the underlying condition and to improve the
outcome for mother and baby. Appropriate management of a hypertensive condition should include more frequent
evaluations of maternal and fetal well-being. The obstetrician must instruct the patient to report immediately any
of the well-known symptoms. The critical questions for a lawyer investigating a birth trauma case, will be whether
the doctor ignored or failed to properly interpret the clinical data, failed to properly monitor the mother's condition,
failed to hospitalize the mother when necessary to determine the severity of the disease, failed to assess fetal
well-being before her condition or the baby's became life-threatening, and failed to properly consider other relevant
clinical information.
Care in the Newborn Period
Care of a baby that has had asphyxia at birth is critical to preventing further injury and minimizing any injury that
has occurred. Some of the goals that are believed to improve the neurologic outcome of a newborn include:
- Maintaining normal blood glucose (sugar),
- Maintaining normal blood pressure,
- Preventing or controlling seizures, and
- Preventing or minimizing cerebral edema (brain swelling).
In assessing the cause of a baby's brain injury, it is often important to consult with a qualified expert in pediatric
neurology and/or neonatology to answer the questions about the role of events before birth versus those immediately
after birth in causing a significant injury.
Legal Consultation
If a family member has suffered a serious, permanent injury related to childbirth, you may want to talk to a lawyer.
We provide free consultations to help determine if you have a valid medical negligence case that should be pursued.
If you have already consulted with another lawyer or are in the process of doing so, we can offer information about
how to evaluate whether you have obtained the right lawyer for your case.
Click here to obtain our free report: "Eleven questions to ask before hiring a lawyer for your injury lawsuit."
We will need to obtain complete medical records to do a good analysis. Contact us with this form to provide
basic information to get the process started:
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