Traumatic Brain Injury and Cerebral Palsy at Birth: Understanding Prolonged Labor Risks and Duty of Care
When there is a concern that medical errors may surround the birth of a child, leading to life-altering injuries, understanding your family’s legal rights and next steps is essential.
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While the birth of a child should be a joyous time for a family, when a birth injury occurs, the family must deal with complicated, unexpected issues — and these complications can result in a lifetime of need.
Injuries to a baby’s brain can occur at various stages surrounding birth: before (antenatal), during (intrapartum), and shortly after delivery (postnatal). These injuries can be due to inherited genetic defects or mutations, infection, or exposure to harmful substances, such as certain medicines, alcohol, or drugs. Sometimes, these complications are caused by medical negligence of health care providers during pregnancy, labor, and before, during, or after delivery.
During labor and delivery, substandard care is most often seen in the form of a failure to respond to the signs and symptoms that the baby is getting insufficient oxygen in utero. Brain cells need oxygen, and if oxygen is deprived, those cells can be damaged. This is particularly true of sensitive fetal brain cells and tissue. The lack of oxygen can cause brain injury to the baby and lead to cerebral palsy (CP). The Centers for Disease Control and Prevention (CDC) defines CP as a group of disorders that affect movement, muscle tone, and posture and result from damage to the developing brain before, during, or shortly after birth. Depending on the severity and areas affected in the brain, the combined brain injury and CP can cause a range of physical and intellectual disabilities.
When substandard medical care results in these types of injuries in a child, it can lead to a medical malpractice claim through which a family can obtain financial resources for the injuries, damage, and cost of care the child will need over their lifetime.
The Roles of the Collaborative Childbirth Care Team
The care of mother and child before, during, and after delivery in a hospital involves a medical team. Before and during delivery, the primary medical provider is typically an obstetrician, a physician who specializes in the management of pregnancy, labor, and the postpartum period. Obstetricians obtain a degree as a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO), followed by postgraduate training, known as a residency, in obstetrics and gynecology. Some doctors obtain additional training by completing a fellowship.
A physician-in-training (an intern, resident, or fellow) may be involved in the delivery, but they are merely an extension of the attending physician of record (the attending obstetrician). An attending obstetrician is a specific, identifiable person who is accredited by the hospital and is responsible for the management of the delivery and for the supervision of residents.
There are also specialized obstetricians who care for high-risk pregnancies, called maternal-fetal medicine (MFM) physicians. A pregnancy may be identified by the physician as “high risk” based on numerous factors, such as age, prior or current medical conditions, and lifestyle choices, where the mother or baby might be more likely than usual to develop health problems before, during, or after delivery. When these factors exist, the patient may (or should) be referred to MFM specialists by their obstetrician or gynecologist for specialized care.
In addition, labor and delivery practitioners — registered nurses (RNs), and certified registered nurse practitioners (CRNPs) with specialized training in obstetrics — monitor the labor process, assist with delivery, and support families during this critical time. Their expertise, when combined with the support of the attending obstetrician, underscores the collaborative nature of childbirth care.
Finally, some mothers choose to deliver by certified nurse midwives (CNMs). These practitioners hold a master’s degree in nursing and have completed specialized training in midwifery, which focuses on prenatal, labor, and postpartum care. CNMs often focus on natural birth methods. A CNM may deliver in a hospital, at a home, or at a birth center, which is not a hospital.
After the child is born, other specialists may become involved, including a neonatologist, who is a physician who specializes in the care, development, and treatment of diseases in newborn infants. Typically, a pediatrician is also consulted to examine the baby after birth, as well. Depending upon the circumstances, other specialists may also need to be consulted. For example, if there is a concern about infection, a request may be made for an examination and consultation by an infectious disease physician.
Fetal Distress
Hypoxic-ischemic encephalopathy (HIE) is a dangerous condition that is caused by a lack of oxygen and blood flow to the brain. Hypoxia is oxygen deficiency; ischemia is a restriction of blood flow to the brain; and when damage to brain cells results, it is referred to as encephalopathy. In severe cases, HIE can cause permanent brain damage, CP, and death. There are several reasons why blood flow or oxygen delivery to the brain can occur, including problems with blood flow to and from the placenta, abnormal fetal position, placental bleeding or tearing, or infection. As these are all known risks of labor and delivery, the medical team has a duty to continuously monitor both the mother and unborn baby during labor for signs, symptoms, and indications of fetal distress and HIE.
