Contraindicated Vaginal Delivery and California Birth Injury Claims
Vaginal delivery is appropriate for many pregnancies, but there are circumstances in which continuing with a vaginal birth may place a mother or baby at significant risk. Depending on the circumstances, a cesarean delivery may be medically indicated because of the baby’s position, a placental problem, fetal distress, a prior uterine surgery, an obstruction to delivery, or another maternal or fetal condition.
When a medical team fails to recognize a condition that makes vaginal delivery unsafe, fails to respond when circumstances change during labor, or delays a medically necessary cesarean delivery, a baby can suffer serious injuries. These injuries may include oxygen deprivation, brain damage, fractures, nerve injuries, or other forms of birth trauma.
The California medical malpractice attorneys at Kalfayan Merjanian, LLP represent families whose children have suffered birth injuries when a healthcare provider’s decisions during pregnancy, labor, or delivery caused or contributed to a child’s injuries. Determining whether a vaginal delivery was contraindicated requires a careful examination of the mother’s medical history, the baby’s condition, fetal monitoring, the progress of labor, the timing of medical decisions, and the applicable standard of care.
When Is Vaginal Delivery Considered Unsafe?
There is no single list of circumstances in which vaginal delivery is always prohibited. The appropriate mode of delivery depends on the individual pregnancy, the mother’s condition, the baby’s condition, gestational age, fetal presentation, medical history, and other factors.
The American College of Obstetricians and Gynecologists (ACOG) identifies several circumstances in which cesarean delivery may be appropriate, including problems with the placenta, breech presentation, certain fetal concerns, failure of labor to progress, and maternal medical conditions that make vaginal birth risky.
That distinction matters in a birth injury case. The mere fact that a baby was delivered vaginally does not establish that the delivery was inappropriate. Likewise, the fact that a cesarean delivery was ultimately performed does not necessarily mean that the earlier decision to continue labor was negligent.
The question is whether, under the circumstances known or reasonably knowable at the time, the healthcare provider complied with the applicable standard of care.
Can a Baby’s Position Make Vaginal Delivery Unsafe?
Fetal presentation can have a significant effect on the safety of vaginal delivery. Most babies are positioned head-down by the time of delivery. A breech baby, however, is positioned with the buttocks or feet toward the birth canal. Breech presentation can create particular risks during vaginal delivery because the baby’s body may not adequately open the cervix for the head, potentially causing the head or shoulders to become lodged. Umbilical cord prolapse is another potential complication.
ACOG notes that planned vaginal delivery of a term singleton breech fetus may be reasonable under specific hospital protocols and appropriate selection criteria. In other words, breech presentation does not automatically make vaginal delivery negligent in every circumstance. The experience of the healthcare provider, the hospital’s capabilities, the baby’s characteristics, and other factors can affect the decision.
A birth injury case involving a breech delivery therefore requires an individualized analysis. If providers failed to recognize the presentation, failed to appropriately assess the risks, or proceeded with a vaginal delivery despite circumstances that made it unsafe, those decisions may warrant further investigation.
What About Transverse or Other Abnormal Presentations?
A transverse lie occurs when the baby is positioned sideways rather than with the head or buttocks directed toward the birth canal. Other malpresentations can also create problems with vaginal delivery.
The significance of an abnormal presentation depends on factors such as gestational age, whether labor has begun, whether the position can be safely changed, and the availability of appropriate obstetric intervention.
ACOG’s guidance recognizes fetal malpresentation as a factor that can affect decisions concerning cesarean delivery, particularly in pregnancies where vaginal delivery presents elevated risks.
If an abnormal presentation is not identified or appropriately managed, the baby may be exposed to prolonged or difficult labor. Depending on the circumstances, complications can include cord compression, oxygen deprivation, or traumatic injury.
Medical records can help determine when the baby’s position was documented, whether the position changed during labor, and what actions were taken in response.
Can Placental Problems Make Vaginal Delivery Dangerous?
Certain placental conditions can make vaginal delivery unsafe. Placenta previa, for example, occurs when the placenta covers or lies very close to the cervix. Depending on the specific circumstances, attempting vaginal delivery can cause significant bleeding. Placenta accreta spectrum disorders can also create serious risks during delivery.
ACOG identifies placenta previa and placenta accreta among medical indications that may require delivery planning that differs from an uncomplicated vaginal birth.
