All of Birth Injury

2006-07-20T23:23:00.000-07:00

Newborn Conditions Associated with Asphyxia

Hypoxic-Ischemic Encephalopathy
The neurological condition of the newborn during the early neonatal (immediate after birth) period is important in determining the cause of the brain injury and in predicting its severity over the long term. The term hypoxic-ischemic encephalopathy (HIE) is a clinical diagnosis of impaired neurological function that is usually made by a neonatologist or pediatric neurologist after delivery. A frequent cause of HIE is fetal asphyxia. Many clinicians use the criteria in Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. Arch Neurol 1976; 33:696-705 to grade the severity of a newborn's neurologic condition after birth.

What is the significance of Seizures?
Seizures often develop in infants who sustained severe birth asphyxia during the first 24 hours of life. Since seizures can exacerbate a pre-existing brain injury, it is imperative that appropriate and timely treatment be implemented. However, researchers do not know for sure whether seizures are the manifestation of a severe brain injury, or whether they cause additional injury. In any event, when evidence of early-onset neonatal seizures is combined with evidence of other neurologic abnormalities resulting in a diagnosis of HIE, a compelling argument can be made that the newborn sustained an acute hypoxic-ischemic brain in-sult.

The Importance of Blood Gas Studies
An analysis of the newborn's acid-base status, together with the results of subsequent blood gas studies, is important in creating a link between birth asphyxia and brain damage. The analysis of umbilical cord blood provides information about how the fetus responded to decreased or inadequate oxygen supply. The term "perinatal asphyxia" is frequently used by pediatricians and neonatologists to describe a brain injury caused by hypoxic and ischemic complications leading to blood gas abnormalities at the time of birth.

It is interesting to note that even though the American College of Obstetricians and Gynecologists suggests that the blood's pH should be less than 7.0, if it is going to be used as a factor establishing a link between birth asphyxia and neurologic injury, this narrow view is not widely supported by the literature. Many other studies confirm that birth asphyxia can cause brain damage even when umbilical cord arterial pH is greater than 7.0. nevertheless, it appears that infants with severe intrapartum asphyxia, quantified by an umbilical artery pH of less than 7.00, are more likely to develop permanent brain injuries.

The Importance of Neuroimaging Studies
Technological advances in CT scanning and magnetic resonance imaging (MRI) have opened new frontiers for establishing a link between asphyxia and hypoxic-ischemic brain injury. While some physicians continue to question whether cerebral palsy can be caused by birth asphyxia, many pediatric neuroradiologists acknowledge that brain damage can result from acute obstetrical emergencies causing total or near total oxygen deprivation, or as a result of partial, intermittent episodes of oxygen deprivation over longer periods of time. Imaging studies reveal different patterns of brain damage in infants suffering acute total asphyxia, as compared to prolonged partial asphyxia. Sometimes, the films can distinguish between hypoxia or ischemia that was acute and produced brain damage in a short period of time, (10 or 15 minutes), and a prolonged hypoxia or ischemia that was present for a longer period of time, (1 hour or longer), before it produced irreversible brain damage.

Each one of the imaging techniques has strengths and weaknesses. It is also important to know whether a particular imaging study was performed at the optimal time to pinpoint when the asphyxial brain damage may have occurred. It is common for clinicians to order cranial ultrasounds, blood gas tests, and EEG's to assess an asphyxiated newborn. Cerebral edema (swelling) often occurs after an asphyxial episode, and seizures can exacerbate the edema and prolong the period during which brain cells are vulnerable.

Remember!
The quality and timing of newborn care may affect the severity of the brain damage that was caused by birth asphyxia. The question that parents will have to consider in some cases is whether the newborn received timely and appropriate treatment to reduce the potential adverse effects of systemic and neurologic complications present immediately after birth, or developing shortly thereafter. Some of the goals thought to improve the neurologic outcome of a newborn include:
Maintaining normal blood glucose,
Maintaining normal blood pressure,
Preventing or controlling seizures, and
Preventing or minimizing cerebral edema

A question that often requires the assistance of a qualified expert in pediatric neurology and/or neonatology to answer is whether the brain cells that were compromised during the initial asphyxial episode were going to die regardless of how carefully and rapidly the newborn's complications were corrected. In other words, was the sequence of events that caused asphyxial brain damage continue to produce additional damage during the first few days of life, or did the failure to stabilize the infant and correct the blood gas abnormalities cause additional brain injury?

