Host Sean Harris talks with Cleveland Attorney John Lancione about obstetric malpractice cases, common injuries for newborn babies, and common complications for mothers. Read the transcript here or listen along in iTunes
Sean Harris: Hello and Welcome to OAJ’s Civilly Speaking. I am your host Sean Harris. Joining us today is Cleveland attorney John Lancione. John focuses his practice on obstetric malpractice cases. John, thanks for being here.
John Lancione: It’s a pleasure to be here Sean.
Sean: We know that almost 140,000 babies are born every year in Ohio, so this affects lots of Ohioans every year. Can you tell us, even starting off very basically, what are some medical terminology that expecting parents might hear during the course of delivery or the child birth process that they may not be familiar with?
John: Well it terms of medical terminology, most physicians and of course lawyers also don’t like to talk in real technical terms to their patients or clients. So things that become familiar to pregnant mothers and their spouses or significant others early in pregnancy will be things such as fetal kick counts. That is just the baby moving in the abdomen, moving in the uterus at about 28 weeks gestational age. When 28 weeks along, babies start to move and the obstetricians like to tell the moms to count the baby’s kicks. Whether it’s the elbow or them moving or the swooshing around in utero, that is the sign of a healthy active baby. So kicks counts are one thing that moms should become familiar with and keep in mind and monitor after about 28 weeks of pregnancy. Terms during the labor itself that should become familiar and moms and dads should have some knowledge about are things such as electronic fetal monitoring. Electronic fetal monitor is a device that monitors the baby’s heart rate in utero because that can tell the physician and nurses a lot about fetal wellbeing. How well the baby is tolerating labor. The fetal monitor not only tracks the baby’s heart rate but also uterine activity. Uterine activity, contractions, are a very important part of the labor and fetuses will tell the doctor and nurses how they are tolerating the contractions by their reaction of the fetal heart rate to those contractions. Those are two items during the pregnancy and during labor that are medical terms that moms and dads should become familiar with.
Sean: And you mentioned fetal monitoring. When does that happen?
John: Fetal monitoring occurs during pregnancy. It’s called antepartum monitoring. Which ante- meaning before delivery and then intrapartum monitoring meaning during delivery. Physicians and obstetricians do fetal monitoring during pregnancy to assess the wellbeing of the fetus. They do several different types of tests. Ones called a non-stress test. Which means they monitor the baby’s heart rate while there is no uterine activity; there are no contractions. And they want to see the baby’s heart rate reaction to fetal movement. Now when you and I go up a flight of stairs, our heart rate goes up. When the baby starts to move its heart rate should go up. They can tell that. It’s fetal heart rate acceleration. Normal acceleration in response to fetal movement is fifteen beats per minute above baseline for fifteen seconds. That shows the fetus is normally oxygenated and most likely neurological intact. Now during pregnancy, the fetal monitor is used to assess the fetus’ response to the stresses of labor. Labor is a very stressful time. It is probably the most stressful physical time in anyone’s life. The fetus is going from the intrauterine environment to the extra-uterine environment and changing over from its fetal circulation to normal extra-uterine circulation. So that monitoring is very important during labor to determine fetal oxygenation and fetal neurological intactness.
Sean: Expectant parents of course are always worried about or concerned about the health of their child. Are there things that expectant parents can do to increase the likelihood of having a healthy baby?
John: Absolutely. I believe that starts with carefully choosing a competent obstetrician. In the age of the internet you can go on and find out anything you want about anybody and that applies to physicians as well. There are physician rating websites, health grades for example. You can get on the county court website and type in the physicians name in the search terms and get all of the lawsuits against them. Checking out your doctor and carefully selecting your doctor is important. Once you have established that relationship follow your doctor’s orders. Always take a pre-natal vitamin to increase the level of folic acids which will prevent neural tube defects. Stop smoking and stop drinking if you do while you are pregnant and live a healthy lifestyle. I mentioned kick counts. That is important to monitor because if the baby slows down that could mean or herald the onset of a potential problem. Oligohydramnios which means low amniotic fluid can result in decreased fetal movement. Umbilical cord compromise can also cause decreased fetal movement which is the baby not moving around as much. During your pregnancy, and in particular when you are in the hospital having your baby, have a patient advocate with you. Not the father or a parent. But a friend who is not going to have that emotional attachment and is going to be there and be a set of eyes and ears, because when the mom is pushing she’s not thinking about anything but getting that baby out and the dad is not thinking anything about the health and wellbeing of his wife and baby. Have someone else in the labor and delivery room with you, a trusted friend as the patient advocate. Lastly, be prepared for anything and have knowledge about what could happen during labor and delivery. You could deliver vaginally, you might have to have a c-section because of fetal intolerance to labor, the baby is not handling labor well; arrest of descent and dilation, when the baby is just not going to come out. So be prepared for that and know that. Have discussions with your doctor beforehand so that you can make an informed decision and they may have to be made very quickly under emergency circumstances. During labor and delivery, I would avoid the use of instrument delivery or operable vaginal delivery with forceps or a vacuum. In today’s day and age the obstetricians during their residency get very little training on the use of forceps and vacuums and it greatly increases the risk of fetal injury. Also, get to 40 weeks. Don’t schedule a c-section because you are going on vacation. Don’t schedule a c-section at 38 weeks or 39 weeks. Get to 40 weeks. Babies need 40 weeks unless there is some maternal or fetal reason to delivery earlier. Don’t let your obstetrician delivery you early by c-section for a convenience for him and don’t do it as a convenience for you. If you don’t have to have an induction of labor with chemical agents to stimulate uterine contractions, don’t do it. Let Mother Nature take its course.
