Neonatal Intracranial Hemorrhage (ICH) (sometimes called a "brain bleed") is a bleeding inside the brain of the newborn. When this happens, the blood vessels within the brain tear and the blood spreads to other areas of the brain tissue. It can be difficult to diagnose an ICH because the symptoms can be slow to occur, and the baby may be acting normally for a while.
The newborns with the highest risk of ICH are premature babies that are born more than ten weeks before the due date. However, ICH can also happen with normal, term deliveries. Severe hypoxic-ischemic insults can cause intraventricular hemorrhage in full-term neonates. It is a sign of severe stresses put on the child during labor and delivery.
There are different categories of newborn brain bleeds, and the area of the brain that is affected will determine the symptoms. When an ICH is in the more severe categories, the baby's life is in danger. Even if the baby survives, he or she can have severe mental or physical damage. If a baby is diagnosed with a severe brain bleed, the medical response will focus on surgical intervention to prevent brain damage or death.
Speed of diagnosis is key. It is medical malpractice for a doctor to miss a diagnosis that any reasonable prudent doctor would make. Every pediatric neurosurgeon will tell you that they would greatly prefer to see a newborn as soon as possible after the diagnosis of intracerebral bleed, hydrocephalus and increased intracranial pressure is made. The sooner the diagnosis is made, the sooner the indicated procedure can be performed. This makes a big difference in the ultimate neurological prognosis is improved.What Causes Neonatal Intracranial Hemorrhage?
The cause of ICH depends on the circumstances of the birth. For example, the premature baby is at a higher risk because the blood vessels of the brain become stronger in the weeks before delivery. Conditions that contribute to ICH in this situation include Respiratory Distress Syndrome (RDS) and unstable blood pressure of the baby. But every baby who is born early does not develop ICH. Sometimes a healthy term newborn can show the symptoms, and these symptoms can be serious.
One of the highest risk factors for a dangerous brain bleed involves vacuum or forceps assisted. This can be caused by the pressure of the forceps or vacuum on the baby's skull as the doctor attempts to help the baby come out of the birth canal. Tiny blood vessels in the brain can be injured and start to bleed. In modern medical care, babies from these assisted deliveries should be closely monitored for signs of distress.
- Questions and answers about mistakes doctors make when delivering babies with forceps
- Study showing vacuum extraction increases the risk of ICH
ICH is labelled by grades that describe how severe the bleed is, and grades 1 and 2 are usually not serious. The doctor and hospital staff will do a medical assessment of the baby, but intervention is often unnecessary.
The brain bleeds that affect brain tissue are grades 3 and 4. These produce dangerous symptoms like seizures, decreased reflexes, and a change in breathing (apnea). The baby may have poor feeding and become "floppy" instead of alert.
There might also be abnormalities in the newborn period such as fussiness, high-pitched cry, and difficulty in sucking. These latter symptoms can also be consistent a baby without a brain bleed, too, of course.
One of the most dramatic signs of a brain bleed is swelling of the ears or head. This swelling crosses the suture lines of the baby's skull, and the baby needs immediate attention. In the grades 3 or 4, a blood clot can form in the brain and cause a condition of too much fluid in the brain (hydrocephalus).Diagnosis & Treatment
If ICH is suspected to be serious (grades 3 or 4), the baby will be moved to a Neonatal Intensive Care Unit (NICU). He or she will need IV fluids and will be monitored for a change in heart rate or breathing. If seizures are present, medication will be given to slow the seizure activity. A blood transfusion may be needed. Other tests will be performed to find out the areas of the brain that are affected. A cranial ultrasound will be done soon after the admission to the NICU, and this does not use any radiation. Many of these birth injury cases are the result of the failure of the doctors to get a neurosurgical consult and perform an ultrasound which would indicate the need for immediate surgery.
An MRI (magnetic resonance imaging) is also used to take detailed pictures of the brain without x-rays. A CT Scan uses x-rays to take multiple images of the brain, and because this involves radiation, it may be used only when surgical intervention is needed.
If surgery is necessary, a neurosurgeon (a specialist in brain and spine surgery) will perform a procedure to relieve the pressure on the baby's brain. For the right diagnosis of ICH, the doctor must perform further testing to determine whether brain tissue is involved in the bleed. According to one clinical study, when ICH involved the brain tissue, the rate of newborn death was almost 25% within that study.
What does the surgery for an infant brain bleed entail? The treatment for an intracerebral or matrix hemorrhage may be an EVD (extra ventricular drainage). The surgeon goes in and relieves the intracranial pressure and dropping the concentration of blood and protein. The idea is that a permanent ventricular-peritoneal shunt can be placed and not be plugged up by blood clots, and excessive protein.