Birth Injury

2006-07-20T23:21:00.000-07:00

An Introduction to Birth Trauma Litigation

During pregnancy, the fetal brain needs adequate supplies of oxygen and glucose, among other things, to develop normally. Oxygen and glucose originate in the maternal blood, where they are are transported to the placenta, then through the umbilical cord, to the fetal circulatory system, and, finally, to the fetal brain. After delivery, the newborn lung replaces the placenta as the primary organ responsible for oxygenating the blood circulating within the newborn infant.

Certain maternal, fetal, or neonatal conditions can interfere with normal blood flow to the fetal or newborn brain ("schemia"), or reduce the oxygen content of the blood perfusing the brain tissue ("hypoxemia"). This can happen before the onset of labor (the antepartum period), during labor and delivery (the intrapartum period), or after birth (the immediate neonatal period). Unfortunately, neonatal intensive care units across the United States continue to admit and treat infants with hypoxic or ischemic complications that eventually lead to permanent neurological injury or other handicapping conditions, such as cerebral palsy.

Sometimes, the clinical condition of the newborn immediately after birth will alert the physicians and parents to the fact that the baby suffered a brain injury. In many of those cases, the primary diagnosis is ("perinatal asphyxia"), or ("birth asphyxia"), or ("hypoxic ischemic encephalopathy"), (referred to by many physicians as HIE). In other cases, the parents may not realize that their child suffered a brain injury until the child fails to achieve developmental milestones during the first year of life.

Regardless of when the parents find out about their child's condition, when they ask physicians for an explanation as to why their child suffered an irreversible brain injury, they are routinely told by their physicians that the outcome was unavoidable. Yet, a review of the clinical records may disclose a history of one or more maternal, fetal, or newborn complications that would have been capable of initiating a sequence of events leading to the brain damage: some of these complications or risk factors are preterm labor, premature rupture of the membranes, hypertension, diabetes, oligohydramnios, trauma, maternal infection, neonatal sepsis, abnormal blood gas studies, nonreassuring fetal heart rate patterns, breech presentation, intrauterine growth retardation, or placental insufficiency due to postdated pregnancy.

Thus, parents may suspect that all of the facts and circumstances that led to the brain damage are not being fully disclosed. They may decide to consult with an attorney, whom they may retain to conduct an independent evaluation of the medical records, with the help of qualified experts, to determine the cause and timing of their child's brain injury, and whether the adverse outcome could have been prevented with proper obstetric or neonatal care or earlier delivery.

This web site provides information concerning a wide range of medical topics, to provide parents with an overview of the many issues that can arise in the pursuit of a birth trauma case. The topics include: placental pathology, electronic fetal monitoring, antepartum fetal testing, perinatal infection, the assessment and management of newborn complications, blood gas testing and pediatric neuroimaging. At a minimum, parents looking for a possible explanation for their child ’s brain injury will learn about the mechanism of birth asphyxia and how asphyxia may contribute to cerebral palsy.

Birth Injury

2006-07-20T23:19:00.000-07:00

Birth Injury, Birth Trauma

Medical Malpractice is one of the causes of traumatic injuries during birth. Monheit, Silverman & Fodera has experience in handling and understanding these complex medical claims.
The brain is the primary center for regulating and coordinating all body activities. Essential to the regulation and coordination of these body activities is the transmission to the brain of oxygen obtained through air inhaled and exhaled during the act of respiration. Traumatic birth injuries is a broad description which is used to describe both avoidable and unavoidable mechanical and anoxic trauma to the brain of an infant during labor and delivery.
Anoxic trauma involves a situation in which there is diminished oxygen in the arterial blood supply despite the infant's otherwise-normal ability to carry oxygen. The diminished oxygen in the blood supply may be due to a reduced oxygen supply, respiratory obstruction, or inadequate respiratory movements.

Mechanical trauma involves some physical act to the body — usually the skull of the infant — which prevents the needed transmission of oxygen to the brain of the infant.
These injuries at birth may result from inappropriate or deficient medical skill or attention, commonly described as malpractice, or the injuries may occur despite skilled and competent obstetric care independent of any acts or omissions by the obstetrician. The most significant traumatic birth injuries are fractures of the skull and intracranial hemorrhage.

When injuries at birth result from inappropriate or deficient medical skill or attention, commonly described as malpractice, the injured child may be entitled to compensation for the injuries suffered. If this is suspected, it is important to investigate to determine the cause of the trauma. In order to determine if there is medical malpractice it is necessary that a medical expert be retained to consult with the plaintiff's attorney. This expert should be well qualified to give a medical opinion, and is therefore frequently board certified in the relevant field of medicine. If, after a thorough review of the pertinent medical records and other sworn statements, a physician concludes with reasonable certainty that the action or inaction of the defendant physician was the cause of damage to the plaintiff, it is appropriate to file suit against the physician/hospital.