If prenatal imaging or other medical information identifies a placental abnormality, the delivery plan may need to account for that condition. A failure to recognize or appropriately respond to such a condition can create risks for both the mother and baby.
In a birth injury investigation, prenatal ultrasound reports, maternal medical records, delivery notes, and communications among members of the medical team may help establish what was known before delivery.
When Does Fetal Distress Require an Emergency Delivery?
A baby’s condition can change rapidly during labor. Fetal heart rate monitoring is one of the tools healthcare providers use to identify potential problems involving oxygenation and fetal well-being.
Abnormal fetal heart rate patterns do not automatically mean that cesarean delivery is required. Providers may attempt appropriate interventions to address the underlying problem, depending on the circumstances. But when those measures do not resolve the problem or the baby shows signs of serious compromise, an expedited delivery may become necessary.
ACOG identifies concern for the baby, including umbilical cord compression and abnormal fetal monitoring, among circumstances in which cesarean delivery may be needed.
The timing of an emergency delivery can become particularly important in a birth injury case involving hypoxic-ischemic encephalopathy, cerebral palsy, or another injury associated with oxygen deprivation.
A legal investigation may examine the fetal heart rate tracing, nursing documentation, physician notes, medication administration, interventions attempted during labor, and the precise timing of the decision to perform an operative delivery.
Can Umbilical Cord Problems Make Vaginal Delivery Dangerous?
Umbilical cord prolapse is one situation that can create an immediate threat to a baby’s oxygen supply. This occurs when the cord slips through the cervix and into the vagina ahead of the baby. As the baby descends, the cord can become compressed.
ACOG notes that cord prolapse can reduce the flow of blood and oxygen to the baby. It can occur in connection with breech presentation and other circumstances that prevent the baby’s presenting part from adequately filling the pelvis.
When cord prolapse occurs, the response must be rapid because prolonged compression can lead to fetal oxygen deprivation.
A birth injury claim may therefore require a detailed examination of when the prolapse occurred, when it was recognized, what emergency measures were taken, and how quickly the baby was delivered.
Can a Previous Cesarean Make Vaginal Delivery Contraindicated?
A previous cesarean delivery does not automatically mean that a woman cannot safely deliver vaginally. A trial of labor after cesarean, or TOLAC, may be appropriate for some patients.
However, the type of uterine incision from the previous cesarean is important. ACOG explains that a high vertical, or classical, uterine incision carries the highest risk of uterine rupture during a subsequent labor, and attempting a VBAC is generally not recommended in that circumstance.
This makes the mother’s prior surgical records potentially important. The incision on the skin does not necessarily reveal the type of incision made in the uterus. The medical records from the prior cesarean may therefore need to be obtained and reviewed.
Uterine rupture can be catastrophic for both mother and baby. If a healthcare provider fails to recognize that a patient is at elevated risk or fails to respond appropriately to signs of rupture during labor, the consequences can be severe.
What If Labor Stops Progressing?
A vaginal delivery can also become unsafe when labor fails to progress.
Labor arrest may occur when the cervix stops dilating or when the baby fails to descend despite appropriate contractions and other efforts. The significance of an apparent labor arrest depends on the stage of labor and the clinical circumstances.
ACOG’s current guidance states that once active-phase arrest of labor has been diagnosed, cesarean delivery is indicated. For second-stage arrest, ACOG recommends assessment for operative vaginal delivery before cesarean delivery when appropriate, taking into account the clinician’s skills, the hospital setting, available resources, patient preferences, and whether the patient is an appropriate candidate for operative vaginal delivery.
Failure to appropriately recognize prolonged or arrested labor can contribute to serious complications. The baby may experience increasing stress, and attempts to complete a difficult vaginal delivery may create opportunities for traumatic injury.
Can Continuing a Vaginal Delivery Cause Birth Trauma?
When vaginal delivery is contraindicated or becomes unsafe, continuing to attempt a vaginal birth may expose a baby to additional risks.
Depending on the circumstances, a difficult delivery can contribute to oxygen deprivation, fractures, nerve injuries, intracranial bleeding, or other forms of trauma. The specific injury depends on what occurred during labor and delivery.
For example, excessive traction during a difficult shoulder delivery may contribute to a brachial plexus injury. Prolonged fetal compromise may cause hypoxic-ischemic injury. Difficult instrumental delivery may produce injuries associated with forceps or vacuum extraction.
