Monday, August 31, 2009

Variations in Fetal Orientation During Pregnancy

Obstetrics litigation often boils down to a question of what events occurred within the uterus during development or during the birthing process. Often, if we are to understand what happened to the fetus at a crucial moment in the pregnancy, we need to have a clear understanding of how that fetus is positioned within the uterus or the birth canal. For this reason, issues of fetal lie, presentation, position or station are eventually discussed in almost all obstetrics cases. Therefore, I will try to provide you with a basic understanding of these concepts so that you can better visualize the wide variety of ways that the baby can be positioned within the mother.

First of all we have to establish our terms. For the purposes of this conversation, I’d like for you to visualize the mother in a standing position so that “down” is toward her feet and “up” is toward her head. “Posterior” is toward her back and “anterior” is toward her front. Right will always mean her right regardless of how the baby is positioned or how you are standing. Just remember that when I use directional terms, it’s all about the mother.

Keep in mind that it is of paramount importance to know the orientation of the fetus within the uterus, particularly at the onset of labor. Orientations that are not ideal may require intervention and, in some situations, cesarean delivery may be the only viable option. During labor, an appreciation of the fetal station within the birth canal can help us to judge how the labor is progressing and which delivery techniques may be warranted at a given time.

Traditionally, the orientation of the fetus is described with respect to its lie, presentation and position. I will provide an overview of these terms. The lie of the fetus can be either longitudinal or transverse. In other words, the long axis of the fetus can either be parallel or perpendicular to the long axis of the mother. Luckily, the fetal lie is longitudinal in about 99% of cases. This is a good thing since a transverse lie cannot allow for the proper vaginal delivery of the fetus.

Once we know the lie, we can determine the presentation. The presentation can be either cephalic or breech, which means that the fetus can be either “head-down” or not. There are a number of different types of cephalic presentation, but the most common is called vertex presentation which refers to the fetus entering the birth canal head first with the upper occipital (back) portion of the head leading the way.

Next, the position of the fetus can be established. Position refers to the relation of the occiput (back of the skull) of the fetus to the left, right, front and back of the mother. In other words, if we know that the back of the fetal head is facing the front of the mother, this is called the occiput anterior (OA) position and if the occiput is facing the right side of the mother, this is called the right occiput transverse (ROT) position. Any combination of these, where the occiput of the fetus is toward the right and toward the front in a diagonal fashion, is called the right occiput anterior (ROA) position. This convention allows us to note any one of the following eight positions: occiput anterior (OA), right occiput anterior (ROA), right occiput transverse (ROT), occiput posterior (OP), left occiput posterior (LOP), left occiput transverse (LOT), and left occiput anterior (LOA).

Finally, we can discuss fetal station. The fetal station is a measurement of how far the fetus has progressed down through the birth canal during delivery. This measurement reflects the relationship of the leading edge of the fetus, generally the top of the head, to the ischial spines of the mother’s pelvis that are halfway between the pelvic inlet and pelvic outlet. When the leading edge of the fetus reaches the ischial spines, this is called zero (0) station. In the currently used “fifths” system the space is divided above and below 0 station in one centimeter increments, so that the space above the ischial spines is designated from -5 station to 0 station and the space below the ischial spines is designated from 0 station down to +5 station. With each centimeter that the leading edge of the fetus progresses, you reach a new station of presentation (-5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5).

You should be aware that a previously widespread system, the “thirds” system, divided the space above and below the ischial spines into arbitrary thirds so that the stations progressed from -3 to +3 without regard to actual centimeter measurements. This is important because only 0 station coincides in these two systems and you can get an inaccurate picture of the case facts if the correct system is not used. To complicate matters, many doctors and hospitals still refer to the old system so it is best to establish early which system is being used in the records of any particular case.

These are the key terms that you will encounter when researching almost any case involving birth injuries or obstetrics mal practice. Hopefully this overview has given you a better understanding of the varieties of fetal orientation and will help you to better visualize the lie, presentation and position of the fetus within the womb.

Tuesday, August 11, 2009

Nursing Home Negligence Cases

One of the most common nursing negligence issues we are called upon to illustrate is the development or progression of pressure sores (sometimes know as bed sores or decubitus ulcers). Pressure sores are areas of injured skin and tissue usually caused by sitting or lying in one position for too long. This often happens if you use a wheelchair or you are bedridden, even for a short period of time (for example, after surgery or an injury). When a change in position doesn't occur often enough and the blood supply gets too low, a sore may form. The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies.

A pressure sore starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure sores are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head. Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

In most cases pressure sores are preventable and, if not prevented, should be recognized early and appropriately treated. In almost all situations, the development of massive pressure sores is evidence of some form of deviation in the standard of nursing care (neglect). Generally the neglect is in more than one area, i.e., hygiene, nutrition, infection control, protection and positioning.

The common areas for the formation of pressure sores and their prevention is a basic area covered in all nursing schools by all licensed nursing programs (LVN or RN). Prevention consists of changing the person's position every two hours or more often if needed. The two-hour time frame is a generally accepted maximum interval that tissue can tolerate pressure without damage. Prevention also consists of protection and padding to prevent tissue abrasion as well as the elements of nutrition, hydration, hygiene, etc. Turning and positioning is common knowledge for physicians, licensed nurses (LVN or RN), and physical therapists as well as paraprofessional care gives (nursing assistants). Turning is applicable even on flotation mattress beds.

Treatment for pressure sores involves removing all pressure from the involved area(s) to prevent further decay of tissue and promote healing. Frequent turning is mandatory to alleviate pressure on the wound and to promote healing. Treatment also involves keeping the area clean, promoting tissue regeneration and removing necrotic (dead) tissue, which can form a breeding ground for infection. There are many procedures and products available for wound care, cleaning and pressure reduction. The use of antibiotics when appropriate is also part of the treatment. Some deep wounds even require surgical removal or debridement of dead tissue. Without all of these elements being in place, the wounds will not heal and, in fact, will quickly worsen.