Obstetric Medical Malpractice
Brien Roche
Obstetric medical malpractice is most often seen in birth injuries . Brachial plexus and cerebral palsy are common outcomes. Also it is seen in other area of decision making.
Vaginal Birth After Cesarean
Vaginal birth after cesarean is on the rise. The rule in obstetrics has been that once a woman has a cesarean any future births will be the same. However with some push from the NIH there has been a change in that line of thinking. In addition, insurers and HMOs, in their attempt to hold down cost, discourage doctors from doing cesareans.
Risk Factors
The risk is uterine rupture. This leads to oxygen loss for the baby. However it is sometimes tough to tell if there has been a rupture. For instance not all women have the same symptoms. Some will report a sharp pain while others may report no pain. So the window of time to deliver a baby after rupture is about 18 minutes. After that the danger of brain damage is very real. Call, or contact us for a free consult.
In making the choice to go cesarean or not other factors to look at are:
- Was the prior a low transverse uterine cut or was it T-shaped;
- Will the mother’s pelvis allow safe passage of the fetus.
- Are there other issues such as herpes, placenta previa or abnormal fetal presentation
- Is the hospital able to perform an emergency cesarean on short notice.
Obstetric Medical Malpractice-Emergent C-Sections
Emergent c-sections are most often called for when the fetal heart rate (FHR) drops down to 60 beats per minute. The American College of Obstetricians and Gynecologists and also the American Academy of Pediatrics have guidelines. They call for the hospital to be able to begin the c-section within 30 minutes.
Some dispute exists whether that 30 minute rule is enough. Many doctors say it should be shortened to 20 minutes. The logic is to keep the time between the onset of decreased heart rate and c-section delivery to less than 25 minutes.
Prompt Response
The National Institute of Child Health and Human Development in 2009 endorsed several things to promote a prompt response:
- allowing all providers to read,interpret and respond to FHR readings;
- all providers be trained to know when an emergent c-section is needed. They then are allowed to begin the process even though the attending may not be present;
- an attending doctor must be available to resolve any emergency;
- the hospital have the people and resources to assist. Call, or contact us for a free consult.
Inducing Birth After Water Breaks?
The notion over the years has been that when a woman’s water breaks it is time to deliver. Consequently if the pregnancy is at term, most doctors will induce labor if it has not already begun. This involves the use of drugs to bring on contractions. The concern, at that point, is the risk of infection. There is the risk of bacteria in the lower genital tract moving into the uterus. This is a threat to the fetus which is no longer in the amniotic sack.
A 1996 study, published in the New England Journal of Medicine addressed the issue of infection. The study dealt with 2,500 women and concluded that mothers were less likely to become infected or have post-partum fever if they underwent prompt induction.
What happens at this stage, if labor is not induced, are frequent vaginal exams. As a result the risk of bacteria getting into the vaginal area increases.
Finally it is the mother’s choice to have labor induced or await the natural onset of labor for at least 24 hours.
Electronic Fetal Monitoring and Obstetric Medical Malpractice
Fetal monitoring is the norm in keeping an eye on a baby’s progress during labor. The normal baseline fetal heart rate is 110 to 160 beats per minute. Levels below 110 are called bradycardia. Rates above 160 are tachycardia. Another factor is the beat-to-beat changes in heart rate. One interval may be long and the next not so long. That can be as important as the baseline. Large changes can mean fetal distress. However small or no changes may also mean fetal distress. These changes may be very subtle. As a result a keen trained eye is needed.
Reduced Oxygen
To some extent this is all a function of reduced oxygen to the baby. A number of things can cause this. Decreased blood flow to the placenta, decreased blood flow through the placenta to the fetus or compression of the cord can effect the fetal heart rate.
Many insurers balk at the performance of a cesarean section because of the expense. However cesarean section is the one means that can quickly remove a fetus from distress.
Reading Heart Rate
There is no consensus in the medical community as to the standard of care to be employed in reading fetal heart rates. A baseline rate of 100-119 beats per minute (BPM) is suspicious of fetal distress. A rate of 80-100 BPM is “nonreassuring”. This may point to impending fetal loss. A rate of less than 80 BPM is ominous. A rate of more than 160 BPM is frequently caused by fever in the mother. However it may also be a response to lack of oxygen.
Decrease And Variability
The most important info is provided in the form of “deceleration patterns” and “variability”.
Within the fetal heart monitor strip is reported not only the fetal heart rate but also uterine contractions. With the onset of a contraction the fetal heart rate should decrease. Its lowest point is at the peak of the contraction. It should steadily return to baseline as the contraction subsides. This pattern is considered normal.
However a late downward pattern is not normal. This means that the fetal heart rate descends after the contraction has begun and reaches the lowest point after the contraction peaks. It then returns to the baseline after the contraction ends. This is caused by a decrease in the oxygen content of the blood flowing to the fetus. A variable decrease shows no regular pattern. Any of these subtle issues must be looked at by the doctor.
Treating Fetal Distress
The treatment for fetal distress is to prepare for a cesarean section. However less drastic measures that may be used are:
- changing the mother’s position
- stopping any drugs to induce labor
- giving more oxygen to the mother by face mask
- increase the mother’s water intake
- add saline solution directly into the amniotic fluid
Call, or contact us for a free consult.
Obstetric Medical Malpractice-Periventricular Leukomalacia
Periventricular leukomalacia misdiagnosis is seen sometimes with premature babies. PVL is a form of brain injury. These infants display developmental problems. In addition they develop cerebral palsy or epilepsy. PVL is frequently misdiagnosed. On an MRI PVL will be noted by scarring around the ventricles. Premature babies who have intraventricular hemorrhage (IVH) are at risk for developing PVL. Its existence is sometimes asserted as a defense to cerebral palsy claims. Medical malpractice attorneys pursuing cerebral palsy claims need to be well versed as to this condition.
Symptoms Of PVL
The symptoms that are displayed by infants having PVL can be very subtle. They may include such things as decreased tone in the lower limbs, increased tone in the neck, apnea, slow heart rate, irritability, poor feeding or seizures. The films must be reviewed by a pediatric neuroradiologist. These provide a wealth of info.
Infants that are ventilated after birth due to being premature are at greatest risk of PVL.
If your baby has been injured as a result of a misdiagnosis of PVL contact us.
Obstetric Medical Malpractice-Neonatal Hypoglycemia
Neonatal hypoglycemia is a lack of glucose getting to the baby’s brain. It can cause brain damage or death to an infant. It can arise even though the baby is fine at birth and free of any apparent problem.
A newborn is in great need of glucose. Growing neurons use glucose as their source of energy. If the amount of glucose is not enough then the neurons die. Neuron loss in certain parts of the brain can cause severe problems. Sometimes this exist with other problems that compound the lack of glucose. This worsens the outlook.
Risks
The things that increase the risk of a baby having too little glucose are many. Fetal distress and any thing that prolongs labor are factors. The classic signs are twitching, tremors or an exaggerated startle reflex. Another sign is a failure to maintain normal body temperature. This may disguise the tremors. That is the parents simply think that the baby is chilly. In fact, there is more to it than that.
This condition can be treated and cured. It must be promptly diagnosed. Any delay worsens the outcome. These are things that the doctors must be on the lookout for.
Call, or contact us for a free consult.For more information on obstetrics see the pages on Wikipedia Also for information on medical malpractice see the pages on this site and the page dealing with birth injuries.