The incidence of birth injuries has been estimated at 2-7 per 1000 live births. Factors which predispose the infant to birth injury include an abnormally large body, a disproportionate large skull, a difficult labor and/or prolonged labor, and/or the presentation of the buttocks instead of the head in childbirth. Overall 5-8 per 100,000 infants die of birth trauma, and 25 per 100,000 die of anoxic injuries.

Even transient injuries which are readily apparent to a parent result in anxiety and questioning that appropriately require supportive and informative counseling by the health providers. Some injuries may be latent initially, but later result in severe illness

Birth Injury

2006-07-20T23:16:00.000-07:00

Erb's Palsy Birth Injury

Shoulder Dystocia
Shoulder dystocia is an obstetric emergency with the potential to severely injure both mother and child. A shoulder dystocia happens when the baby’s shoulder becomes stuck behind the mother’s pubic bone during delivery; most shoulder dystocia situations are diagnosed when the baby’s head delivers but the shoulders do not follow. If shoulder dystocia occurs, any amount of traction placed on the baby’s head can cause severe nerve injury. Shoulder dystocia is one of the most difficult complications that can occur during delivery, because a shoulder dystocia situation carries such high risk for complications.Erb's Palsy is one of the most common (and serious) shoulder dystocia injuries. Erb's Palsy results when a shoulder dystocia condition is mishandled, resulting in damage to the nerves connecting the neck and arm. Shoulder dystocia can stretch the nerve tissue and cause damage resulting in permanent paralysis of the arm.

Risks During Delivery
A properly trained obstetrician will identify any shoulder dystocia risks and take steps to avoid injury during the delivery. Increased risks of shoulder dystocia are linked to high birth-weight babies, overweight or obese mothers, and a long second stage of labor. Shoulder dystocia can be prevented by scheduling a caesarean section (c-section) for high-risk mothers. If shoulder dystocia occurs during the birthing process, there are 16 different techniques to free the trapped shoulder and ensure safe delivery. Shoulder dystocia is a serious situation, but does not have to result in injury.About 1 or 2 babies in 1,000 suffer brachial plexus injuries at birth, and about 1 in 10 of these babies need treatment. Unfortunately, medical mistakes do occur and in the case of shoulder dystocia, the mistakes can be lasting with conditions such as Erbs Palsy.

Brachial Plexus Palsy
Brachial Plexus Palsy occurs when the brachial plexus, a network of nerves, is damaged. Since the brachial plexus conducts signals from the spine to the arm and hand when it is damaged a limp arm can result. The brachial plexus is a network of nerves formed by fibers, which are located between the shoulder and the neck. Most often brachial plexus injuries happen during birth when excessive lateral traction is applied to the fetal neck region. In cases of brachial plexus palsy the upper part of the brachial plexus is involved. The brachial plexus palsy injuries are 90% of the time caused by traumatic stretching of the plexus during birth. Many babies with brachial plexus injuries are larger than average at birth.

Types of Erb's Palsy
There are different types of brachial plexus injuries. Children with Erb’s Palsy are all affected in different ways; depending on the type of nerve damage in Erb’s Palsy children the symptoms can range from mild to severe. With Erb’s palsy there are four different types of nerve injuries, including:
1. an avulsion meaning the nerve is torn from the spine
2. a rupture meaning the nerve is torn but not where it attaches to the spine
3. a neuroma meaning the nerve has tried to heal but scar tissue has grown around the injury placing pressure on the injured nerve praxis. While the nerve has been damaged, it has not been torn and improvement should be seen within 3 months.
4. Neuropraxia is the mildest form of a nerve injury. Neuropraxia, the most common form of Erb’s palsy is localized to the specific place where the injury occurs. It is a physiologic block of nerve conduction within an axon without any anatomical interruption. Many infants born with brachial plexus palsy have neuropraxia and sometimes recover within 4-6 weeks.

Symptoms of Erb’s Palsy
Symptoms of Erb’s Palsy are usually very obvious. A baby suffering from Erb's Palsy can be seen with the affected arm laying by their side and an extended elbow devoid of movement. The injuries that are associated to Erb’s palsy are the neck, clavicle, shoulder, and arm. Some precautions should be used with children with brachial plexus injuries are shoulder or elbow dislocation, a frozen shoulder, soft tissue or joint contractures. Lifting a child with Erb's Palsy from under the armpits should always be avoided.Examples of different symptoms of Erb’s Palsy:
no muscle control and no feeling in the arm or hand
little control of arm movements
the use of hands but not of the shoulder or elbow
the entire arm may be paralyzed with the hand and fingers hanging limp
facial paralysis on the affected side
not able to sit up without assistance
the inability to crawl without the use of therapeutic devices.

