Forceps and Vacuum Births Gone Wrong

Forceps and Vacuum Births Gone Wrong Forceps and Vacuum Births Gone Wrong

Dangerous Deliveries: Forceps and Vacuum Births Gone Wrong

Rachel Melancon and her fiancée, Allen Coats, were overjoyed when they learned in the spring of 2013 that they were having a baby. “I just found out that you are swimming in my tummy. I have waited for you so long,” the 24-year-old expectant mother wrote in her diary upon learning the happy news.

But as Melancon neared her Christmas due date, she grew uneasy. Despite a normal pregnancy, the first-time mom was petite and her baby was getting big. Worried that a vaginal delivery might be difficult given her slight, 4ft 11in frame, she asked her doctor on several occasions if he’d consider performing a cesarean section. He advised against it, allegedly telling her the procedure would leave a scar.

Melancon, it turned out, had good reason to worry. After going into labor three days past her due date, she struggled for more than 18 hours to give birth. A Pitocin drip intended to strengthen her contractions and speed up her labor caused dangerous fluctuations in her baby’s heart rate—and by the time she was instructed to push, Melancon was running a 103-degree fever and exhausted.

Eventually, Dr. George Backardjiev decided to try delivering the baby with forceps, but when he clamped the metal instrument around the baby’s head, Melancon and her fiancée heard two loud “popping” noises that sounded like clay pottery cracking.

After multiple failed attempts to deliver the baby with forceps, Backardjiev finally decided to perform an emergency C-section, but it was too late for little Olivia Marie Coats, who emerged lifeless from her mother’s womb. As X-rays and an autopsy would reveal, the 7-pound 14 oz. newborn had suffered two skull fractures, a brain bleed and other injuries. She died four days later after her traumatic birth when her parents removed her from life support.

Assisted Vaginal Delivery

When used properly, assistive devices such as forceps and vacuum extractors are valuable tools that can help aid and expedite the safe delivery of babies. But in the wrong hands, or in the wrong circumstances, the instruments can cause significant injuries ranging from lacerations to bruising to skull fractures to nerve damage.

There are two primary methods of assisted vaginal delivery. In a forceps delivery, the doctor grips each side of the baby’s head with a curved metal instrument resembling a pair of oversized, hinged salad tongs and gently guides it out of the birth canal. A vacuum extraction works similarly, with the doctor attaching a soft, rounded cup to the crown of baby’s head with suction and applying traction with each contraction as the mother pushes to gently pull the baby out.

Both instruments have a long history of use.

The Chamberlen family, a family of French Hugenot refugees who ran a family midwifery practice in England for several generations, is credited with the invention of obstetrical forceps in the late 16th Century. The Chamberlens went to great lengths to keep their tools secret for more than 100 years by shrouding the instruments in a large gilded box and blindfolding the laboring mothers they used them on, but eventually their secret got out. Other forceps models emerged in the 18th and 19th century and by the 1960s, forceps were used in almost one-third of all deliveries.

The earliest recorded attempt at delivering a baby with a vacuum-type instrument was in 1706 when James Yonge, a surgeon at the Naval Hospital in Plymouth, England fashioned a crude extractor out of a cupping glass and air pump and unsuccessfully attempted to a deliver a baby after the mother had been laboring for four days. While vacuum extractors didn’t come into widespread use until the 1950s, the instruments have since surpassed forceps in popularity. Approximately 82% of the 105,000 assisted vaginal deliveries performed each year utilize vacuum devices.

The rate of assisted vaginal deliveries, also known as operative vaginal deliveries, has declined precipitously over the past several decades. In 1994, nearly 10% of live births in the U.S. were performed with the help of forceps or vacuum extractors. Only 3% of births today are assisted vaginal deliveries.

The medical indications for both instruments are the same. The American College of Obstetricians and Gynecologists (ACOG) recommends an operative vaginal delivery be considered during a prolonged or drawn-out labor, when the mother is too exhausted to push effectively, or when the mother has a heart condition or other medical condition that might make prolonged pushing dangerous.

