BIRTH INJURIES

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QUICK FACTS

  • Birth injuries occur at the rate of 6-8 out of every thousand babies who are born in the United States
  • In 2018 upwards of 300,000 babies were born with some type of birth injury.
  • While some birth injuries are unavoidable, many birth injuries can be prevented through the proper identification and planning for high risk patients. 

BIRTH INJURIES

Overview

For 9 months, expectant parents eagerly await the birth of their child.  During this time period, they envision what their child will look like and dream about his or her future.  Sadly, these dreams can be destroyed by a preventable medical mistake.

Birth injuries continue to occur at the rate of 6-8 out of every thousand babies who are born in the United States.  A birth injury, in contrast to a birth defect, can occur in an otherwise healthy baby at any point during gestation, but it is most common during the labor and delivery process.  In 2018, based upon the National Vital Statistics Report, 3.79 million babies were born in the U.S. and its territories. This means upwards of 300,000 babies were born with some type of birth injury.  While many birth injuries result in relatively minor physical and cognitive disabilities that can dissipate, others result in catastrophic outcomes.

Serious birth injuries occur to the most vulnerable patients, resulting in lifetime disabilities and needs.  While the emotional impact of a birth injury is incalculable, the financial cost of caring for birth injury victims can be staggering. Parents have a strong desire and every right to know whether their child’s birth injury was preventable.

While some birth injuries are unavoidable, many birth injuries can be prevented through the proper identification and planning for high risk patients.

Dangerous Birth Conditions

Fetal Weight

When fetal weight exceeds 4000 grams (8.8 pounds), the baby is considered macrosomic.  As fetal size increases, the chance of a birth injury likewise increases.  The baby squeezes and twists through the birth canal by maternal uterine contractions. The larger the baby (in comparison to the mother’s pelvis), the greater the risk of injury for the baby as he or she passes through the birth canal.  The medical term for a large baby and a mother with a small pelvis is cephalopelvic disproportion.  With babies who weigh 8.8 pounds to 9.9 pounds, the risk of a birth injury increases twofold.  For those babies who weigh more than 11 pounds, the risk of birth injury jumps more than four times the risk of a baby who weighs less than 8.8 pounds.  A macrosomic baby is at risk getting stuck in the birth canal. This can cause fetal death, a brain injury, or result in Shoulder Dystocia/Erb’s palsy.

Abnormal Fetal Position

Fetal Position is essential to safe delivery.  When the baby enters the birth canal, the baby’s head is positioned downward with the baby looking towards the mother’s back.  This is known medically as a cephalic presentation.  Most babies settle into this position during the 32nd and 36th week of a normal 40-week gestation period.  The risk of a birth injury increases with breech (feet down) and occiput posterior position (face up).

Oligohydramnios

In medical terms, Oligohydramnios is the presence of low levels of amniotic fluid.  The amniotic fluid bathes the baby in the womb and is essential for its protection against trauma and infection during gestation.  Oligohydramnios is reported to occur in approximately 11 percent of all pregnancies.  The amniotic sac in which the baby develops is formed within 2 weeks of conception.  It is comprised of water provided by the mother and as the baby develops, becomes primarily comprised of fetal urine. The baby moves within the womb with assistance from the amniotic fluid.  Amniotic fluid can be easily and reliably measured by ultrasound. There are numerous conditions which can cause Oligohydramnios.  These include congenital defects in the baby’s kidneys, placental abnormalities, premature rupture of membranes and late for date pregnancies.  While it can be present at any point in the pregnancy, it is most often diagnosed in the third semester. If present in the first half of pregnancy, it can cause serious complications, such as birth defects and an increased chance of miscarriage or stillbirth.  If Oligohydramnios occurs during the second half of the pregnancy, it can result in preterm labor and IUGR.    If diagnosed close to term, delivery is often recommended. Conversely, if not close to term, therapeutic interventions, such as amniocentesis can be performed to treat the condition.

Premature Birth

The normal gestation period is 40 weeks. Because the unborn baby continues to develop throughout pregnancy, the closer the baby is to term, the less the risk to the baby of suffering a birth injury.  However, approximately 10 percent of baby’s (approximately 380,000 in 2018) were born premature (prior to 37 weeks). While neonatal care has significantly increased the survival rate for premature babies, in most instances, the longer baby can remain in utero until term, the better it is for the baby’s wellbeing.

Maternal Obesity

Maternal obesity is defined as a Body Mass Index of over 40.  This translates into the expectant mother being more than 100 pounds over her ideal body weight.  Maternal obesity increases the risk of gestational diabetes and a higher need to use instrumentation (i.e.forceps or vacuum extraction) during delivery, all of which have been proven to lead to a higher rate of birth injury.