The purpose of monitoring the mother and unborn baby during labor is to alert the care team to issues and intervene in a timely manner if, as, and when there are concerns about the baby’s health or life. Interventions could be as simple as administering oxygen, repositioning the mother, or could lead to delivery by surgery (Cesarean section or C-section). To evaluate whether the baby is under stress and at risk for HIE, the medical team uses electronic fetal monitoring (EFM) during labor along with other signs and symptoms, such as the baby’s movement and the overall progress of labor. EFM is a continuous test that records the baby’s heart rate and the mother’s contractions — data that becomes part of the medical chart. EFM is typically performed externally. Elastic strips are used to secure two measuring devices to the mother’s abdomen. An ultrasound device is also positioned over the mother’s abdomen, and this is used to measure the unborn baby’s heart rate. A pressure gauge placed at the top of the mother’s abdomen is used to measure the frequency of the mother’s contractions. Internal monitoring can occur after the uterine sack ruptures (the “water breaking”). During internal monitoring, a small electrode is placed on the baby’s scalp in utero to get a more accurate tracing of the fetal heartbeat. EFM is universally used in the United States and around the world, and, in conjunction with other signs and symptoms, provides the medical team with critical information about the baby’s condition and whether the baby is in distress, whether there is sufficient oxygenation, and whether the baby is at risk for HIE, brain damage, and CP.
An abnormal fetal heart rate during labor and delivery, an abnormal neurological exam after birth (the Apgar score, discussed below), and an abnormal umbilical artery blood gas result (an analysis of blood from the umbilical cord) are consistent with an acute intrapartum hypoxic-ischemic event that occurred during labor and delivery and which can cause brain damage, HIE, and CP. When those facts are present, an experienced lawyer should carefully review the facts and circumstances to determine the best course of action.
By closely monitoring the progression of labor, the movement of the child, the baby’s heart rate, and the mother’s contractions, the medical team has, or should have, the information necessary to make appropriate decisions regarding the timing of delivery to avoid HIE, brain damage, and CP.
Responding to Fetal Distress
Fetal distress (or non-reassuring fetal status) refers to abnormal changes in the fetal heart rate, changes in movement, or changes in vital signs during labor that may indicate compromised oxygen supply or other concerns. Early intervention (such as additional oxygen, repositioning, or surgical delivery by C-section) during this phase is crucial to prevent long-term consequences like HIE.
During delivery, it is the professional responsibility (the duty of care) of the entire medical team to monitor the health of the mother and fetus. Providers must be prepared to intervene if, as, and when complications arise.
After delivery, the medical team remains responsible for monitoring the health of both the mother and the newborn. This includes identifying any signs of respiratory distress or complications of preeclampsia (maternal high blood pressure) as well as any other postpartum issues that could affect maternal and infant health.
Causes of Medical Negligence Before, During, and After Birth
Medical malpractice occurs when a medical team provides substandard care or fails to use the care that would be exercised by a reasonable and prudent medical practitioner to protect the infant and mother from harm. If the medical team’s care is substandard, they are responsible for the injuries and damage that result from that substandard care.
Examples of Substandard Care
Failure to Monitor: If the medical team fails to monitor the baby’s heart rate, the mother’s contractions, the baby’s movement, and the process of labor, or fails to act when the baby has abnormal patterns, it can lead to undetected fetal distress. If the team is not aware of the distress, it cannot initiate timely, necessary interventions, which can result in compromised oxygenation and brain injury.
Delays in Response: If health care practitioners delay in recognizing or responding to signs of maternal or fetal complications (including high blood pressure, abnormal fetal motion, or signs of abnormal labor progression), they can increase the risks of oxygen deprivation and injury.
Inadequate Prenatal Care: Failure by the medical team to consider, monitor, and advise the mother of risks of infection or other injury they know or should know about — or the failure to adequately screen for risk factors during prenatal visits — may prevent timely identification of high-risk pregnancies. Without appropriate risk management strategies in place, the likelihood of complications during labor increases.
Poor Communication: Ineffective communication among the health care team members can lead to misunderstandings and delayed interventions. Ensuring that all providers are aware of the condition of the mother and fetus is required for coordinated care.
Recognizing and Responding to Prolonged Labor
On average, labor lasts 12–24 hours for a first birth and 8–10 hours for subsequent births. Prolonged labor is defined as the duration of labor exceeding the normal period — typically 25 hours or more for a woman who has never given birth and over 20 hours or more for a woman who has given birth. Prolonged labor carries increased risks for brain injury and CP in infants, and medical practitioners have a duty of care to prevent such occurrences.
