by John McKiggan

This is the third in a series of three articles about how medical experts determine when a newborn brain injury occurred.  The first article in this series dealt with neuroimaging.  The second discussed cord blood gas analysis.

A newborn with signs of neurologic injury can suffer that injury any time during pregnancy, during labour and delivery and during the first days and weeks of life.  Lawyers representing injured children must prove when injury occurred.

What is an Electronic Fetal Heart Monitor?

The fetal heart is monitored during labour.  There are two ways to monitor the fetal heart during labour.  The first is to listen periodically with a handheld device, called intermittent auscultation (IA).  The second is to have continuous assessments using electronic fetal heart monitor (EFM).

Most labours today are monitored by EFM.  IA is only appropriate in low risk pregnancies, but tends not to be used in most labours.  At the same time that the fetal heart rate (FHR) is monitored, so too are the uterine contractions.

EFM shows how your baby is doing

The EFM provides a “tracing” of the fetal heart rate patter that is printed on a continuous strip of graph paper.  There is also a tracing of the uterine contractions that correspond with the fetal heart rate patterns.  Certain patterns are known to be reassuring signs of a healthy well oxygenated baby. Other patterns are more worrisome and can be indicative of possible problems that may need to be addressed. Finally there are some patterns that are ominous and require immediate action by your health care team.

The patterns on the strip are read and interpreted by midwives, nurses and physicians.  They watch for patterns that are reassuring for fetal well-being.  Where these reassuring patterns appear, it is considered safe for the baby to continue to the labour.  Where the patterns cannot be seen as reassuring, the obstetrical team must consider if there is some need to change the management of care during labour, or in more worrisome circumstances, move to delivery more quickly.

You can read more about EFM patterns and what they mean in the detailed article written by BILA founding member John McKiggan :  WHAT IS ELECTRONIC FETAL HEART MONITORING AND WHY IS IT IMPORTANT?

Does the EFM show signs of distress?

It is important during labour to be satisfied that the fetus is well-oxygenated.  Labour is a time of stress for the fetus.  The birthing process is inherently stressful.  In order for the fetus to move down the birth canal the mother’s uterus must contract in a regular pattern, normally involving regular contractions of a certain frequency, duration and intensity.

Oxygen is delivered to the fetus through the mother’s uterus, the placenta and delivered in blood through the umbilical cord.  When the uterus contracts there can be a temporary interruption in blood flow to the fetus and, therefore, a temporary interruption in the supply of oxygen.  These periodic interruptions in oxygenation are followed by periods of rest that, in normal labour, allow the fetus to recover.  Where oxygenation is interrupted  for too long, it may be difficult for the fetus to recover.

Reduced oxygenation shows as signs of distress

Reduced fetal oxygenation will be reflected in certain changes in the FHR pattern.  These patterns are readily seen on the EFM tracing.  It is important for the obstetrical team to watch for these changes in pattern and to appreciate if the patterns reflect excessive stress on the fetus.  In the event of patterns suggesting excessive fetal stress, it is necessary to take action to reduce that stress, with a view to seeing the FHR patterns return to normal.

Where steps are taken to relieve fetal stress and the patterns fail to return to normal within a reasonable period of time, the obstetrical team must take action to get the baby delivered quickly.

Non-reassuring FHR patterns may also reveal the likely time that the baby gets injured in situations where the baby is left in the uterus for too long.  The goal of EFM is to make sure the baby is delivered before these types of patterns develop.  Unfortunately, there are times where the obstetrical team fails to act as quickly as they should, allowing these alarming patterns to develop.  In these situations the newborn may suffer injury to the brain that may have been avoidable with proper care.

EFM patterns will allow the experts to refine the timing of injury suggested on both neuroimaging (discussed in the first article in this series) and with umbilical cord blood gas analysis (discussed in the second article in this series).  Pulling together the evidence needed to prove a case requires coordinating multiple experts to deliver opinions that complement each other.  That is one of the key functions of the lawyer representing affected children.

Want more information?

If you want more information about newborn birth injuries, or have questions about a possible birth injury claim, you may want to read a copy of our book; Birth Injury Lawsuits: A Parent’s Guide. 

The members of the Birth Injury Lawyers Alliance wrote this consumer education guide to help parents understand their rights and their child’s rights when faced with an injury caused by medical negligence.  This is the only legal guide in Canada written specifically for parents of children injured during child birth.

 The book is available to download on our website for free.  If you would like a print copy, the book is for sale on Amazon (all proceeds go to charity), but we will send you a copy at no charge, if you call us, toll-free at 1-800-300-BILA (2452).


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