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Wednesday
Oct142009

Iatrogenic Fetal Injury: How often are babies cut during a c-section?

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A new mother recently posted on BabyCenter about the scalpel laceration that her daughter sustained during an emergency cesarean on July 4, 2009. She reported feeling helpless and watched her newborn girl grab at her face in pain, scratching the cut.

From the woman’s point of view, the doctor arrived at 7:00 p.m. on the Fourth of July with blood-shot eyes and performed the surgery so quickly in an effort to return to his holiday celebration that he erred twice—first with the original laceration and then by using some kind of non-dissolving suture that became infected after two weeks.

According to the woman, the doctor never said he was sorry and offered her what she felt were excuses. Disclosure of errors to patients and apologies remain hot topics among physicians who admittedly invest a lot of energy learning ways to avoid litigation. One theory on apologizing to patients is that patients will seek out a lawyer to fill in the gaps and answer their unanswered questions.

The woman is talking to a malpractice attorney and feels that the doctor should be held accountable for “get[ting] her face fixed” when she is older.

 

How often are babies cut during cesarean surgery?

James Alexander and colleagues at the University of Texas Southwestern Medical Center looked at 37,110 cesarean deliveries over a two year period (1999 and 2000) in 13 medical centers with a goal of describing both the incidence and type of iatrogenic fetal injury from cesarean delivery. More than one percent of all infants had an identified fetal injury. Skin laceration was the most common at 0.7 percent (272 cases) and other injuries included cephalohematoma (88 cases), clavicular fracture (11 cases), brachial plexus (9 cases), skull fracture (6 cases), and facial nerve palsy (11 cases).

The study also found that fetal injury did not vary in frequency with the type of skin incision, preterm delivery, maternal body mass index, or infant birth weight greater than 4,000 g, but did vary greatly based on the reason for the cesarean surgery as well as with type of uterine incision and length of time from decision to incision.

Nursing Birth posted the verbiage of an actual elective primary cesarean consent form which includes “Injury to the baby” as one of the possible risks and complications of the surgery.

According to the anonymous NICU nurse of Reality Rounds, lacerations from cesarean sections at the hospital at which she works are rare and very seldom serious. She stated via e-mail that she has seen far more neonatal lacerations from forceps and scalp electrodes than from a cesarean and someone from pediatric plastic surgery is always called in for any facial laceration. The worst case she can recall was a baby girl who received a shallow laceration underneath her eye, but the majority of wounds do not require stitches—only Bacitracin and steri-strips.

Forthrightness with the women whose babies were injured is a priority at her hospital. Said the nurse, “We have always been completely honest with the patients, and honestly, none of them were very angry or upset.”

While very uncommon, some doctors believe that the incidence of iatrogenic (doctor-caused) fetal injury is frequent enough to inform women considering a cesarean of the risk. An article entitled, Iatrogenic Fetal Injury that appeared in the Green Journal in November 2005, cites and photographically documents a case of a baby whose finger was amputated during an elective cesarean section. According to the authors of the article, “Clearly, when considering the stressful circumstances of an emergency cesarean delivery, it is not surprising that the probability of complications is greater than in elective cases. The incidence of iatrogenic fetal injury is high enough to warrant inclusion as a specific complication when obtaining consent.”

 

Image source: BabyCenter screenshot


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Reader Comments (19)

Weird, because I was just in a surgery YESTERDAY where the doctor cut the baby. The mother came in around 9pm, 3cm dilated with membranes intact and an engaged presenting part at 36+ weeks (G2P1, one prior vaginal delivery) but was comfortable, not laboring. In fact she was 3cm dilated at her 9am scheduled office appointment and we were expecting her all day to come in and be evaluated. They just happened to find that she was 3cm dilated at the appointment...she wasn't even contracting more than some braxton hicks now and then. (She apparently decided to go home and take her time getting ready, packing and arranging child care for her kids. Totally reasonable since she was NOT in LABOR). However the kicker.... she was breech. So the doctor came in at 9:30pm and decided she had to have a cesarean RIGHT NOW! The anethesiologist and charge nurse ended up arguing with him, since techically there is supposed to be an emergent or urgent reason for performing a cesarean section during evenings or night shift (since we have an OR team on days) and that the there was an opening in the OR schedule for the morning at 0730 and OBVIOUSLY she wasn't in labor since 12 hours later she was STILL 3cm. Plus we were hoppin that night and performing a cesarean would put a real strain on the staff (as it is I had to stay late to finish up scrubbing the case because there was no one available to relieve me.) Well this doctor was friggin pissed. He went into her room, checked her again and said "She's four centimeters and high, REALLY HIGH! SHe could rupture and prolapse a cord at any minute! This is an emergency!" We were all like "WTF?!? 30 minutes ago she was 3cm and engaged and now the baby has gone backwards in station and is floating? Give me a BREAK!"

Anyways, he called the case and emergency and we had to comply. I scrubbed the case. And I want to remind you, this was NOT an emergency, (unless of course you call the doctor wanting to get home and go to bed an emergency). I have scrubbed many many cases and I have to tell you, unless it is a TRUE emergency (like a prolapsed cord for example) or the doctor is an ass, almost all the docs I work with take extreme care when they cut through the uterus, putting very very little pressure on the scapel and taking very light swipes only about an inch wide until they are almost through. Then they usually poke their finger though the last paper thin layer of the uterus and then use bandage (blunt) scissors to cut the uterus open as NOT to cut the baby. But not this doc...not this night. He plowed through that uterus with only two swipes of the blade, a really wide cut too. I was really taken a back at how fast he went. So when I passed the baby to the baby nurse I muttered "Check that baby's butt".