Labor is described in three stages:
- Stage 1 — Early and active labor
- Stage 2 — Delivery of the baby
- Stage 3 — Delivery of the placenta
Prolonged labor specifically refers to an extended first or second stage. Labor can be prolonged due to several factors. They include:
- Maternal exhaustion
- Ineffective uterine contractions (inadequate frequency and strength of contractions)
- Fetal malpresentation (the fetus is not positioned optimally for birth)
- Maternal health complications, such as pelvic abnormalities, obesity, and other medical conditions
Provider Responsibilities
Given the potential risks associated with prolonged labor, medical practitioners have the professional responsibility to monitor, assess, and intervene when necessary to ensure optimal outcomes for both mothers and infants. Medical providers must:
Assess and Monitor: Continuous monitoring of maternal and fetal conditions during labor is essential. Practitioners must regularly assess the effectiveness of contractions, FHR patterns, and maternal vital signs for early identification of signs of distress or potential complications.
Intervene Timely: If, as, and when labor is prolonged, practitioners should consider interventions such as administering medications to enhance uterine contractions (oxytocin) or recommending assisted delivery techniques when appropriate.
Communicate Clearly: Effective communication with the laboring mother regarding the progress of labor and potential interventions is vital. The medical team must ensure that the patient is informed, which can facilitate collaborative decision-making and reduce anxiety.
Prepare for Emergencies: The medical team must be prepared to manage complications arising from prolonged labor, including having protocols in place for emergency C-sections if fetal distress is identified or if labor progresses without sufficient progress.
Apgar Scores: A Vital Diagnostic Tool
There are a variety of methods used by health care professionals to obtain an accurate diagnosis of a brain injury in an infant, including physical and neurological evaluations and imaging, such as CT scans, to assess the extent of the injury.
An Apgar score is an assessment tool used immediately after birth to evaluate a newborn’s overall health and vital functions.
This quick, systematic scoring system measures five criteria:
- Appearance (color)
- Pulse
- Grimace response
- Activity (muscle tone)
- Respiration
Each criterion is graded by the medical team on a scale from 0–2, resulting in a total score ranging from 0–10. A high Apgar score indicates that the newborn is in good health. A low Apgar score indicates potential complications, including oxygen deprivation or distress during delivery. When a newborn receives a low Apgar score, it raises immediate concerns for health care providers and parents alike, as it may be an early indicator of neurological impairment or other medical issues. For instance, a score of 4 or lower at one minute after birth often prompts further evaluation for a brain injury, particularly in cases of asphyxia or prolonged labor.
The relationship between the Apgar score and brain injury underscores the importance of prompt medical assessment and intervention. These scores can help the medical team and parents know the immediate health status of their child and inform necessary next steps. The Apgar score provides a preliminary snapshot of a newborn’s well-being and serves as a tool to identify infants who may require closer observation and care to address potential long-term consequences.
Addressing Post-Delivery Complications
The medical team’s responsibility extends beyond the delivery room. After the birth of the child, new members join the medical team, including pediatricians and neonatologists. These providers are responsible for timely recognition and intervention in the face of postpartum complications. Various complications, including respiratory distress, the effects of preeclampsia, hypoglycemia, and hyperbilirubinemia, may be present and require vigilant monitoring and appropriate responses for the health of the infant. Early detection and treatment of these conditions are crucial in preventing post-delivery complications, such as brain injuries and serious neurodevelopmental disorders, such as CP.
Types of Post-Delivery Complications
Respiratory distress is among the most critical complications that can arise shortly after delivery. It can be intermittent, or it can stem from factors such as:
- Meconium aspiration (when a newborn breathes in a mixture of meconium, baby’s first feces, and amniotic fluid)
- Transient tachypnea (temporary and mild respiratory problems of babies that begin after birth and last about three days)
- Congenital anomalies affecting the lungs
Early identification of respiratory distress is essential because prolonged hypoxia, which can result from respiratory distress, can result in severe outcomes. Medical teams assess newborns with tools such as pulse oximeters and physical examinations to monitor respiratory function. Prompt interventions may be required to provide the necessary oxygen by supplemental oxygen or mechanical ventilation. The failure to recognize and treat inadequate oxygenation increases the risk of brain injury.
Preeclampsia is a condition of persistent high blood pressure in women during pregnancy. This condition can have lingering effects that may endanger the infant’s health even after delivery. Recently born infants born to mothers with preeclampsia are at increased risk of neurological complications due to factors like intrauterine growth restriction and placental insufficiency. These conditions often lead to lower birth weights and can predispose infants to further complications post-delivery. Pediatricians must monitor for signs of compromised health in these infants, including blood pressure anomalies and neurological assessments, to ensure appropriate interventions, such as enhanced feeding protocols and supportive care.
