Trauma during an instrumental delivery

One of the causes of cerebral palsy is trauma during an instrumental delivery.

How can trauma happen during delivery?

Trauma can occur during an instrumental delivery. An instrumental delivery is when an obstetrician or midwife uses instruments to help a baby to be born. This can be because;

• The baby is not moving out of the birth canal as would normally be expected
• There are concerns about the baby's wellbeing during birth
• The mother is too exhausted and therefore unable to, or has been advised not to, push during birth

There are two types of instruments that can be used in an instrumental delivery.

Forceps delivery

Forceps are smooth metal instruments that look like large tongs. They're curved to fit around the baby's head. When used correctly the forceps are carefully positioned around the baby's head and joined together at the handles. With a contraction and on a mother’s pushing, an obstetrician pulls to help deliver the baby.

Ventouse delivery

A ventouse is a soft plastic cup which is attached to the top of the baby’s head. Vacuum pressure is applied, permitting the obstetrician to rotate or otherwise adjust the baby to allow for safe delivery. During a contraction and with the help of a mother’s pushing, the obstetrician or midwife pulls on the ventouse to help deliver the baby.

If used properly these instruments help to safely deliver babies.

Once one instrument has been used unsuccessfully, with no descent of the baby, despite correct application, a second instrument should not be applied, as doing so carries the risk of inflicting trauma on the baby.

If these instruments are placed incorrectly, applied with excessive traction or pressure, or if the obstetrician pulls excessively, the baby can be severely injured.

Used incorrectly, these instruments can cause mechanical injury and trauma to the baby’s skull such as fractures, and severe damage to the brain which may result in cerebral palsy.

How is brain damage as a result of trauma during delivery diagnosed?

The diagnosis is generally a clinical one, if a baby has suffered traumatic damage to the brain when born the baby may appear pale and lifeless, breathe weakly or not at all, and may have a very slow heart rate. They may require resuscitation and/or breathing and circulation support and fluids. The baby may experience seizures.

A definitive diagnosis will usually be made following an MRI or CT scan, as scanning the brain should enable doctors to see the damage caused. If seizures are suspected then an electroencephalogram (EEG) can be used to detect the seizure activity in the brain.

Depending on the instrument used there may also be telltale signs of trauma. For example when a ventouse is used incorrectly it could lead to a fluctuant, boggy mass developing over the scalp of the baby. Forceps may leave a mark on the baby’s face where they were locked into position and in the extreme cases of trauma they may also cause skull fractures.

How is traumatic injury treated?

The treatment will depend on the clinical symptoms. The main focus of the doctors will be to ensure that the brain is sufficiently oxygenated and the blood pressure is fine to stop further damage occurring.

If it is established quite soon after birth that the baby has suffered brain damage then the doctors may “cool” the baby to 33˚C for a number of days after the birth to try to reduce the level of neurological damage.
As well as cooling, the baby may be given coma-inducing drugs if the blood vessels in the brain have been damaged by the trauma as a comatose brain needs less oxygen to function giving the brain time to heal.

Anti-seizure drugs are also given to try and minimise any additional brain damage that might be caused by seizures. Diuretics may also be given to reduce the pressure inside the brain.

Surgery may also be necessary to minimise additional damage to the brain. For example the misuse of forceps may lead to skull fractures that require surgical repair.

Leigh Day clients and traumatic instrumental deliveries

Leigh Day brain injury lawyers act on behalf of a number of clients who have suffered serious brain injury as a result of a traumatic instrumental delivery.

The cerebral palsy team represents a client who was injured following a traumatic instrumental delivery.

Our client was delivered by an emergency caesarean section after a failed instrumental delivery. When trying to delivery our client the doctors attempted a forceps delivery which was described in the notes as “not perfectly achieved” and there was a suggestion that there was an attempted delivery with a ventouse before the doctors resorted to an emergency caesarean section.

Our client was born in poor condition with no respiratory effort and no response to stimulus. She required resuscitation and was transferred for cooling. After cooling upon rewarming she was noted to be suffering seizures and anticonvulsants were commenced.

Our client was diagnosed shortly after birth with intracranial haemorrhage (bleeding in the brain) and a sub-galeal haematoma (a collection of blood between the skull and the scalp). A CT scan confirmed a fracture on the left side of her skull. A MRI revealed “findings in keeping with severe head trauma”.

Our client now suffers from serious physical and learning disabilities affecting her and her family’s everyday lives.

We obtained independent expert evidence to try to establish what had gone wrong during our client’s delivery. Our experts advised us that in their view the that the blades of the forceps were not locked correctly, and so instead of cradling the baby’s head when force was used to try to close the blades the baby’s skull was crushed This fractured her skull and caused damage to her brain.

Only after we had thoroughly investigated the case and put full details to the NHS Trust responsible for the hospital where our client was delivered did they admit liability for her injuries.

Leigh Day is now seeking compensation for our client so that her high level needs can be met.