Treatment for Erb's Palsy
Treatment for Erb’s Palsy generally consists of daily exercise and physical therapy to improve functionality of joints and muscles. In about 20% of the cases, babies born with Erb’s Palsy will greatly benefit from surgery between the ages of 5 and 12 months. Infants with brachial plexus palsy can benefit from surgical procedures to increase their arm functions. Since most children with Erb’s Palsy have damage to multiple nerves of the brachial plexus, more than one procedure, preformed by a pediatric neurosurgeon, may be necessary.
Erb's Palsy Birth Injuries Settlements and Verdicts

$10.5 million settlement for a child who suffered severe brain damage as a result of medical malpractice which occurred during prenatal care.
$5 million settlement for a newborn child who suffered brain damage during delivery resulting in severe cerebral palsy.
$2.6 million settlement for a child who's fetal distress was ingnored by the obstetrition, resulting in a severely brain damaged baby with cerebral palsy.
$1.1 million settlement for a baby that suffered a brachial plexus injury during birth, resulting in Erb's Palsy.
$13.3 million verdict for a child damaged at birth due to a mistake during delivery, causing Erb's Palsy.
$1 million verdict for a baby who suffered Erb's Palsy and Klumpke Palsy due to the doctor's negligent management of a shoulder dystocia.
$500,000 settlement for child with brachial palsy after shoulder dystocia during delivery.

Birth Injury

2006-07-20T22:58:00.000-07:00

Cerebral palsy

Introduction:
Cerebral palsy is a permanent and irreversible crippling condition affecting the brain and the central nervous system of an infant or a young child. It can be caused by various means. Some of the more common causes are listed below. They include those that occur during the pregnancy, those occurring during the process of birth and those occurring during the newborn period.

Possible causes of cerebral palsy during the pregnancy:
- specific types of infections occurring for the first time during pregnancy, these include toxoplasmosis, rubella, cytomegallovirus (CMV), herpes simplex, untreated group B strep
- placental abnormalities including placental insufficiency or premature aging of the placenta during the pregnancy, premature or sudden separation of the placenta from the wall of the uterus (placental abruption), intrauterine growth retardation (IUGR) of the fetus
- severe malnutrition of the mother, frequent use of certain types of prescription, nonprescription or illegal drugs, frequent use of alcohol by mother during pregnancy, exposure to certain types of toxic chemicals or other harmful environmental hazards
- mother's untreated high blood pressure, preeclampsia, eclampsia, toxemia, diabetes, problems with her thyroid or other conditions
- effects of certain types of genetic defects or syndromes

Possible causes of cerebral palsy during the birth process:
- untreated umbilical cord compression, prolapse or occlusion, unrecognized or untreated signs of fetal distress from pressure on the umbilical cord or due to dystocia, the baby being stuck in the birth canal because of its size or the position of its descent down the birth canal, placenta being prematurely sheared by the birth process-- placenta previa or placental abruption
Possible causes of cerebral palsy during the newborn period:
complications of severe prematurity, including problems with the heart, blood pressure, circulation, breathing, meconium aspiration, nutrition, hydration, temperature, infection, jaundice, bleeding, hereditary conditions which interfere with the baby's digestion, untreated seizures.
These are just a few of the more common causes, there are numerous others.

The mechanisms of injury
How is it that these conditions cause cerebral palsy to occur in some infants and not in others? Each of the causes noted above has the potential to interfere with proper development of the nervous system or potential to interfere with the delivery of oxygen and nutrition to the brain of the fetus or the newborn infant.
When the delivery of oxygen and nutrition to the brain is interrupted or severely impeded or decreased for a period of time, the brain becomes injured.
Depending on the location and the extent of the brain damage, the brain damaged infant may begin to show signs of delayed development, abnormal activity, increased tone, spasticity, seizures, bleeding in the brain, paralysis of the extremities-- quadriplegia or diplegia, hypotonia–flaccidity in the trunk, mental retardation and other signs of defects in physical and mental functioning.