Low blood sugar in newborns (neonatal hypoglycemia) is a common condition that can lead to significant health issues if not responsibly managed by the medical team. Low blood sugar levels can occur because of poor feeding, maternal diabetes, or infections. Prolonged neonatal hypoglycemia can lead to brain injury and developmental delays. The medical team must routinely screen infants for glucose levels and provide timely interventions, such as administering intravenous dextrose, to prevent adverse outcomes.
Commonly known as jaundice, this condition is caused by an excessive accumulation of bilirubin, a brownish-yellow substance that forms as red blood cells break down. Elevated bilirubin levels can cause kernicterus, a severe form of brain damage resulting from bilirubin poisoning. The medical team must implement preventive measures, including promoting early and frequent breastfeeding and utilizing phototherapy when bilirubin levels rise beyond safe thresholds to mitigate these risks.
Postpartum infections can have a profound impact on a newborn’s health. Infections can cause sepsis, which complicates recovery and potentially affects the infant’s long-term well-being. Sepsis in newborns (neonatal sepsis) is a serious medical condition that affects babies younger than 28 days old. Sepsis is the baby’s extreme internal response to an infection, and it causes inflammation and blood clotting that reduces blood flow to the baby’s limbs and vital organs, including the brain. It can lead to brain damage and even death. It is crucial to quickly recognize signs of infection and conduct appropriate diagnostic tests, including blood and urine tests and x-rays. Prompt diagnosis and care that addresses this complication can reduce risks and improve long-term health outcomes for infants. (Similarly, mothers can get endometritis, an infection in their uterus after childbirth, which, if not accurately diagnosed and treated, can lead to infection and sepsis.)
The responsibility of the medical team to both mother and child does not end at delivery; it extends into the crucial postpartum period, where vigilance and prompt responses to complications can mean the difference between long-term health and serious challenges.
For parents of children with a CP diagnosis, it is important to understand that each case is different, and there is no set standard for the type of medical care a child will need going forward. The treatment plan completely depends on symptom severity, which may change over time, but early medical intervention can improve the outcome.
At a minimum, the patient’s care team will include:
- A primary care pediatrician
- A physical medicine and rehabilitation (physiatrist) specialist to coordinate your child’s care and develop a treatment plan in consultation with other providers
- A pediatric neurologist
- Other health specialists, such as dietitians, and physical, occupational, speech language, and recreational therapists
Orthopedic surgeries may be required to treat muscle tissue shortening or reduce pain and improve mobility in joints and tendons. And additional treatments may also be needed for vision, hearing, continence, nutrition, feeding, sleep, and oral care.
In addition to treatment and therapy, medications will be required, including those that improve functional abilities, relax muscles and nerves, and manage pain, drooling, seizures, osteoporosis, and mental health issues.
Obtaining Financial and Legal Support for TBIs at Birth
Each state has unique laws and procedures with strict deadlines and rules regarding birth injury cases. Some states require a certificate or affidavit of merit (a sworn statement) from accredited medical specialists before proceeding with a medical negligence case. Other states have minimum requirements for the qualification of experts, caps or limits on the damages that can be recovered, procedures for alternative dispute resolution, or screening boards that review the claims.
Accountability for substandard care is a cornerstone of medical professional responsibility. Medical facilities, physicians, and other medical practitioners are required to have professional liability insurance to cover claims that may be resolved through settlement or a jury verdict.
If you or your family have any concerns or questions regarding harm suffered during pregnancy, labor, or delivery, you should speak with an experienced lawyer as soon as possible. They can provide you with more information regarding individual state laws, such as statutes of limitations, minors’ tolling statutes, statutes of repose, and an evaluation of the merits of a medical malpractice case.
Most experienced medical negligence attorneys will meet with you, obtain the medical records, have the matter reviewed by medical experts and, if there is a basis to further investigate, agree to take the case on a contingent fee basis, which in many states means no legal fee or reimbursement of costs to the attorneys unless there is a recovery. Do not wait until the last minute. Experienced attorneys need time to obtain and review the full medical records and consult with experts.
To evaluate any birth injury case, an experienced lawyer needs to evaluate the complete medical records for both mother and child. The investigation that follows (including consultations with multiple expert physicians) will focus on whether the medical providers followed the standards of medical care, and if not, whether the malpractice caused the injuries suffered by the child.
Many birth injury cases settle after all the evidence is gathered and the case is proven. And if there is no settlement, jury trials are available in most States. While a lawsuit will never change what happened, full and fair compensation can make life-changing differences for catastrophically injured children and their families. Medical negligence lawsuits not only seek justice for those who have been damaged by birth injuries but also encourage the entire health care system to improve and to adhere to the highest standards of practice.
For more information, see Legal Help
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