Rh Incompatibility

Rh factor is a protein that is found in certain red blood cells.  Approximately 8 percent of the population carries this protein and these people are identified as Rh-positive.  Conversely, those people who do not carry this protein are identified as Rh-negative.  When an expectant mother and the baby’s father are not both Rh-positive or Rh-negative, they are called Rh-incompatible.  Importantly, Rh-Incompatibility does not pose a problem during the mother’s first pregnancy.  However, in subsequent pregnancies, Rh-Incompatibility can pose serious health risks to the baby.  If an Rh-negative mother is pregnant with a baby after her initial pregnancy that is Rh-positive (inherited from the baby’s father), the mother’s Rh-negative antibodies will identify the Rh proteins on the surface of her baby’s red blood cells as foreign and the mother’s antibodies potentially can cross the placenta and attack the baby’s red blood cells.  This can cause the baby to become severely anemic. When this occurs, the baby’s red blood cells, which deliver oxygen to the baby, are destroyed faster than the baby’s body can re-produce them and ultimately result in the baby experiencing life-threatening multi-system organ failure. Fortunately, Rh-Incompatibility is easily diagnosed by way of a simple blood test.  If diagnosed during the mother’s first pregnancy, the mother will receive an Rh-immune globulin injection (Rhogam) around week 28 of her pregnancy and a second shot within 3 days of giving birth. These shots act similar to a vaccine and prevent the mother’s body from making Rh antibodies that could potentially impact her future pregnancies.

Maternal Age

Those mothers who are 19 years or younger or 40 years and older have a statistically higher risk of pre-term labor, which increases the risk of a birth injury.

Prolonged Labor

Each labor is different and can pose risk to both the infant and mother.  When labor exceeds 18 hours, compression on the baby’s brain can prove to be too difficult for the baby to withstand.  During labor, the mother’s contractions and the baby’s heart rate are continuously monitored by Electronic Fetal Monitoring.  This enables obstetricians and obstetrical nurses to monitor and assess the baby’s physiologic response to the forces of labor.  If the forces of labor begin to deprive the baby’s brain of oxygen, signs of fetal distress will become evident on electronic fetal monitoring strips to the trained obstetrician or obstetrical nurse.

Often the most severe birth injuries are due to oxygen (anoxic brain injury or hypoxic ischemic encephalopathy) the baby experiences deprivation during the birthing process.  It is for this reason that accurate interpretation of Electronic Fetal Monitoring is essential.  The proper interpretation of the baby’s response to the stress of labor will guide the type and timing of interventions that range from change of maternal position to the administration of fluid to delivery by Cesarean Section.

Instrumented Deliveries

The primary medical equipment used to perform instrumented deliveries are forceps and vacuum extractors.  Forceps are placed on the baby’s head to enable the obstetrician to guide the baby through the birth canal.  A vacuum extractor is a suction device that attached to the baby’s head and pulls the baby through the birth canal.  Both forceps and vacuum extraction deliveries pose the risk of injury to the baby’s head and the possibility of brain damage.

Maternal Infection

Mothers who have certain types of infections before or at the time of delivery experience a higher birth injury rate.  If not diagnosed and treated properly, maternal infections can spread to the placental and fetal membranes where it poses potential significant risk to the baby. While there are numerous infectious organisms that can cause injury to a baby during the birthing process, Group B Streptococcus, commonly referred to as GBS, is the number one risk of infection to newborns.  While GBS is present in many healthy women, if the baby comes into contact with this organism as he or she passes through the birth canal, the baby can suffer a serious and life-threatening infection.  The potential risk factors for GBS are premature labor, a past history of GBS, and premature rupture of maternal membranes. Expectant mothers should be screened for GBS and, if present, be treated with antibiotics.

Pre-Eclampsia

This is a condition that typically occurs toward the end of pregnancy (however, it can also occur during the post-partum period which extends until 6 weeks after delivery).   It is believed to be triggered by abnormalities in the placenta and is reported to occur, in varying degrees, in upwards of 9 percent of all pregnancies. If not properly diagnosed and treated, it can cause significant risk to mother and baby.  If untreated, Pre-Eclampsia can evolve into Eclampsia which poses the immediate risk of maternal and fetal death, thereby mandating emergent delivery regardless of fetal age.  The risk factors for Pre-Eclampsia include a personal or family history, pregnancy with twins or triplets and maternal age younger than 18 or older than 40.

Meconium aspiration

Meconium is the thick, dark green fecal material that represents the baby’s first bowel movement.  Although babies receive their nutrients in utero through their umbilical cord, they still can and do swallow in the womb.  Since Meconium is produced as the baby’s GI tract matures, it only impacts the baby close to term as Meconium is not produced prior to the timeframe.  In most instances, Meconium stays in the baby’s intestine until birth. However, if the baby experiences stress in utero prior to birth, the baby can pass Meconium filled stools that mixes with the amniotic fluid surrounding the baby.