Sean: You mentioned something earlier there that I wanted to circle back to, that’s the idea of patient advocate, someone who is not a family member. What kinds of things should that person be looking out for, what other than being generally just eyes and ears?
John: To that person I would say “Trust your gut.” Go into that labor and delivery with some knowledge about fetal monitors and fetal heartrates. What are normal fetal heartrate baselines? Is that heartrate varying from a normal fetal baseline which is between 110 beats per minute and 160 beats per minute? Anything that is under 110 beats per minute is considered fetal bradycardia or low fetal heartrate. Anything above 160 beats per minute is considered fetal tachycardia. Those two parameters, above and below, can herald fetal intolerance to labor, fetal illness, something that needs to be addressed immediately. The heartrate monitor is both an audible monitor, you can hear the heart beating just like if you had a stethoscope on the baby’s heart, and you can also see it graphically on a computer screen. So try to get some familiarity with that. If the nurses aren’t responding, go out of that room authoritatively with respect and get the nurse’s attention. The nurses are the eyes and ears for the doctors. The OB’s are usually in their offices seeing patients during the day and they may have two or three patients in the hospital in labor. The patient advocate needs to make sure that nurse is responsive and attentive. If they are not responsive, go to the charge nurse. You have got to have someone watching that baby at all times during labor and delivery.
Sean: John, when clients come to see you generally something unfortunately has gone wrong. What are some of the common injuries that you see in your practice?
John: The most common injury that I see in my practice is fetal brain damage resulting in the development of cerebral palsy. I think everyone knows what cerebral palsy is. They see a child or even an adult in a wheelchair with contractures and lack of trunk support and lack of neck support. That is a very specific injury to a very specific part of the brain that is a result of lack of oxygen and lack of blood flow to the brain, most likely during labor and delivery. Scenarios that are very common are that the fetus is not tolerating uterine contractions. When the uterus contracts there is an absolute cessation of blood flow between the uterus and the placenta, which is normal and a normal healthy fetus can tolerate that if the contractions are spaced far enough apart. Once the contraction stops the fetal oxygenation returns to normal within about 90 seconds. When the contractions are too closed together, which used to be called uterine hyper stimulation, now it has been changed to uterine tachysystole. Normally what happens is the result of the use of Pitocin which is a synthetic form of a chemical that the mother’s body normally produces which stimulates uterine contractions. A lot of obstetricians induce labor with Pitocin to get the contractions started and the nurses administer it pursuant to the physician’s order. Every labor and delivery unit will have set orders, standard orders for Pitocin. But what they do is just keep on pushing Pitocin, we call it “pitting”. Pit is the short term for Pitocin. We call it pitting to distress; pitting the fetus to fetal distress, because the uterus is contracting and contracting and contracting. The contractions are too strong or there is too short of a resting time between the contractions or the contractions are too long. So basically, every time there is a contraction the baby is holding its breath; we call this fetal breath holding. If that fetus cannot recover and self-resuscitate in utero it is going to suffer from a lack of oxygen. Sometimes these nurses are not well educated or are not attentive, they are distracted or have too many patients, the doctor is at home in the middle of the night sleeping or in the office provided office care to patients and that fetus starts to suffer from a lack of oxygen. When that happens there will always be abnormalities in the fetal heartrate. Either diminished fetal heartrate variability, which is a sign of lack of oxygen; absence of fetal heartrate accelerations, which is a sign of acidosis, metabolic acidosis in the fetal circulation as a result of lack of oxygen. If it gets bad enough we call it a fetal heartrate crash, the baby‘s heart just cannot take it anymore, the brain stops sending signals to the heart to modulate the heartrate and the baby’s heartrate just drops, it goes down below 100, 90 60 and sometimes the baby literally has no heartrate in utero and that leads to an emergency c-section. When that blood flow stops, that is called ischemia or lack of circulation. Typically what precedes that is a lack of oxygen which is called fetal hypoxia. That happening very acutely or it happens over a prolonged period of time. The Acute, We call it acute near total asphyxia; which means the baby is fairly well oxygenated before the heartrate stops, there is no blood flowing, deep structures of the brain will become damages first which are the motor centers of the brain which will result in the weakness and contractions of the arms and legs and trunk and neck which is a profoundly disabling injury. These children will never walk, most of them will never talk, and they will never be potty trained or fed. Most of them will get a g-tube in their stomach. They are profoundly disabled and will require 24/7 care the rest of their lives. The other type of injury is what we called a prolonged partial injury where there is a prolonged partial hypoxia and ischemia to such an extent that it damages the outer parts of the brain which control the cognitive functions of the child. Those children then have developmental and cognitive impairment and need significant extensive care on a lifelong basis. Some of these children also suffer a combination of both; both the acute near total asphyxia