Other situations that might warrant an assisted vaginal delivery are when the baby stops descending down the birth canal, or if the baby appears to be in distress. Forceps and vacuum extractors can also be utilized to help guide the baby’s head out after the body has already emerged in a feet-first breech position.

While C-section is also an option in many of these circumstances, a 2015 ACOG practice bulletin on the subject states that operative vaginal delivery can often be “safely accomplished more quickly than a cesarean delivery” and that forceps and vacuum deliveries remain “an important part of modern obstetric care” despite their decline in use.

Complications and Injuries

Despite the benefits, operative vaginal delivery still poses a risk of injury for both mother and baby. In fact, a 2006 report by the Agency for Healthcare Research and Quality found that “vaginal births with instruments” accounted for the highest injury rates among the 157,700 mothers and newborns suffering potentially avoidable birth injuries that year.

Forceps can cause lacerations and bruising to the infant’s face and head. Usually, such trauma is mild and will heal within a few days but occasionally results in permanent scarring or disfigurement. Although rare, a botched forceps delivery can also result in skull fractures, facial nerve injuries, brain damage, seizures, eye trauma, other catastrophic brain injuries, and even death.

Forceps can also cause injury to the mother, including tears to the vagina, perineum, and anal sphincter. Tears that are severe enough can result in short-term or long-term fecal or urinary incontinence. Other severe forceps-related complications can include: blood loss or infection; uterine rupture; injuries to the urethra or bladder; and damage to ligaments and muscles resulting in the prolapse of pelvic organs. Some women also end up with psychological repercussions, including post-traumatic stress disorder (PTSD), in the aftermath of a traumatic birth experience.

Eun Sook Maing and her newborn both suffered severe injuries during her delivery at St. Vincent’s Medical Center in Manhattan in 1998 after a medical resident allegedly “yanked” on the baby’s head with forceps for 23 minutes, according to the Maings’ lawyer.

Daniel Maing, who was born lifeless due to severe oxygen deprivation, had to be revived and suffers from cerebral palsy. Maing’s mother, meanwhile, suffered a severe tear from the botched forceps delivery extending from her vagina all the way through to her rectum. She later developed a rectovaginal fistula, which is an abnormal opening between the vagina and rectum that allows gas and fecal matter to pass through the vagina.

Following a three-week trial, a jury found St. Vincent’s and its doctors responsible for the injuries to Daniel and Eun Maing—awarding the family $19 million in damages.

Vacuum extractors can also cause injuries to mom and baby if not performed correctly.

Most babies born by vacuum extraction will often experience some minor cone-shaped swelling atop their head called a chignon. This sort of swelling is generally harmless and typically disappears within several hours to a couple of weeks. But if too much suction is applied or the vacuum extractor is placed in the wrong position, serious complications can occur. These injuries can include scalp lacerations, bleeding under the scalp, facial nerve palsies, retinal hemorrhage, intracranial hemorrhage, and brachial plexus injuries.

Approximately 16% of babies delivered with vacuum suction will develop a cephalohematoma, a pooling of blood between the scalp and the skull. While this is usually not serious and will clear up on its own within a couple of weeks, it can sometimes lead to dangerous increases in bilirubin resulting in neonatal jaundice. The longer the duration of the suction, the more likely a cephalohematoma is to occur.

A more serious complication sometimes associated with vacuum deliveries is subgaleal hemorrhage, which occurs in an expansive region between the scalp and skull and can lead to massive blood loss, shock, and death. While subgaleal hematomas are rare events, occurring in approximately three out of every 1,000 live births, studies have demonstrated up to a 25-fold increase in the potentially lethal condition when vacuum extraction is used.