Risk Factors associated with Meconium passage in utero include late for date pregnancies, placental abnormalities, oligohydramnios, Pre-Eclampsia, and fetal distress.

If Meconium is passed in utero, the baby likely will breathe in the Meconium.  Unlike stool which is filled with bacteria, Meconium is sterile. While typically not life-threatening, Meconium aspiration can lead to respiratory distress. Upon delivery, a baby who is in respiratory distress from Meconium aspiration can appear cyanotic (bluish skin coloring), experience difficulty breathing and have low Apgar scores. Typically, successful treatment will only require the immediate suctioning of the baby’s mouth and airway.  However, in severe cases, intubation may be required to assist the baby to breathe. In either case, the prognosis for Meconium aspiration is typically very favorable.

Placental Abnormalities

The placenta, which develops during pregnancy, attaches to the wall of the uterus.  It provides the vital function of providing oxygen and nutrients to the developing baby and removes waste products from the baby’s blood. The baby is attached to the placenta by his or her umbilical cord.  A healthy placenta is essential to the baby’s wellbeing. A number of potential placental abnormalities can jeopardize the baby’s wellbeing including:

  • Placenta previa

    This is a condition where the placenta attaches to the wall of the uterus low down near the cervix.  It is estimated to occur in 1 in 200 pregnancies and is more prevalent in smokers, older mothers and those with a multiple gestation pregnancies (i.e., twins).  Placenta previa poses risk of a placental tear, premature labor, and increased fetal infection.

  • Placenta Accretia

    This serious condition fortunately only occurs in an estimated 1 in 2500 pregnancies.  This condition is characterized when the placenta attaches itself too deeply to the uterine wall.  Normally, the placenta detaches from the uterine wall after delivery. In placenta accretia, part or all of the placental wall remains attached to the uterus after delivery and can result in significant maternal blood loss.  It usually does not cause any signs or symptoms during pregnancy, but vaginal bleeding may occur in the third trimester. Placenta accretia is usually diagnosed by ultrasound.  If diagnosed, the baby will be delivered by Cesarean Section followed by a hysterectomy due to the future serious risks this condition poses to the mother.

  • Placental Insufficiency

    When the placenta fails to function properly, it is unable to supply the baby with adequate amounts of nutrition.  Placental insufficiency occurs in approximately 1 in 300 pregnancies and causes Intrauterine Fetal Growth Restriction (IFGR) which results in low birth weights.  Typically, babies who are below the 10th percentile are considered to be of a low birth rate.  Those babies who experience IFGR have a higher rate and a higher incidence of Cerebral Palsy.   If Placental Insufficiency occurs early in the pregnancy, it prevents the baby from thriving in utero and can result in Pre-Eclampsia, preterm delivery and placental abruption.  There is no cure for placental insufficiency. However, treatments include bed rest and the administration of Betamethasone shortly before delivery as this steroid medication enhances the baby’s lung development for an expected early delivery.

  • Placental Abruption

    This is when the placenta separates either completely or partially from the uterine wall.  It is most common in the third trimester and is associated with premature membrane rupture, history of placenta previa, smoking, alcohol use, maternal hypertension and defects in the structure of the placenta or uterus.  Placental abruption is often accompanied by vaginal bleeding, abdominal pain and fetal heart abnormalities. It poses tremendous risk to the baby as it disrupts essential nutrient exchange and requires u.

Umbilical Cord Conditions

  • Cord Prolapse

    The umbilical cord acts as the baby’s lifeline.  It is connected to the placenta and permits oxygen and nutrients to reach the baby and waste products from the baby to be eliminated.  An umbilical cord prolapse occurs when the cord exits the birth canal before the baby’s head. If this occurs, the cord can become pinched off and the baby can become deprived of oxygen which can cause a life-threatening situation for the baby.

  •  Nuchal Cord

    Similar to umbilical cord prolapse, a nuchal cord occurs when the baby’s umbilical cord gets wrapped around the baby’s neck during delivery.  If not reversed, it likewise can result in a serious brain injury or fetal death.

Types Of Birth Injuries

Birth injuries can range from very minor to catastrophic.  Unlike a birth defect from an unavoidable congenital condition, the following birth injuries are caused by the conditions described above and can occur during pregnancy as well as during the labor and delivery process.

Head Injuries

Injuries to the head can occur from instrumental deliveries (forceps, vacuum extraction) and cephalopelvic disproportion.  These injuries, which range relatively from minor to rather severe, include:

Caput Sucedaneum

The presence of scalp swelling in a newborn infant that presents at birth after prolonged or vacuum extraction deliveries.  It is superficial in nature and typically will resolve within several days without treatment.