insult and the prolonged partial and they are profoundly cognitively and physically disabled. That’s the main one and is typically a result from the delay in delivery of a baby in distress. Another scenario that we see a lot is a faulty resuscitation. Labor and delivery is a very stressful event. Some of these babies come out and need to be resuscitated; they need to have a little breathing for them. Sometimes they need to be intubated and need to have a machine breathing for them for a few minutes until they reestablish their heartrate. They get some chemical agents into the baby’s circulation through the umbilical vein catheter and the baby becomes robust and healthy almost immediately. Sometimes these resuscitations are delayed because they don’t have adequate personnel in the delivery room. It is required by every standard in the medical community to have someone who is certified in neonatal resuscitation (to be in the delivery room). Obstetricians should be certified in neonatal resuscitation; which means they have to know how to intubate a baby and get them breathing again. They have to know how to do chest compressions on a baby to get its heart started again. Those personnel are in the room in a timely manner but not properly trained that can result in the exact same outcome which is cerebral palsy. Finally, prematurity. We have one of the highest prematurity rates in the world here in the United States. Nobody really knows why babies are born prematurely but it can be prevented. There are certain signs that will tell the obstetrician that we need to take some steps to prevent prematurity. Whether it is an incompetent cervix, or a previous cervical surgery, or abnormal pap smears. Bed rest and medications may be prescribed to get this baby to 32 weeks. Most 32 weekers who are born do very well. We try to get these babies up to 32 weeks if we can and obviously up to 40 weeks if there are no real medical issues causing the prematurity. So those are the three areas: delayed delivery, faulty resuscitation, and prematurity that result in these adverse fetal outcomes.
Sean: John, we have been talking about the health of the baby. I want to shift gears here and talk about the health of the mother. There is a perception these days with the advances in medical technology that women don’t die in childbirth, is that true?
John: Well, I think you would be surprised to know that the United States has one of the highest maternal death rates in the world. For a country with the most advanced medical system, more mothers die during pregnancy or shortly after pregnancy due to pregnancy related complications here in the United States than in most developed countries and more than some third world countries. The top causes of maternal death are maternal hemorrhage, bleeding after delivery from the uterus, postpartum infection, which happens a lot with c-sections, and then hypertension disorders or blood pressure related disorders, the main one of that is preeclampsia. I could spend a whole day talking about preeclampsia. The other factor that causes maternal death is thromboembolic disease, or deep vein thrombosis, blot clots that form in the leg that then break off and travel to the lungs and cause pulmonary embolism, which is a blood clot of the pulmonary artery in the lungs that can cause death. So those are the four leading causes of maternal death: hemorrhage, infection, hypertensive disorders, and blood clots.
Sean: John, are there special considerations that parents expecting a second child should be aware of?
John: Yes, there are some medical conditions that if they occurred in the first pregnancy they are more likely to occur in the second pregnancy. First one being prematurity. If you had a prematurely delivered baby you are at an increased risk for delivering subsequent babies prematurely. If you had pregnancy related hypertension with preeclampsia in your first pregnancy you are more likely to have preeclampsia in the subsequent pregnancy. If you have a c-section for your first delivery you will have an option for VBAC, vaginal birth after caesarian section. That will be offered by most physicians unless there is contrary indication to a VBAC, but it is general accepted that it is safe to have a vaginal birth after a c-section. But there are increased risks. Your obstetrician will have you sign off on a form and have you initial items of risk that you are willing to encounter for both yourself and your fetus if you undergo a VBAC. Now, that form discourages most women from wanting to have a vaginal birth after a c-section and they just go with a repeat c-section. There are risks of VBAC and one of those is uterine rupture. The uterus can rupture at the site of the uterine incision from the c-section. When that happens, it is an obstetrical emergency. The doctor has about 15 minutes, give or take, to get that baby out because essentially when the uterus ruptures the baby is free floating in the mother’s abdomen. Fetal circulation ceases because of the disconnection between the uterus and the placenta and that baby is on its way to heaven unless it is out in about 15 minutes or so.
Sean: John, now is the time on civilly speaking when we ask you 5 questions. Are you ready? Are you prepared?
John: I hope so.
Sean: Alright, first question, when they make the movie of your life, who would you like to play yourself?
John: Wow, that’s tough. I would probably prefer to play myself.
Sean: Tell us what your first car was.
John: 1978 Chevy Blazer.
Sean: Other than being an attorney, what is the most interesting job you’ve ever had?
John: Being a father.
Sean: Question 4, what is your musical guilty pleasure?
John: Playing air drums, or air piano, or air guitar.
Sean: any particular genre?
John: I see myself playing a lot to Neil Diamond, a lot of Mo-Town, Springsteen.
Sean: Question number 5, True or False…Neil Diamond will play the role of John Lancione in your biography?
Sean: John Lancione, thanks for being here.
John: Thank you.