Most birth injury medical malpractice lawsuits involve interpretation of fetal monitoring strips. The most common obstetrical procedure is electronic fetal monitoring (EFM) during labor. Monitoring is typically accomplished externally by wrapping a belt with sensors around the mother's belly.
Alternatively, EFM can be done by attaching an electrode to the fetus. The monitor produces a continuous paper strip that tracks the baby's heartbeat on the top and the pattern of the mother's uterine contractions along the bottom. This allows the labor and delivery health care providers to follow the fetal heart rate and how it responds to contractions. The relationship between these two is critical to the health of the baby.
It is the rare plaintiff's case that electronic fetal monitoring alone could have prevented the birth injury. Instead, the plaintiff's usually argue that the entire course of medical care during the labor and delivery resulted in delay, and an asphyxic injury resulting in a brain injury that flowed from a breach of the standard of care. Still, electronic fetal monitoring is vitally important because there are too many things that can go wrong during childbirth. The baby's condition can deteriorate rapidly during labor. This is why there is almost universal acceptance of EFM during childbirth.
The purpose of EFM is to see the warning signs and act on them before the child's brain, and other vital organs suffer harm. The fetal monitor really is mostly about oxygen. If the fetal monitoring strips indicate that the baby does not have the oxygen it needs, doctors are often required to deliver the child right away by cesarean delivery because the baby cannot tolerate the hostile environment any longer. The warning signs include
- Loss of variability
- Decelerations with slow returns to baseline
- Prolonged decelerations
- Repetitive decelerations
- Uterine hyperstimulation
The question is whether the doctors listen to the baby talking to them with a non-reassuring fetal heart rate that suggests the fetus is not tolerating the labor and delivery process. If this message of declining oxygenation status and loss of fetal reserves is not heard, the fetus is at serious risk for experiencing hypoxic-ischemic injury. This failure to listen to what the baby is telling the physicians and nurses through the EFM leads to birth injury lawsuits.
- Settlements and verdicts in failure to monitor fetal hear rates cases
Fetal distress means the womb has become a hostile environment. The baby is not getting enough oxygen or any other nutrients. The fetus gets oxygen from the mother's oxygenated blood. This requires the transfer of oxygen from the mother's blood to the baby's blood. This is done via the placenta.
If the fetus has non-reassuring fetal heart rate characteristics, such as tachycardia, variable decelerations, lack of heart rate variability, bradycardia, the child is at risk for hypoxia, ischemia, acidosis, declining fetal oxygenation, loss of fetal oxygen reserves, and asphyxia, all of which can cause brain and organ damage.
The main signs of fetal distress are fetal bradycardia or tachycardia, late, persistent, or variable decelerations, and the absence of beat to beat variability in the heart rate. So many birth injury malpractice cases are the result of doctors and nurses going to extremes in the face of fetal distress. They either overreact or, more commonly, underreact.
Fetal heart rate monitoring is the process by which doctors and nurses use electronic devices to track the baby's heart rate in response to contractions during labor and delivery. There are two separate components. The top is the baby's heart rate; the bottom is the contractions. This contraction panel is necessary in large part because the baby should have specific changes in heart rate based upon the contractions.
Besides the absolute heart rate, the variability of the heart rate is closely monitored. The heart rates should have variability -- a steady heart rate is a cause for concern -- but not too much variability.
There is significance to the findings or patterns on fetal heart tracings that are generally recognized as reflecting intrapartum fetal hypoxia and birth asphyxia (in other words, oxygen deprivation). A good obstetrician understands that these tracings are harbingers of potential concern. So a good OB will recognize and understand the significance of fetal heart tracing abnormalities such as bradycardia, tachycardia, late and variable decelerations and diminished or absent long term or short term variability. (We explain these terms below.) The medical literature unambiguously states that recognition of these abnormalities can help to reduce the risk of birth injuries by recognizing patterns that closely associate with metabolic changes and brain damage in the neonate.
The fetal heart monitor is looking at the fetal heart rate and how the fetal heart rate response to uterine contractions. So you want to see how uterine contractions impact the fetus. Specifically, you ant to see if uterine contractions are squeezing the blood flood to the uterus.
When the uterus contracts normally, the blood flow to the uterus slows or even stops. If the child is not in distress, they easily tolerate that temporary loss of blood flow. How do they do this? They have a good oxygen reserve and they recover quickly.
If the baby has, for example, a compromised placenta, they cannot tolerate the blood flow interruption caused by the contraction. The result is a heart rate decline, usually after the uterine contraction. This is called a late deceleration. This is an important warning sign for doctors and nurses. Many do not take a late deceleration as seriously as they should and many birth injury malpractice cases have this as an origin.
The sinusoidal pattern is a fetal heart rate pattern that is a sign the baby is in great danger. It is a stable baseline heart rate that has no beat-to-beat variability. So what you see is a smooth FHR tracing. It is associated with high rates of fetal death. The primary cause of a sinusoidal pattern is anemia. If the fetus had a blood loss, you might see a sinusoidal heart rate. (It is sometimes confused with a sawtooth pattern which is troubling but less ominous.)