Subgaleal Hemorrhage

Occurs when blood accumulates above the skull and below facial plane that separates the scalp’s skin from the skull.  It is caused by traction on the scalp during delivery and can result in massive life-threatening blood loss. The physical signs include diffuse swelling of the head that continues to expand for hours to days after delivery, skin pallor and an elevated heart rate from significant blood loss.  Treatment includes blood volume resuscitation and frequent vital sign monitoring.

Skull Fractures

Can be caused by forceps and vacuum extraction deliveries.  Most often, skull fractures in newborn babies are asymptomatic and self-limiting in nature that do not require further treatment

Intracranial Hemorrhage

Can involve the epidural, subdural, subarachnoid, intraventricular and sometimes the intracerebral spaces.  Depending upon the location and the extent of the bleed, neurosurgical evacuation might be required to alleviate pressure from compression on vital brain structures.

Nerve Injuries

Cranial Nerve Injuries

The most common cranial nerve that is injured from a mechanical delivery (forceps) or cephalopelvic disproportion is the facial nerve. This clinically presents as diminished movement or complete loss of movement on the affected side. Fortunately, facial nerve palsies typically resolve spontaneously.

Brachial Plexus Injuries

Result when the cervical spine nerve roots become stretched during delivery.  The recognized risk factors for a Brachial Plexus Injury include macrosomia, Shoulder Dystocia, breech presentation, difficult delivery, and instrument assisted deliveries. Brachial plexus injuries can cause temporary paralysis (Neuropraxic), motor and sensory dysfunction that extends upwards of 12-18 months (Axonotmesis), or permanent nerve damage (Neurotmesis).

ERB’S Palsy

Involves injury to the 5th and 6th cervical nerve roots.  The most common type of brachial plexus injury, it causes inability to lift the affected arm above the shoulder and results in clear size differences between the affected and unaffected arms.

Klumpke’s Palsy

Involves injury to the 8th cervical spine and higher thoracic spine nerve roots.  It causes paralysis of the hand muscles, the inability to grasp and numbness on the inner portion of the forearm.

More Common Injuries

Bone Fractures

Bone fractures can occur with difficult removals from the birth canal and certain presentations.  In particular, clavicle fractures occur in upwards of 2 percent of all live births.  Often the fracture is purposeful as it is a recognized treatment intervention to deliver the baby during a difficult vaginal delivery.  Reported risk factors for clavicle fractures include shoulder dystocia, increased birth weight (more than 8.8 pounds), and increased maternal age.  Fortunately, these fractures typically heal without any long-term complications.

Lacerations

Fetal lacerations have been reported at the rate of 3 percent with Cesarean Section delivery.  The most common location for laceration is the scalp and face. The overwhelming majority of these lacerations occurred during an emergent Cesarean Section delivery.  Fortunately, most of the reported lacerations were mild and required minimal treatment. However, a small percentage of these lacerations were more severe and several required plastic surgery.

Brain Injury

The most devastating birth injury for any baby and parent is a brain injury.  As with other birth injuries, brain injuries can range from relatively minor to completely debilitating.  Cerebral Palsy is the medical term used to describe babies who are born with brain damage caused by inadequate oxygenation.  A lack of adequate oxygen supply to the brain can cause devastating and permanent cognitive, motor and emotional impairments.  These are often classified as anoxic brain injury or hypoxic ischemic encephalopathy.   

During the labor process, when a baby is stressed by the forces of labor, the baby will respond with an increased heart rate.  This is the baby’s autonomic response to its brain’s need for more oxygen. In other words, the baby’s heart will beat faster in an effort to satisfy the brain’s need to be supplied with more oxygen.  Eventually, the heart, if taxed for too long, will be unable to meet the brain’s need for more oxygen. It is comparable to a drowning person. A drowning person will repeatedly struggle to reach the surface to gasp for air.  At some point, the physical demand becomes too great, and the person can no longer muster the strength to reach the surface and will drown. A baby who continuously fights against the forces of labor to supply adequate oxygen to his or her brain will likewise ultimately be unable to meet the brain’s oxygen demands.  When this happens, the baby’s heart will slow and the baby’s brain will not receive the amount of oxygen it requires to remain viable. It is for these reasons that the baby’s response to the forces of labor must be properly analyzed by electronic fetal monitoring. liver the baby during a difficult vaginal delivery.  Reported risk factors for clavicle fractures include shoulder dystocia, increased birth weight (more than 8.8 pounds), and increased maternal age.  Fortunately, these fractures typically heal without any long-term complications.

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