Some babies recover from ICH and do not show any signs of neurological damage. However, because brain tissue can be involved, it is important to watch the child's physical and mental development. Brain damage can be slow to manifest until an important milestone is missed. Long-term complications of brain damage can be seen in loss of muscle control (ataxia), weakness on one side of the body (hemiplegia), and in developmental disabilities. Cerebral Palsy is directly linked to brain injury. Cerebral palsy has causes besides a difficult delivery, but a severe brain bleed at birth should be noted in the medical history.Additional Risk Factors
Besides prematurity, the highest risk is a delivery requiring use of a vacuum or forceps. If the obstetrician uses BOTH a vacuum and forceps, there is no question that this is likely to cause a brain bleed. Both have been associated with hemorrhages. Traction in the occipital-frontal direction can also cause kinking of the deep venous system of the brain and result in rupture or hemorrhage.
Emergency cesarean sections also increase risk, and so is the breech delivery (the baby's feet or buttocks delivered first). First-time mothers are more likely to need the doctor's intervention, and this means the rate of ICH is higher for babies of new mothers.
One of the greatest risk factors for the baby is the hidden nature of ICH: the bleed can be so slow that damage can occur before the symptoms show. The diagnosis can even be made as much as 30 days after the birth, although this is unusual. Any baby with a difficult or emergency delivery should be considered a risk for ICH.
ICH is also often a secondary childbirth related injury. Stresses on the child like acidosis, sepsis, acidosis, asphyxia, and prolonged fetal distress can directly injure the cells of this child's brain. This can also contribute to the development of the intracranial hemorrhage. The result can be a secondary injury to the brain like cerebral edema and hydrocephalus.Intracranial Hemorrhage Settlements and Verdicts
Summarized below are reported settlements and verdicts from cases in which the primary birth injury involved was ICH.
- Macdonald v. Women's Healthcare Assoc. (Florida 2017) $2 million: Plaintiff's claimed that defendant doctor and hospital staff was negligent in using a vacuum extractor to assist in delivery. The use of the extractor allegedly ruptured blood vessels causing an intracranial hemorrhage and the baby was later diagnosed with cerebral palsy. The case settled for $2 million.
- Benson v. Legacy SHGD (Michigan 2017) $5.8 million: Newborn suffered intracerebral bleeding after being born prematurely at 29 weeks. The malpractice claims alleged that the OB/GYN practice rendered negligent prenatal care by failing to avoid the preterm delivery and failing to manage and diagnose a maternal infection. The defendant denied liability but eventually settled the case for $5.8 million.
- Blokh v. Finley (New York 2017) $2.2 million: In this case the baby suffered brain injuries resulting from intracranial hemorrhage and oxygen deprivation. The parents alleged that the brain injuries resulted because the defendant doctors let the pregnancy run over 2 weeks past the due date, exposing the baby to increase risk. Plaintiffs claimed that the injuries could have been avoid by simply inducing her labor earlier. The case settled for $2.2. million.
- Mittchell v. Lau (New York 2016) $2.1 million: Baby was born premature and suffered a grade 3 intracranial hemorrhage which led to development of periventricular leukomalacia and he was diagnosed with cerebral palsy. His parents alleged that the doctors were negligent in failing to manage the pregnancy so as to avoid the premature birth. The doctors claimed they acted reasonably and the premature delivery was caused by an infection. A jury in Nassau County awarded plaintiffs $2.1 million.
- Pita v. Bronx-Lebanon Hops. (New York 2014) $1.7 million: baby suffered intracranial hemorrhage and brain lesions during delivery which left him with permanent cognitive impairment. His mother alleged that the doctor was negligent in his use of obstetrical forceps and that the hospital failed to provide proper neonatal care. The case settled for $1.7 million.
Medical Literature on Neonatal Intracranial Hemorrhage
We have hyperlinks above to much of the medical literature on ICH. Here are a few more articles that provide additional support to the science of this page.
- Hong H, Lee J (2018): Intracranial hemorrhage in term neonates. Childs Nerv Syst 34:1135–1143.
- Towner D, et. al (1999): Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med. 1999;341(23):1709–14
- Bowerman, R, et. al (1984): Natural history of neonatal periventricular/intraventricular hemorrhage and its complications: sonographic observations. Am J Neuroradiol 5:527-538.
If your child has suffered a birth injury, our law firm has experience and resources to help you determine the cause. We can help you both receive the compensation you deserve for the harm that was done. Our lawyers see cases where the doctors failed to prevent newborn ICH or to diagnose it in time to prevent complications. Severe ICH is always an emergency, regardless of the cause. Preventing newborn ICH should be a top priority in deliveries that involve vacuum or forceps assistance.
Too often, it is not the top priority and the result is neurological impairment secondary to an intracranial hemorrhage. Our lawyers handle these cases for victims throughout the country. Call Miller & Zois today and speak to a childbirth injury medical malpractice attorney at 800-553-8082 or get an online case evaluation.