Birth Injury Guide

Birth injuries can encompass a diverse set of traumas afflicting a newborn during labor and/or delivery resulting in structural damage or functional deterioration. These can include brain related injuries from oxygen deprivation or hemorrhage, birth trauma from excessive pressure on the baby’s head or body, or contracting an infection from the mother.  There are many identifiable risk factors that increase the likelihood of birth injuries. These are classified into three categories including fetal presentation, delivery mechanisms and maternal factors. The fetal factors include the following: macrosomia (larger than average for gestational age), breech presentation, abnormal fetal presentation, prematurity and precipitous delivery. Macrosomia can result in related injuries such as shoulder dystocia (brachial plexus injury), rib or clavicle fractures and scalp hematomas. Poorly controlled maternal diabetes is one of the leading causes of macrosomia. A breech presentation (buttocks or feet as presenting part) can result in intracranial hemorrhage, brachial plexus palsies, gluteal lacerations and long bone fractures. Abnormal fetal presentations such as transverse (sideways) and facial can result in lacerations, excessive bruising and retinal hemorrhage. Premature and precipitous (extremely rapid) deliveries are both related to potential bruising as well as intracranial and extracranial hemorrhage. [1]

A number of birth injuries are minor with no long lasting negative effects, while others can result in permanent disabilities placing an unexpected burden on the parents to care for a developmentally and/or physically disabled baby through adulthood. Symptoms from birth injuries can be mild and often not identified until the baby is school age, while others are detected immediately following birth. The symptom severity depends on the type of birth injury and each baby’s individual circumstances.  This article will focus on birth injuries that include brain damage, cerebral palsy, brachial plexus, Erb’s palsy and shoulder dystocia.

Brain-related Birth Injuries

Brain injuries often result from oxygen deprivation during the labor period that can include anoxia (complete lack of oxygen), hypoxia (inadequate oxygen levels) and birth asphyxia (low levels of oxygen to the baby before, during or just after birth). The most common complications leading to oxygen deprivation include trauma to the baby in utero, problems with the placenta, umbilical cord prolapse, pre-eclampsia/eclampsia, excessive medications of the mother and shoulder dystocia. [2] Brain injuries can result if the physician and/or nurse caring for the mother during labor and delivery don’t identify fetal monitor changes that may indicate a baby is not getting enough oxygen. These brain injuries could potentially be prevented if a cesarean section delivery was done in a timely manner.

One of the leading brain-related injuries in relation to birth trauma is cerebral palsy (CP) that affects an estimated 800,000 children with approximately 8,000 to 10,000 new cases diagnosed each year. CP is a group of neurological disorders that can occur from a lack of oxygen to an infant’s brain during labor and delivery that affects a child’s ability to control his or her muscles. CP can also develop from maternal and/or infant infections and infant stroke. It was once thought that the main cause of CP was the lack of oxygen during the birth process, however;  it is now thought that the brain damage that leads to CP can happen before birth, during birth or during the first month or years of a child’s life, while the brain is still developing. [3] [4]

Brachial Plexus Birth Injuries

The brachial plexus is a complex network of nerves between the neck and the shoulders that control muscle function in the chest, shoulder, arms and hands, as well as sensation in the upper extremities. The nerves of the brachial plexus may be stretched, compressed or torn in a difficult delivery when the neck and/or arm is forcibly pulled or stretched resulting in loss of muscle function or paralysis of the upper arm. Injuries to the upper brachial plexus (C5, C6) affect the muscles of the shoulder and elbow and injuries to the lower brachial plexus (C7, C8 and T1) can affect muscles of the forearm and hand. The classic obstetrical brachial plexus injury is Erb’s palsy that involves the upper portion resulting in weakness in the shoulder and biceps. Total plexus involvement that represents 20 to 30% of all plexus injuries involves all five nerves and can result in children having no movement at the shoulder, arm or hand. [5] Mild brachial plexus injuries may heal without treatment and early daily physical therapy is often started within three weeks of birth to maintain range of motion from the shoulder to the hand. More severe plexus injuries may require surgery to regain arm and hand function. [6]