In 1998, following a rash of reports of subgaleal hematomas and brain bleeds following vacuum extractions, the Food and Drug Administration issued a warning to practitioners alerting them to the life-threatening risks associated with vacuum devices. The FDA’s alert urged “CAUTION” when using vacuum assisted delivery devices and outlined the signs and symptoms of a subgaleal hemorrhage such as diffuse swelling of the head and evidence of hypovolemic shock, including low blood pressure, pale appearance, and increased heart and respiratory rate. Such signs may occur immediately after birth, or several hours later.

But nearly two decades later, reports of subgaleal hemorrhages and other catastrophic brain injuries linked to vacuum extractors continue to occur.

In 2012, Stefanie Davis and her husband, Jon, sued the U.S. government after a doctor at Weed Army Community Hospital in California allegedly applied a vacuum extractor incorrectly to the parietal region of their son’s head during a C-section delivery.

While the doctor described the delivery as having “no complications,” according to court documents, nurses who cared for the infant in the nursery documented abrasions, blistering, swelling, and bruising at the vacuum site and later became alarmed as the swelling and bruising spread.

Within two hours, the baby was struggling to breathe and his heart was racing. The loss of blood into the subgaleal space in his head was causing him to go into shock and develop seizures. The baby was transferred to the NICU at Loma Linda Medical Center, where he was later found to have suffered a “devastating” stroke.

The Davis’s $50 million lawsuit was eventually settled for $2.5 million, but their son will never lead a normal life. Because of the brain injury he suffered, he has difficulty speaking, walking and still struggles with seizures. “Although he will benefit from ongoing therapy and neurologic and orthopedic management of his condition, he will continue to suffer from a significant neurologic handicap for the rest of this life,” according to court documents.

Contraindications and Prerequisites

While complications associated with operative vaginal delivery can’t always be anticipated, there are a number of situations where operative vaginal delivery is contraindicated and should not be attempted.

Vacuum and forceps delivery should not be performed if the baby’s head is not engaged, or descended into the pelvic cavity, or if the position of the baby’s head is not known. Operative vaginal delivery should also not be attempted until the cervix is completely dilated and fetal membranes are ruptured. Instruments should also be avoided if the baby suffers from a bleeding disorder like hemophilia or demineralization conditions such as osteogenesis imperfecta because such conditions predispose the infants to intraventricular hemorrhage (brain bleeding) and skull fracture.

Vacuum extraction is also discouraged in women pregnant fewer than 34 weeks as it increases the risk of a brain bleed in the baby. Babies that have had blood samples taken from their scalp or undergone repeated attempts to place a fetal electrode in their scalp are also poor candidates for vacuum extraction, because they face an increased risk of a cephalohematoma and bleeding from the scalp in general. Vacuum extraction is also contraindicated if the baby is in an abnormal position, such as breech or sideways, or if the mother is believed to have cephalopelvic disproportion, meaning the baby’s head is too large to pass through the birth canal.

Sequential use of forceps and vacuums is also discouraged and “should not be performed,” according to the ACOG, because studies have shown an increased rate of complications to both mother and child when more than one instrument is used. Among the complications more likely to occur in infants were: intracranial hemorrhage, brachial plexus injury, facial nerve injury, seizure and breathing difficulties. Mothers, meanwhile, were more likely to suffer from severe vaginal tears, hematomas, and post-partum hemorrhage.

With either procedure, the doctor must be prepared to abandon the attempt to deliver vaginally if the baby fails to descend or if complications occur and convert to an emergency C-section. Neither instrument should be used until the physician has obtained informed consent from the mother—meaning that the physician has explained the benefits and risks of the procedure and various alternatives. The mother must have also have been adequately anesthetized and have emptied her bladder prior to the placement of instruments.

Proper placement of the chosen instrument is absolutely essential.

In vacuum extraction, for instance, the cup should be placed over the baby’s sagittal suture, which is the main seam that runs down the center and top of the skull, and approximately 2 cm in front of the posterior fontanel, or soft spot located at the back of the head. The doctor should also avoid rocking movements or actively rotating the baby’s head with the suction cup.  Traction should only be applied during a contraction when the mother is pushing and only in a direction that is consistent with the mother’s pelvic curvature.

