Abstract
Head trauma may occur during delivery and can lead to a number of conditions. When an infant is injured during birth, the cause of injury is generally due to mechanical forces, such as compression, excessive or abnormal traction during delivery, and the use of forceps. A 39-year-old woman who was a primagravida (first pregnancy) with a gestational age of 26 weeks premature pregnancy was referred to a hospital in Tehran due to premature rupture of membranes (PROM) and fever. She arrived 2 h after rupture (noting that the rupture lasted for one week and then the baby was delivered). Antibiotics were given early on. After weak labour pain, vaginal examination revealed that the cervix was fully dilated and one of the feet of the foetus had come out of the cervix and was seen in the vagina. The foetus had died. The delivery staff used traction with force. Due to the age of the foetus, the head was relatively big and could not be delivered; the neck was thin and broken and the head separated from the body. The mother underwent a caesarean section to deliver the head of the foetus a week after PROM. The father of the dead newborn foetus sued the hospital and the staff responsible for the delivery. When medical professionals damage the trust between patients and their families and babies are injured children, they should be held accountable.
Introduction
Head trauma may occur during delivery and can lead to a number of conditions including caput succedaneum, cephalohaematoma and normal head deformity due to birth forces, subgaleal haemorrhage, subdural haemorrhage, subarachnoid haemorrhage and epidural haemorrhage.
Most birth injuries are the result of mechanical forces, such as compression, excessive or abnormal traction during delivery, the use of forceps (especially mid-cavity), instrumental deliveries, vacuum measures, vaginal breech deliveries and other devices used by the medical staff during delivery. 1
Birth injuries are defined as the impairment of neonatal body function due to adverse events that occur at birth and can be avoidable or inevitable. Despite good prenatal care, birth trauma usually occurs particularly in long and difficult labour or foetal malpresentations. 2
Birth injuries can be divided into two categories based on their aetiology: (1) injuries deriving from hypoxia and ischaemia; (2) injuries deriving from mechanical stress during labour and delivery. 3
Most birth injuries show specific or characteristic elements of the pathogenetic mechanism. Risk factors should be presented as pathological conditions or diseases (macrosomia, abnormal maternal pelvis, previous shoulder dystocia, chronic placental insufficiency, preeclampsia, foetal malformations, etc.), which could provoke or facilitate birth trauma in the situations of commonly standardised perinatal care, with increased frequency. 4
Mismanagement of delivery: doctors may fail to note or disclose knowledge of the high risk of birth injury or congenital defects. This could be prior to conception or during pregnancy. 5
Twenty-seven out of every 1000 births involve some sort of injury. 6 A birth injury can happen at any time during labour and delivery or immediately following birth. When a birth injury is caused by an avoidable mistake(s) or carelessness of a doctor, nurse or other medical professional, medical malpractice has occurred. 6
Case presentation
A 39-year-old primagravida with a 26 weeks’ gestational pregnancy was referred to a suburban hospital in Tehran due to premature rupture of membranes (PROM) and fever. The woman arrived at the hospital 2 h after rupture of her membranes. Antibiotics were given on arrival. Her labour lasted for 30 min with weak labour pains following the PROM. One week after this rupture, the delivery of the baby was attempted.
Vaginal examination showed the cervix was fully dilated at the point of delivery, and a foetal foot had come out from the cervix and was seen in the vagina. The delivery staff used strong traction; but due to the age of the foetus, the head was relatively big and could not be delivered, and a forceps delivery was not attempted because while tractioning the head may remain in the uterus. The uterus shut down too quickly for the delivery of the head to take place. The baby was dead and neck was broken before the delivery was attempted. The staff considered crushing the baby's head and delivering it vaginally to avoid the need to deliver the head by caesarean section, but this was not possible. Foetal heart rate monitoring was carried out during delivery. The measurements are recorded in the mother's medical records as follows:
The weight of the baby at birth was 1000 g and his body length was 33 cm, chest diameter was 33 cm and the head size was 34 cm. The head appeared enlarged when compared to the rest of the body.
There was no sign of hydrocephalus. The baby's head was delivered separately by caesarean section. The father of the dead newborn made a complaint against the medical staff for negligent delivery. The complaint was sent to the chief of the hospital; in consequence, the foetus was sent to the legal medicine organization for autopsy and further evaluation.
In the event, the hospital's obstetric practice guidelines were changed to avoid a repetition of this disastrous case.
Discussion
The birth of a child is one of the most precious events for parents. Unfortunately, errors and malpractice by medical professionals can and do result in significant injuries, disabilities and even death during pregnancy and the birth process. Birth injuries usually cause physical harm to the newborn during pregnancy, labour, delivery and aftercare and can affect the life of each family member. 7
If the birth injury was due to the failure of medical staff to properly identify the risk factors or due to surgical or anaesthesia errors, the family may also recover medical and hospital expenses. The first step is to consult an experienced law firm to consider the legal options. 1
Errors by medical staff cause birth injuries in up to 2% of all birth injury cases and can increase the severity of an injury or cause permanent disability. If you believe that your child’s birth injury was the result of medical errors, you may have a medical malpractice case. 1
A foetal death may result in a medical malpractice claim, if the treating physician failed to provide the level of care of a reasonably skilled and knowledgeable healthcare professional under the circumstances. 8
When an intervention is planned (oxytocin, forceps, caesarean, epidural and so forth), doctors should document the informed consent discussion clearly.
Doctors need to be present when their patient is in labour, especially when there are significant risk factors or complications. Telephone management of labour is fraught with hazards. 9
When therapeutic experts/medical professionals fail due to avoidable errors, they should be held responsible.
Footnotes
Acknowledgments
The authors wish to thank the Rasoul Akram Hospital Clinical Research Development Center (RCRDC) for technical support.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.