Birth Injuries From Delayed C-Section
Cesarean delivery (c-section) is a common surgical procedure in which a baby is delivered by surgically opening the mother's abdomen and uterus. In the U.S., almost 1 out of every 3 babies are delivered via c-section. C-sections are often necessary when normal vaginal delivery presents unnecessary risks to the mother or baby. Over half of all c-section deliveries are scheduled in advance in response to risk factors that develop as the pregnancy progresses. For example, if the baby is abnormally large (fetal macrosomia) or in an abnormal position (e.g., breach or transverse presentation) doctors will normally schedule a preemptive c-section to avoid harm to the baby. In other cases, however, a c-section is an emergency procedure performed in response to situations that arise during vaginal delivery. When complications arise during delivery and the baby is under duress, a prompt emergency c-section is often the only way to avoid injury to the baby.
- History and Evolution of C-Sections
Most cesarean deliveries (c-sections) are scheduled in advance as a preemptive measure in situations where attempting a vaginal delivery may be too risky. Below are some of the most common reasons why doctors may opt for a scheduled c-section:
- Fetal Macrosomia: Fetal macrosomia is the medical term for babies that are abnormally large prior to birth. Babies are defined as "macrosomic" whenever their gestational or birth weight excess 8 pounds 13 ounces (4,000 grams). Fetal macrosomia is diagnosed in approximately 9-10% of all pregnancies. Male babies are 3 times more likely to be macrosomic. Fetal macrosomia can make normal vaginal delivery very dangerous and create a significant risk of birth injuries. The reason for this is somewhat obvious: it is much more difficult for an abnormally large baby to pass through the birth canal. When fetal macrosomia is accurately diagnosed in advance, a preemptive c-section is always warranted. Monitoring fetal growth and diagnosing macrosomia is a key part of good prenatal care. Unfortunately, fetal macrosomia is notoriously difficult to identify during pregnancy mainly because there is no actually weigh the baby inside the mother. The 2 primary indicators of macrosomia are:
- Large Fundal Height: fundal height is a measurement of the distance between the mother's pubic bone and the top of the uterus. A larger than average fundal height is often a sign of macrosomia.
- Amniotic Fluid Levels: Excessive amounts of amniotic fluid (an uncommon condition called polyhydramnios) is also a key indicator of fetal macrosomia.
- Abnormal Fetal Presentation: In a normal vaginal delivery, the baby is supposed to come out head-first and face-up. This is called the vertex position and most babies rotate into this position near the end of pregnancy (after week 33). Abnormal presentation (malpresentation) refers to any case where the baby does not rotate into the normal vertex position prior to delivery. The most common types of abnormal presentation are breech & transverse.
- Breech Presentation: breech presentation is when the baby is positioned to come through the birth canal backward - with their butt or feet first instead of the head. Breech position occurs in a 3-4% of all childbirths and is much more common with premature births.
- Transverse Presentation: transverse presentation occurs when the baby is positioned sideways, across the mother's stomach, instead of head first.
Abnormal presentations, such as breech and transverse, will make normal vaginal delivery very risky. When the baby is not in the normal position their passage through the birth canal will be much more difficult and potentially complicated. When abnormal presentations are identified in advance, a scheduled c-section is usually the best course of action to avoid potential birth injuries.
- Placenta Previa: The placenta is a sack usually located at the top of the uterus which supplies the baby with nutrients during pregnancy. Placenta previa is a condition that occurs when the placenta is lying too low in the uterus, near or covering the cervix. Placenta previa is not common and occurs in just 1 out of every 200 pregnancies. When placenta previa is present towards the end of pregnancy, a scheduled c-section delivery will almost always be required to avoid dangerous complications.
- Birth Canal Obstruction: A scheduled c-section may be necessary if the mother has some sort of mechanical issue, such as a uterine fibroid, obstructing the birth canal. A uterine fibroid is a noncancerous tumor that grows in the muscles tissue or walls of the uterus and can obstruct the birth canal. Fibroids are diagnosed in almost 10% of pregnancies and are more common in older mothers.
In many cases, a cesarean delivery is performed as an emergency procedure during an attempted vaginal delivery. Emergency c-sections are typically ordered in response to complications or signs of fetal distress during labor and delivery. The most common reasons for an emergency c-section are:
- Fetal Distress: During labor and delivery, doctors and nurses constantly monitor the vital sign of the baby, specifically the baby's heart rate, using fetal monitoring strips. Fetal monitoring devices are used to give doctors and hospital staff early warning signs that a baby is under physical duress during labor and delivery. Doctors and nurses must continuously monitor and interpret the fetal monitoring devices for signs of potential dangers to the baby. When indicators of fetal distress occur, the OB/GYN and hospital must immediately respond with an emergency c-section to avoid potential birth injuries.
- Umbilical Cord Problems: Any sort of complications or problems with the umbilical cord during childbirth can be very dangerous to the baby because the umbilical cord is literally the baby's lifeline. Compression of the umbilical cord during labor and delivery can restrict the flow of oxygen and nutrients to the baby's brain and result in permanent brain damage. A compressed umbilical cord is usually cause for an immediate emergency c-section. The longer the umbilical cord remains compressed, the greater the danger to the baby. Umbilical cord prolapse is another complication that can require an emergency c-section. Normally the cord is supposed to come out after the baby. Prolapse of the umbilical cord occurs when the cord drops down the cervix into the birth canal before the baby. This is dangerous because the cord can become stuck, entangled or compressed as the baby comes down afterward.
- Rupture of Membranes: Membrane ruptures are serious complications that can occur during labor and delivery (or later stage of pregnancy). A uterine rupture is a rare event that occurs when the uterus actually tears open and the baby comes out into the abdomen. Uterine rupture occurs in only 1% of all pregnancies, and it almost always occurs in women with scars from prior c-sections. This is the primary reason why vaginal delivery after a prior c-section is considered high risk. Another type of membrane rupture is placental abruption. Placental abruption takes place when the placenta actually tears away from the inner wall of the uterus prior to delivery. Placental abruption can happen very suddenly, often without warning. When placental abruption occurs it can be very dangerous for the baby because the detached placenta will often block the flow of oxygen to the baby. An emergency c-section must be performed immediately in response to placental abruption.
- Placental Insufficiency: Another reason an immediate Caesarean section might be required to protect the fetus is placental insufficiency. This is the inability of the placenta to deliver oxygen and nutrients to the baby.
It is a well-recognized fact that a significant percentage of birth injuries are caused by medical errors and mistakes during labor and delivery. There are various types of medical negligence or error that commonly result in birth injuries. However, delay in performing a c-section is by far the leading cause of malpractice-related birth injuries. Failure to schedule a c-section or negligent delay in performing an emergency c-section is strongly linked as the cause of many brain injuries.