Not every birth injury means that the delivery was negligent. Some complications can occur even when medical providers follow the appropriate standard of care. The legal issue is whether the injury was caused by a failure to provide the level of care reasonably expected under the circumstances.
What Evidence Can Show That Vaginal Delivery Was Contraindicated?
A potential birth injury case requires evidence concerning what the medical team knew, when they knew it, and how they responded.
The mother’s prenatal records may establish whether providers identified risk factors before labor. Ultrasound records can document fetal position and placental location. Prior surgical records can identify the type of uterine incision from a previous cesarean. Laboratory results and other medical records may reveal maternal conditions affecting delivery.
Once labor begins, fetal monitoring records can become particularly important. They may help establish how the baby’s condition changed over time and whether providers recognized signs of fetal compromise.
Other evidence can include nursing notes, physician progress notes, medication records, operative reports, delivery records, neonatal records, and documentation of communications among members of the medical team.
The timing of events may be especially important. A medical record might show when an abnormal fetal heart rate pattern appeared, when a physician was notified, when an emergency cesarean was ordered, when the patient entered the operating room, and when the baby was delivered.
These details can help medical experts evaluate whether the response was timely and appropriate.
Why Are Medical Experts Important in These Cases?
Birth injury cases involving an allegedly contraindicated vaginal delivery usually require specialized medical analysis.
California’s standard medical negligence instructions recognize that expert testimony is generally required to establish the applicable standard of care, whether the healthcare provider breached that standard, and whether the breach caused the injury. California courts similarly explain that a plaintiff in a medical malpractice case will almost always need an expert to establish the applicable standard of care and how the provider’s conduct failed to meet it.
An obstetric expert may review the prenatal and labor records and determine whether the delivery plan was appropriate based on the circumstances. Depending on the injury, additional specialists may evaluate neonatal records, neurological injuries, orthopedic injuries, developmental consequences, or other medical issues.
The expert analysis may address questions such as whether a cesarean should have been performed earlier, whether an emergency condition was recognized in time, whether an attempted vaginal delivery was appropriate, and whether a different course of treatment would more likely than not have avoided or reduced the child’s injury.
Additionally, California law requires proof of causation in a medical negligence case. The state’s standard jury instructions explain that the plaintiff must establish that the negligent conduct was a cause-in-fact of the injury and that medical causation generally must be established through competent expert testimony based on reasonable medical probability.
What Should Parents Do If They Suspect an Unsafe Vaginal Delivery?
Parents who believe their child suffered a birth injury should preserve the child’s medical records and obtain copies of the records relating to the pregnancy, labor, delivery, and neonatal treatment.
It can also be useful to document the child’s subsequent medical care, diagnoses, therapy, developmental evaluations, and recommendations for future treatment. The child’s condition may continue to develop after discharge from the hospital, making follow-up medical evidence important to understanding the extent of the injury.
A lawyer investigating a potential birth injury claim may also need to obtain fetal monitoring records and other information that is not necessarily included in a brief hospital discharge summary.
The goal is to reconstruct the delivery based on contemporaneous evidence rather than relying solely on a parent’s recollection of events during a stressful and complicated birth.
Evaluating a Potential Birth Injury Malpractice Claim in California
A vaginal delivery is not inherently unsafe, and a poor outcome does not by itself establish medical negligence. Some complications are unavoidable even when healthcare providers provide appropriate care. But when a medical condition makes vaginal delivery unsafe, the failure to recognize that condition or to transition to an appropriate method of delivery can have serious consequences.
Whether a vaginal delivery was contraindicated depends on the circumstances. Fetal presentation, placental abnormalities, fetal distress, umbilical cord complications, prior uterine surgery, arrest of labor, maternal health conditions, and other factors may affect the appropriate delivery plan. The evidence must then be evaluated to determine whether the healthcare providers met the applicable standard of care and whether any failure caused the child’s injury.
Kalfayan Merjanian, LLP represents families whose children have suffered birth injuries and can investigate the medical records, fetal monitoring, delivery decisions, and expert evidence involved in a difficult birth. If you believe your child’s injury may have resulted from an attempt to deliver vaginally when a cesarean or other intervention was medically necessary, contact Kalfayan Merjanian, LLP to discuss the circumstances of the delivery and your family’s legal options.