Who is responsible?
All parents of children with cerebral palsy want to know, what happened to their child to cause the crippling condition, whether the injury could have been avoided, and what can be done now.
The truth is, at times cerebral palsy occurs even with the best possible medical care, and there is nothing that should have or could have been done by the health care providers to avoid the injury.
But there are many other cases in which the injury could have been prevented altogether or the brain damage may have been made considerably less severe if timely and appropriate intervention by the health care providers had occurred.
The only way to determine whether the injury was avoidable and whether a law suit should be filed is for an experienced medical malpractice lawyer to have the prenatal, delivery and newborn medical care record reviewed by appropriately credentialed professionals who understand the complex physiological relationship between the mother and the fetus during gestation, the stresses that the infant undergoes during the process of birth, the mechanisms it uses to cope with those stresses, the process of adjustment of the newborn to life outside the womb, and its requirements and responses to certain types of stresses and factors in its environment. Lawyers who handle these claims are familiar with the issues that will arise in a law suit and know how to seek review by an appropriate expert.
What can you do legally?
Many physicians have taken the position that cerebral palsy is not and cannot be caused by doctors and that it is virtually always caused by factors beyond the doctor's control, long before the baby is born. This view, while not supported by the credible research or literature, is nevertheless surprisingly common among certain physicians and nursing practitioners.
To get a fair review of the probable causes of your child's cerebral palsy brain injury, it is very important for the lawyer representing you to make sure that the professionals who review your case are free of such biases. One way you can ensure that your case is going to be thoroughly and fairly reviewed for technical medical and legal merit, is to hire an attorney who spends much of his or her professional time pursuing law suits for clients suffering from cerebral palsy or brain damage associated with the period surrounding the delivery.

Birth Injury

2006-07-20T22:07:00.000-07:00

Birth Injury

What is a birth injury?
Occasionally during the birth process, the baby may suffer a physical injury that is simply the result of being born. This is sometimes called birth trauma or birth injury.

What causes birth injury?
A difficult birth or injury to the baby can occur because of the baby's size or the position of the baby during labor and delivery. Conditions that may be associated with a difficult birth include, but are not limited to, the following:
large babies - birthweight over about 4,000 grams (8 pounds, 13 ounces)
prematurity - babies born before 37 weeks (premature babies have more fragile bodies and may be more easily injured)
cephalopelvic disproportion - the size and shape of the mother's pelvis is not adequate for the baby to be born vaginally
dystocia - difficult labor or childbirth
prolonged labor
abnormal birthing presentation - such as breech (buttocks first) delivery

What are some of the more common birth injuries?
The following are common birth injuries:
caput succedaneumCaput is a severe swelling of the soft tissues of the baby's scalp that develops as the baby travels through the birth canal. Some babies have some bruising of the area. The swelling usually disappears in a few days without problems. Babies delivered by vacuum extraction are more likely to have this condition.
cephalohematomaCephalohematoma is an area of bleeding underneath one of the cranial bones. It often appears several hours after birth as a raised lump on the baby's head. The body resorbs the blood. Depending on the size, most cephalohematomas take two weeks to three months to disappear completely. If the area of bleeding is large, some babies may develop jaundice as the red blood cells break down.

Bruising/forceps marksSome babies may show signs of bruising on the face or head simply as a result of the trauma of passing though the birth canal and contact with the mother's pelvic bones and tissues. Forceps used with delivery can leave temporary marks or bruises on the baby's face and head. Babies delivered by vacuum extraction may have some scalp bruising or a scalp laceration (cut).
subconjunctival hemorrhageSubconjunctival hemorrhage is the breakage of small blood vessels in the eyes of a baby. One or both of the eyes may have a bright red band around the iris. This is very common and does not cause damage to the eyes. The redness is usually absorbed in a week to ten days.
facial paralysisDuring labor or birth, pressure on a baby's face may cause the facial nerve to be injured. This may also occur with the use of forceps for delivery. The injury is often seen when the baby cries. There is no movement on the side of the face with the injury and the eye cannot be closed. If the nerve was only bruised, the paralysis usually improves in a few weeks. If the nerve was torn, surgery may be needed.

Brachial palsyBrachial palsy occurs when the brachial plexus (the group of nerves that supplies the arms and hands) is injured. It is most common when there is difficulty delivering the baby's shoulder, called shoulder dystocia. The baby loses the ability to flex and rotate the arm. If the injury caused bruising and swelling around the nerves, movement should return within a few months. Tearing of the nerve may result in permanent nerve damage. Brachial palsy is treated with immobilization of the arm with a brace or splint. Special exercises are also used to help maintain the range of motion of the arm.
fracturesFracture of the clavicle or collarbone is the most common fracture during labor and delivery. The clavicle may break when there is difficulty delivering the baby's shoulder or during a breech delivery. The baby with a fractured clavicle rarely moves the arm on the side of the break. There may be bruising over the broken bone. Simply immobilizing the arm and shoulder is the recommended treatment and healing begins quickly.

Birth Injury