I know that doctor was rushing, I know it because I have worked with him when he wasn't in a rush and he was acting different. And there was no reason for it. Also, this doctor is actually one of the only docs that will attend VBACs at my hospital so he usually does a double layer closure of the uterus. Well when I handed him the second stich for the uterus he asked for the facial stich instead. I said "Aren't you going to do a double layer closure?" And he looked right at me and said,

"Not tonight."

Later on in the recovery room the baby nurse told me that the doctor had indeed cut the baby. About a two inch cut on his little butt cheek. Superficial but still. And the worst part is that this doctor blew out of the OR as soon as it was time to close, leaving the chief resident to staple her up, which meant that he didn't tell the mother he had cut her baby, the nurse had to. And I have to say that it is not the nurse's responsibility to do so, it is the SURGEON'S! But the nurse didn't want the woman to have to wait till the morning to hear it from the doctor, especially since if the nurse didn't tell her the mother would have seen it and started to ask questions!


Sorry, I just had to get that story off my chest. I mean, I am not telling this story to scare anyone but it happens. It's not so rare that no one knows what to do when it happens. We have a special incident report the doctor has to fill out etc etc. Ive been part of at least 5 surgeries where the doctor cut the baby, and I've only been an L&D nurse for 2.5 years. It certainly happens enough to warrant telling patients that it is a risk to surgery. I am just glad that this baby was indeed breech. Because I have seen cuts on the face and I always think how close the cut is to the eye :(

This story bothers me for a variety of reasons. #1 I believe that that cut was completely and utterly preventable. #2 If that doctor attended vaginal breech births OR if she wasn't breech, she would have been sent home because she wasnt in labor. And she could have potentially gone a few more days, if not weeks, without delivering. She had a previous vaginal delivery after all, it isnt uncommon for multips to have a dilated cervix before labor. It bothers me that this baby was born (delivered) prematurely just because she was breech.

~Melissa aka "NursingBirth"
www.nursingbirth.com

October 14, 2009 | Unregistered CommenterNursingBirth

This story brought tears to my eyes. What is truly a crime!

October 14, 2009 | Unregistered CommenterLena Hong

"There was no obvious deficit in the range of motion of the joints of the digit. The child appeared to thrive well and left the NICU having nearly doubled his birth weight."
DISGUSTING to hear. It totally sounds like they're saying, "See? No biggie." If the baby could talk, however, and was expressing his version of the event, they'd have a hard time downplaying it like that. Makes me so mad, the way that babies are such a casualty of birth sometimes. I just want to run into hospitals and start shaking people..."YOU DON'T HAVE TO DO THIS!" like a lunatic.

October 14, 2009 | Unregistered CommenterPoppy Street

James Alexander and colleagues at the University of Texas Southwestern Medical Center looked at 37,110 cesarean deliveries over a two year period (1999 and 2000) in 13 medical centers with a goal of describing both the incidence and type of iatrogenic fetal injury from cesarean delivery. More than one percent of all infants had an identified fetal injury. Skin laceration was the most common at 0.7 percent (272 cases) and other injuries included cephalohematoma (88 cases), clavicular fracture (11 cases), brachial plexus (9 cases), skull fracture (6 cases), and facial nerve palsy (11 cases).

This part actually struck me as incredibly ironic. I was told my "elective primary c/s due to suspected fetal macrosomia" was going to preven injuries like "clavicular fracture" and "brachial plexus" injury. Hmmm...have the surgery to avoid it and then have your baby end up with it anyway. Oy!

October 14, 2009 | Unregistered CommenterPampered Mom

Oh Melissa, that makes me sick to think about.

October 14, 2009 | Unregistered CommenterEG

My friend who had a C-section due to transverse lie when her water broke (not treated as an emergency! -- the C-section was about 3 hours after ROM, starting about 8 a.m.), also had this -- her daughter got a cut on her thigh or butt. I *think* I've read somewhere that breech or transverse babies are more likely to be cut than cephalic-presenting babies, but I can't remember for sure. This cut wasn't *too* bad -- needed some surgical superglue, but nothing further.

October 14, 2009 | Unregistered CommenterKathy

Ow. Reading this story and the one in Nursing Birth's comment make me cringe and make my stomach clench up. (Not that those negative sensations are anything in comparison to what the infants and their mothers have endured by scalpel).

I hope I never am responsible for this. I will definitely not blaze out of the operating room if I am.

October 14, 2009 | Unregistered CommenterMomTFH

Whew, Nursing Birth. That is... awful.

MomTFH, if you ever do err in this way, think of Karen Strange's Rupture and Repair concept. :) You're going to be such a good midwife with a knife.

October 14, 2009 | Registered CommenterJill

Rushing through a surgery, like Melissa described, would certainly make the chances of fetal injury greater. I used to work with a doctor the nurses nicknamed "Ginsu", take a guess as to why. I bet there are quite a lot of "Ginsu" OB's out there. Very creepy, just in time for Halloween......

October 14, 2009 | Unregistered CommenterReality Rounds

I hope I am a good midwife with a scalpel! No benihana's style cesareans for me, RR. I'll leave the Ginsu knives at home.

October 15, 2009 | Unregistered CommenterMomTFH
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