Shoulder Dystocia Birth Injury

Shoulder dystocia (SD) is a rare, unpredictable and unpreventable obstetric emergency involving prolonged head to body delivery time that happens when one or both of a baby’s shoulders get stuck inside the mother’s pelvis during labor. SD is a delivery that requires additional obstetric maneuvers to release the baby’s shoulders after gentle downward traction has failed. Risk factors for SD include infants born to mothers with diabetes, maternal obesity and macrosomia. SD is frequently associated with permanent birth-related injuries and maternal complications. Brachial plexus injuries are one of the most important fetal complications of SD. Other SD fetal complications can include clavicle and humerus fractures, fetal hypoxia, with or without permanent neurological damage, and fetal death. [7]

Fetal Heart Rate Monitoring

Electronic fetal monitoring (EFM) is a procedure introduced in the 1970’s in which instruments are used by trained providers to continuously record the heartbeat of the fetus and the contractions of the woman’s uterus with special equipment. EFM used as a tool may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem and also prevent treatments that are not needed. External monitoring is done with two belts placed around the woman’s abdomen and internal monitoring is done by using a wire electrode usually placed on the baby’s scalp after the amniotic sac is broken. Abnormal fetal heart rate (FHR) patterns do not always mean there is a problem, but physicians and nurses will try to find the cause and take steps to help the fetus get more oxygen. If these actions are not effective, the provider may decide to deliver the baby right away, often by cesarean section. [8]

Non-reassuring fetal heart tones is the most common reason for first-time cesarean sections in the U.S. and because this can be considered a vague diagnosis, several professional organizations in the U.S. came together to decide upon standard definitions for FHR tracings as category I, II and III. Category I is normal and does not require intervention. Category II is called indeterminate and may require intervention, while category III is considered abnormal and requires intervention that may result in preparing for immediate delivery. Physicians and nurses should be adequately trained in EFM along with hands-on listening of FHR to achieve the benefits from continuous labor support. [9] Interpretation of FHR tracing by the providers involves understanding multiple complex aspects of the FHR  in correlation with the uterine contractions. Decelerations or decreases in FHR that are frequently addressed in the damages of birth injury cases can occur with maternal or fetal issues including fetal distress from hypoxia and often result in the need for interventions during labor and delivery to try to prevent fetal complications. [10]

Birth Injury Standard of Care Violations

Birth injuries can often be prevented by the physicians and nurses following the appropriate standard of care for the mother and baby throughout the prenatal period, labor, delivery and birth. This level of care involves carefully monitoring the health of the mother and baby and promptly identifying and treating any suspected abnormal findings. Potential signs of medical malpractice involving a birth injury can include an understaffed delivery room, inattentive or unqualified providers, minimal monitoring of the mother and baby and lack of informed consent for procedures.  Deviations in the standard of care that are often seen in birth injury litigation include the following:

• Failure to monitor, detect and treat maternal infections
• Failure to monitor fetal distress and take appropriate action
• Failure to plan and carry out a timely cesarean section
• Failure to identify and treat a prolapsed umbilical cord
• Failure to identify and treat a shoulder dystocia
• Failure to use tools correctly to assist a birth

Birth injuries can be temporary and minor with no long lasting negative effects, while others can result in permanent life-long disabilities for the baby and family. Our Medical Legal Solutions team consists of nurses with education, training and experience in high risk obstetrics and labor and delivery. Our team is available to assist you with determination of birth injuries and infant/maternal damages assessment. To learn more about how we can assist you with your birth injury, medical malpractice and personal injury cases, contact us.

[1] Neurological Neonatal Birth Injuries: A Literature Review
[2, 3] Birth Injury Guide
[4] Cerebral Palsy (CP)
[5] Boston Children’s Hospital – Erb’s Palsy (Brachial Plexus Birth Palsy)
[6] OrthoInfo Erb’s Palsy (Brachial Plexus Birth Palsy)
[7] Shoulder dystocia: an Evidence-Based approach
[8] Fetal Heart Rate Monitoring During Labor
[9] The Evidence on: Fetal Monitoring
[10] Intrapartum Fetal Heart Rate Monitoring

Additional Resources
Levels of Maternal Care
Erb’s palsy – Who is to blame and what will happen?
Brachial Plexus Injuries