How to prevent birth injuries and death during labor & delivery
Practical tips to improve chances for a successful, healthy labor and delivery
As a father of four who has been in the hospital room for every minute of each labor and delivery, I know that having a baby is one of the most exciting and precious events that anyone can experience.
We all have seen the preparations that would-be parents undertake to prepare for the new baby’s arrival–choosing the perfect name, going to baby showers, painting and furnishing the nursery, stocking up on supplies, and selecting that special outfit the baby will wear when leaving the hospital.
Also, if you’re like me, you read books, ask questions, and want to be involved in all of baby’s developmental stages–eye contact, baby “babble,” sleeping through the night, turning over. It seems as though the list goes on, and continues to expand as we are faced with enrolling for school.
The fact is–I will always take an active role in my children’s lives, and some stages are critical. Pregnancy and birth is certainly one of the most critical stages in a child’s entire life because it can so dramatically impact the quality of life they have.
So what about the actual medical care–are there any things you can do to help increase the odds of a safe birth and healthy child?
Fortunately labor and delivery works out well for most people, but I have handled numerous lawsuits where the baby is brain-damaged. Unfortunately, in some of these cases, everything was fine until minutes before delivery, and then someone didn’t do their job properly (whether it was a nurse, doctor, or some other health care provider).
I want to provide my practical observations as both a parent who has been through the process four times and as a medical malpractice lawyer who has had to deal with many unfortunate instances where things have gone wrong—often where the tragic outcome was entirely avoidable. This article covers some things that parents can do to lower the lower the risk of medical and nursing errors.
Planning Early in the Pregnancy
There are many things that an expectant mother should do early in the pregnancy to provide her baby with a favorable, healthy environment in which to grow and develop.
• Make sure your obstetrician is qualified. Find out about his or her experience. If you have any factors that put you in the category of a high-risk pregnancy (including the mother being 35 or older), consider using a maternal fetal medicine specialist (perinatologist). Perinatologists have additional training and typically provide more thorough prenatal care.
• Seek prenatal care early and as recommended by your doctor throughout your pregnancy.
• Take prenatal vitamins daily, with at least 400 micrograms of folic acid. In recent years, folic acid has been shown to drastically reduce some birth defects, including spinal cord abnormalities like spina bifida.
• Eat a healthy diet and check with your health care provider about foods to avoid, like certain fish that contain high levels of mercury. Before eating or drinking anything questionable, consult your health care provider.
• Consult your health care provider if you have any illness or get a cold during the pregnancy, or if anything feels abnormal.
• Before taking any over the counter or prescription medication, make sure it is cleared by your health care provider.
• Beware of environmental contaminants. For example, the Natioinal Alliance of Safe Pest Control's Pest Control Safety for Expectant Mothers publication references research suggestive of a 60% higher risk of having a child with autism spectrum disorder if they live within one mile of a place where organophosphate pesticides were used.
Preparation for the “Home Stretch”
In the last trimester of pregnancy, there are several things you should prepare for:
1. Hospital preregistration: Of course, it is also a good idea to pre-register with the hospital, so there is no paperwork to fill out in the middle of active labor. When you are completing the preregistration paperwork, it would be a good time to purchase a car seat and have it properly installed for safety.
2. Tracking fetal movement: This is one of the best tools for monitoring the baby’s well-being. Plus, it has the advantage of being non-invasive and the mother can do it wherever she is. A mother should be aware of her baby’s pattern or habits of movement at different times during the day. By the 24th to 28th week of pregnancy, a mother can do “kick counting,” which means noting the time it takes the baby to complete 10 movements, at approximately the same time of day when the baby is usually most active. The goal is for 10 movements within two hours; most babies accomplish this within 15 minutes.
3. Decreased fetal movement may help identify potential problems with a pregnancy, and should be communicated immediately to your health care provider. Timely evaluation allows intervention and may prevent potential problems, including brain damage and/or stillbirth.
Pregnancy and Birth Journal: Take Notes and Ask Questions
This is not a “what am I thinking” journal; it is a “what is happening” journal. Of course, you may enjoy jotting down the warm and fuzzy impressions you have of your pregnancy and birth, and your child may appreciate it later. However, the most important thing is to try to do everything you can to have a healthy child and safe delivery, so be sure not to neglect the very practical, and seemingly mundane, elements of pregnancy, labor, and delivery.
I recommend that all of my clients pay close attention what is going on around them whenever they go to a hospital, and to speak up quickly and ask questions if something seems wrong or simply different than expected.
Doctors and nurses will speak in the language they understand. Do not be afraid or intimidated to require clarification or to even question what is happening.
Bring a small notepad with you so you can jot down questions for your doctor. It is also a good idea to write down the names of the nurses, physicians, and other personnel who are taking care of you and anything significant that they tell you. Everyone’s memory fades with time, but if something goes wrong, this information will prove helpful to the investigation of what happened.
