By Giles Manley, MD, JD
CPFN Medical Advisor

Electronic fetal heart monitoring is used in nearly all hospital births in the United States. The technology has been around for decades. But medical records of brain-injured infants I review each week frequently show that although fetal monitoring was showing the baby was experiencing high levels of distress while still in the womb, nurses or doctors failed to take appropriate action.

What Is Electronic Fetal Monitoring?

Electronic Fetal Monitoring (EFM) involves hooking the laboring mother up to a machine that records the baby’s heart rate. Changes to the heart rate, which are indicated on a graph called a tracing that is printed out by the monitor, can indicate that a baby is being deprived of oxygen for some reason, such as the cord wrapped around its neck. If the tracings show unusually high or prolonged stress, it may be critical to deliver the baby by C-section to avoid brain injury from lack of oxygen.

Why Do Mistakes Occur?

Medical best practices are clear about how to interpret tracings and when to take action. But preventable mistakes still happen. There are several possible reasons for this:

• Medical and nursing school programs used to use terminology to describe the actual patterns and changes in patterns that can be seen in fetal monitor tracings. The American College of OBGYN (ACOG), over a decade ago, grouped all this terminology into three different categories so that now tracings are described as Category I, which is reassuring, II, which they call indeterminate, or III, which is worrisome and mandates delivery as soon as possible. The issue is that some Category II tracings are relatively reassuring and monitoring further is acceptable, while others are much more worrisome and require delivery as soon as safely can be accomplished. What ACOG failed to do was put in place recommendations to address these different scenarios in Category II tracings, which has resulted in improper communication between health care providers, delay in deliveries and unfortunately oxygen deprivation and brain injury leading to CP in babies whose tracings were “technically” Category II.
• Nurses may delay alerting doctors to signs of worrisome tracings. They may hesitate to “bother” the doctor, or they may keep trying other techniques, such as turning a laboring mother to her left side or suggesting she squat, to try to alter the situation.
• A doctor’s order for an emergency C-section may not be carried out within 30 minutes because of staffing or facility issues or simple miscommunication.

These situations, and others like them, are why I tell parents to learn enough about EFM to know when they ought to be insisting that a doctor be called or that the baby be taken by C-section. In fact, my partner, Howard Janet, and I feel so strongly about parents learning the basics of interpreting fetal monitor strips that we included a chapter in our book, Patients’ Rights and Doctors’ Wrongs – Secrets To A Safer Pregnancy And Childbirth, that easily teaches a layperson the basics they need. It is far better to start insisting on a C-section that later isn’t needed (if tracings return to normal), than to need one and not get it done in time.

How Is Improper Fetal Monitoring Linked to Cerebral Palsy?

Cerebral palsy is a neurological issue that affects muscle tone, movement, and motor skills, as well as reflexes, posture, and coordination. The disorder causes lifelong issues with physical function, and it has no known cure. Instead, parents help their children with CP to manage their symptoms with a variety of physical, occupational, speech, nutritional, and recreational therapies.

There are many different factors that can cause cerebral palsy in babies. Cerebral palsy can be caused by abnormal development of the brain or damage to the developing brain, whether from stroke, infection, or other issues. It also can be caused by a birth injury—damage to the parts of the brain that control movement—before, during or shortly after birth. Because oxygen deprivation can lead to brain damage, proper fetal monitoring is critical to ensuring a safe delivery and a healthy baby.

Brain Injury Symptoms

Most cases of cerebral palsy in newborns result from brain damage (often due to a lack of oxygen) that occurred before or during birth—also known as congenital CP. It’s important to remember that brain injuries and brain damage can fall in a wide range of severity, from mild to severe. A newborn’s symptoms will depend on the severity of their injury. However, the most common signs that develop in infants with brain damage include:

• Visible injuries on the scalp
• Unresponsive to light and other stimuli
• Seizures
• Excessive fussiness
• Need for head cooling
• Unusual lethargy
• Increased or decreased blood pressure
• Need for assistance with breathing
• Admission to the neonatal intensive care unit for greater than 48 hours
• Dilated pupils
• Slow or rapid pulse
• Need for resuscitation at birth
• Low glucose levels requiring intravenous supplementation

Tips for Expectant Parents

In an effort to prevent possible birth injuries, I recommend parents:

• Tell your labor and delivery team you want to be informed about any evidence that oxygen levels to your baby have dropped and what action is being considered.
• Confirm that an obstetrician and anesthesiologist are in-house and available to respond in an emergency situation.
• Know the chain of command in the hospital so that if you feel your concerns are being ignored, you know who to call for a second opinion and intervention. The chain is initiated by getting the charge nurse or nurse manager involved immediately.
• Encourage expectant couples you know, especially those with high-risk pregnancies, to learn about EFM.

As a board-certified obstetrician for more than 20 years, I know how important it is that parents take an active role in labor and delivery decisions. Learning about fetal heart monitoring should be a part of every expectant parent’s birthing education.

Improper fetal heart monitoring that results in serious injury, such as CP, may be medical negligence. If you believe this kind of negligence may have occurred during your pregnancy or labor, you may be eligible for compensation that can help your family and child manage the lifelong challenges and expenses associated with a severe birth injury. The Cerebral Palsy Family Lawyers at Janet, Janet & Suggs are an experienced legal and medical team who are able to answer your questions, research your case, and provide the representation you need to fight for any compensation you may be entitled to under the law. Contact us to schedule a free consultation today.