With forceps, the blades should be placed symmetrically and evenly against the sides of the head in alignment with the sagittal suture and with the posterior fontanels one fingerbreadth above the shanks, according to ACOG guidelines. Asymmetric application of forceps can cause uneven compression of the head and intracranial bleeding.

A 2015 study published in BJOG (the British Journal of Obstetrics and Gynecology) found that “suboptimal” placement of instruments occurs in approximately 30% of attempted operative vaginal deliveries performed at two Irish teaching hospitals and that the misplaced instruments are associated with a higher incidence of complications.

Ultimately, the success and safety of an instrumental delivery is dependent on the training and skill of the physician—and current trends suggest that newer generations of doctors aren’t getting the training they need to be competent in using forceps.

Only half of the 4th year obstetrics and gynecology residents surveyed in one recent study reported feeling competent about performing forceps delivery in their practice and one-third reported performing fewer than 10 during their training. Another study found that most training programs in North America “no longer expect proficiency in mid-cavity forceps delivery.”

Whether the “dying art” of forceps deliveries should be rejuvenated, however, remains a topic of hot debate in the medical community—with some critics arguing that forceps deliveries should be avoided or abandoned all together in light of the tragedies that seem to keep making headlines.

Among the more high-profile cases was Emma Portogallo’s botched delivery at a hospital in England in 2009. According to press accounts, doctors attempted to expedite her long labor by using a vacuum extractor, but failed in eight attempts to deliver the baby. Portogallo was then rolled into an operating room and given an epidural but still felt “severe tugging” as doctors extracted her baby with forceps.

The tugging was so intense, according to media reports, that Portgallo was “repeatedly dragged down the operating table” and suffered bruising to her upper arms. When her son, Xavier, was finally born, his left eyeball was hanging out of its socket and his skull had been fractured.

Portogallo, meanwhile, told a British newspaper that she hadn’t even consented to the procedure that left her baby blind in one eye and brain-damaged. “The doctor who delivered the baby came to see me after the birth and handed me a form. ‘Sign this, please,’ she said without explaining what it was for.’”

Recovering Damages

For those who’ve been harmed by a botched vacuum or forceps delivery, the financial toll can be staggering, with lifetime care and treatment associated with these traumatic birth injuries often costing millions of dollars.

Fortunately, skilled and experienced medical malpractice attorneys can often help families recover the costs associated with injuries caused by medical negligence.

In the spring of 2017, a federal judge in Pennsylvania awarded Christina Late, Nathan Armolt, and their five-year-old son $41.6 million in damages after determining the doctor who delivered him deviated from the standard of care and acted negligently by performing a mid-forceps delivery on Late when there was no indication for one.

As a result, the baby was born with “multiple skull fractures, pervasive bleeding in the brain and severe destruction to the cerebellum and brain stem” that caused the infant to suffer breathing problems, seizures, headaches, insomnia and required multiple brain surgeries, according to the judge’s decision in the case.

The child will never recover from his injuries, however. Despite therapy, “D.A.” suffers from a lack of coordination, right-sided weakness, and an uneven gait that leaves him dependent on a wheelchair. He also suffers from a severe intellectual disability, which will require life-long supervision and eventually, placement in a residential facility.

In 2016, a jury awarded Rachel Melancon $10.2 million in the wrongful death suit she filed against the Medical Center for Southeast Texas and Dr. Backardjiev after the physician allegedly crushed her baby’s skull with forceps. Backardjiev was ordered to pay $9.7 million of the judgment.

While the money won’t bring back Olivia, or Melancon’s fiancée, Allen Coats, who committed suicide in 2015, Melancon told the jury she hoped her case might prevent other babies from suffering the same fate as her daughter. “I’m here for justice, closure and so that this doesn’t happen to anybody else,” the grieving mother testified.

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