Fetal Monitoring During Labor & Delivery
Most hospital labor and delivery units routinely use electronic fetal monitoring (EFM) during labor. A nurse will position two transducers (they look like big elastic belts) on the mother’s abdomen, which are held in place by a belt. The transducers are connected to equipment that produces a continuous printed strip (called fetal monitor strip, or just strip).
The EFM measures the mother’s contractions and the baby’s heart beats (fetal heart rate), and allows observation of the relation between the two. Most EFM equipment has a video monitor so you can watch it in real-time and the equipment usually has a volume to allow you to listen to the audio of the fetal heart beat.
Click here for a photo of the EFM equipment used during the labor and delivery of one of my children. Notice the two irregular lines (usually in waves) on the video screen in the photo. The upper line records the fetal heart beat; the lower line records the maternal contractions.
Health care providers look for “reassuring” characteristics of a strip. A reassuring strip means that the odds of problems with the baby caused by poor blood or oxygen flow are greatly reduced. If there is something of concern, the doctor or nurse may describe it as “nonreassuring.” You should listen for these terms and ask questions if you hear them. Also, you can ask them if the strip is reassuring, and see if the doctor or nurse will review and explain the strip to you.
A “reassuring” strip has several characteristics:
• A baseline of 120 to 160 beats per minute. If you look at the upper line in the EFM photo, you will notice that it is not straight, but instead it varies up and down. The baseline is the average, or you can think of it as an imaginary straight line on the EFM through the mid-point (average) of the EFM tracing.
• Good long-term variability. When reviewing several minutes of EFM video or tracing, it is reassuring for it not to look flat, but instead to look somewhat curvy.
• Good short-term variability. The EFM equipment records every fetal heart beat, and it is reassuring if the heart beats are different.
• Accelerations (lasting 15 or more seconds above the baseline, peaking 15 or more beats per minute). Accelerations are jumps in the fetal heart beat.
Factors that are “nonreassuring” include:
• Late decelerations are drops in the fetal heart rate following a contraction. To meet the technical definition of a late deceleration, the EFM tracing must last for at least 20 seconds, starting with the peak of the contraction to the lowest point of the deceleration. With late decelerations, the fetal heart rate improves after the contraction has ended. They are thought to be caused by insufficiency of the uterus and placenta, which can cause hypoxia (reduced oxygen to the baby) and metabolic problems. Any late decelerations should keep you in the hospital (instead of being sent home for any amount of time). Repetitive late decelerations typically require an emergency C-Section.
• Bradycardia is a fetal heart rate of below 80 beats per minute.
You may also hear the health care providers refer to two other types of decelerations:
• Early decelerations are drops in the fetal heart rate just before a contraction and are usually caused by head compression during a contraction. They are considered normal and common.
• Variable decelerations are caused by umbilical cord compression and can happen at any time—i.e., they are not related to a contraction. They may not be problematic unless they last more than 60 seconds.
At most hospitals, the EFM videos for all of the labor and delivery rooms are displayed on a video screen at a central nurse’s station as well as in each mother’s room. The hospital should have adequate staffing for a nurse to be at the nurse’s station monitoring the screens and looking out for irregularities. Unfortunately, that does not always happen.
Further, some hospitals do not ensure that their labor and delivery nurses are properly trained to recognize and act upon problems. Expectant mothers and their family members should keep an eye on the EFM and, in general, what’s going on. Upon admission, ask questions about how the process will work, and request that the nurse provide a quick orientation to the EFM equipment. If, during labor and delivery, you notice something on the EFM that looks strange or different, or if the equipment has an alarm event, certainly find the nurse and ask questions until you get an answer.
If there is a problem with the fetal heart rate, you should expect the nursing staff to take steps similar to this:
• Reposition the mother. Sometimes the problem with the tracing is caused by the position of the transducer. Other times the position may be causing a problem for the baby.
• Start oxygen by a face mask.
• If the labor and delivery has been augmented by Pitocin, discontinue it.
• Start or increase IV fluids. • Notify the OB/GYN physician.
• Perform a vaginal exam to check for the baby’s position and if there is a prolapsed umbilical cord.
• Prepare for an emergency C-section.
Chain of Command
If you have a concern that is not addressed by the bedside nurse, realize that your rights do not stop there. Each hospital has a “chain of command” that can be invoked to get proper patient care. Click here for an example chain of command policy from Memorial Hermann Children’s Hospital, in Houston, Texas. The chain of command is normally used by hospital staff members who cannot resolve a problem. If your nurse is inattentive, ignoring requests, slow in responding to your requests, or you feel that there is a serious problem with the care being provided, ask to see the charge nurse or nurse supervisor. You may also ask to have the attending physician paged, or to speak to a hospital administrator. Even during evenings and weekends, all hospitals will have an administrator on call, so you can ask to have that person paged. It is always better to have a problem addressed immediately, rather than to risk a tragic outcome because of a medical or nursing error.
If your little one was injured during labor and delivery, or because of poor prenatal care, call 281-580-8800 for the experienced Houston medical malpractice and birth injury attorneys at Painter Law Firm.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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