Bradycardia is slowing of the heart rate below for a ten minute period. The marker is usually around 115-120 beats per minute. If a baby has severe bradycardia, the brain may not be getting oxygen. Brain damage starts approximately 10 to 17 minutes later. The variability in that range can depend on the strength of the baby's fetal reserve. If a baby who has a full fetal reserve, it will take a longer bradycardia to produce an acute near total asphyxia than if the baby has weakened fetal reserves because the baby can sustain that bradycardia longer before brain damage begins.
Generally, if a baby can be delivered before 10-17 minute period after a bradycardia, the child will do well. But if the baby experienced stress, evidenced by decelerations and other non-reassuring signs, the baby may not be able to withstand that final slowing of the heart rate and they don't have as much time.
Tachycardia is the opposite of bradycardia. Tachycardia is a heart rate greater than 150-160 beats per minute (bpm). A sustained heart rate above 150-160 suggests the possibility of fetal distress because a common cause of tachycardia is oxygen deprivation. A normal fetal heart rate should be somewhere between 115 and 150. Generally, a heart rate below 115 needs or over 150 needs to be evaluated. If the baby is in distress, the standard of care often requires the obstetrician to take immediate steps to deliver the baby.
The baby's vagus nerve slows down its heart rate. But a fetus does not have a developed vagus nerve as we do. So the fetal heart rate more irregular than ours. So a healthy baby will have up and down heart rate oscillations.
If the baby's heart rate does not have variability, it could because the baby is "asleep." During this their quiet time, they may have a lack of variability. Some drugs can decrease variability. But lack of variability in conjunction with other evidence can be a sign the baby is in trouble because it is not getting the oxygen it needs.
So if the fetus loses the ability to adapt and then stabilize, so you would expect to see a flat baseline with minimal variability and late decelerations. That is the classic findings that you would see with fetal hypoxia.
Ultimately, variability shows the baby is responding the its environment appropriately. So it is good to see variability. But obstetricians and nurses cannot assume that variability means the baby is not in distress. There are too many birth injury malpractice cases where the doctors assume the variability is the assurance they need and ignore other warning signs of a fetus in distress.
Decelerations are drops in the fetal heart rate. Early decelerations are just a reflection of the baby's head being squished. That sounds bad, but it is very normal. They are usually a normal consequence of labor and indicate periods of time when the fetal heart rate drops below its baseline. But the fetus is losing oxygen during each deceleration. A significant pattern of repeated decelerations leads to acidosis, hypoxia, and ischemia. The result of these injuries can be permanent neurological damage to the child's brain.
A late deceleration does not begin until the peak of the mother's contraction or after the contraction is completed. A 20 to 30 beats per minute drop qualifies as a late deceleration. The nurse monitoring the strips absolutely needs to let the OB know when the baby's fetal monitor shows a late deceleration a deceleration is a sign the back lacks oxygen and a C-section would be the safest course to protect the child.
Keep in mind that the obstetricians should not necessarily sound the alarm because they see a late deceleration. The pattern is the key. One late deceleration can be from the fetus' position or because of an excessively long contraction. But when you see reoccurring late decelerations, there may be a real problem. If they're occurring on a regular basis, then you have evidence of accumulative effect. If it occurs intermittently, you might note it, but you certainly wouldn't do any differently.
Our lawyers have looked at a lot of fetal heart strips. For sure, the most common sign of fetal hypoxia - a fetus deprived of oxygen - is a large number of late decelerations.
A variable deceleration shows no regular heart rate pattern. They often involve sudden drops in the fetal heart rate that are often followed by just as sudden returns to the normal baseline rate. These decelerations are characterized by a sudden, abrupt drop in along with usually a similarly abrupt return to baseline. The baby is noticing a temporary decrease in oxygen, but then just bounces right back.
They are often caused by umbilical cord compression. When the contraction occurs, the umbilical cord is squeezed. The baby's blood pressure go up. The heart rate will fall. The contraction is causing you'll see a sudden fall in heart rate and then a recovery. You see very abrupt V-shaped quick fall. This is called a variable deceleration, meaning that the cord is compressed.
Variable decelerations are a concern. But are less common and less worrisome than late decelerations.
An elective C-section is scheduled. For example, a mother having a repeat C-section or has a breech presentation. It is a C-section that's done either for maternal or fetal indications that are not an emergency. In this case, the mother or the baby is not in severe distress. Some malpractice cases are for failure to schedule a C-section. But most claims are for failure provide an emergency C-section when fetal distress signals call for one.
If your child has suffered a birth injury and you believe a mistake was made, Ron Miller or Laura Zois today. We can talk about your options and what we can do for you. We have a track record of success in wrongful death and catastrophic injury medical malpractice cases. We can help you and your baby gets the financial compensation you need and deserve. Call Miller & Zois today and speak to our Maryland birth injury medical malpractice attorneys at 800-553-8082 or get an online case evaluation.