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How can an LNC assist you in a "brain bleed" case?

LNC, Legal Nurse Consultant
Legal Nurse Consultant - Neonatal cases

June is brain injury awareness month.

One of the most common brain injuries in preterm babies is Intraventricular hemorrhage (IVH). It is seen in approximately 21% of preterm infants born at < 32+6 weeks gestational age(GA). It is basically bleeding in the brain's ventricular system and initiates in the germinal matrix which is a highly vascular region.

The first 72 hours post birth ('the critical window') is the highest risk period for acute preterm brain injury and 95% of IVH cases are detected by day 5. This means it is very important to implement neuroprotective interventions within the first few days to reduce the incidence of brain injury.

As a Legal nurse consultant, I would approach an IVH/ brain bleed case with the following questions in mind to assess deviations in the standards of care or to find missing information in the record:

1. Did the mother present with premature rupture of membranes (PPROM) intrauterine infection and was she treated with the right course of antibiotics? Infection and PPROM are risk factors for IVH.

2. Were antenatal corticosteroids (recommended for all deliveries <34+6wks) administered within 7 days of delivery, with the last dose being given more than 48 hours before birth?

3. Is there evidence in the medical record that magnesium sulfate was administered for fetal neuroprotection for babies less than 33+6wks gestation?

4. Did the mother's coagulation studies indicate she was at a risk for bleeding? Was Vitamin K administered to mom?

5. Looking at the delivery notes, was there any mention of prolonged second stage of labour, trauma during delivery, use of forceps or vacuum, breech presentation and if the baby was in fetal distress? A C-Section delivery should be considered when there are increased risk factors and malpresentation.

6. Was " the small baby protocol" implemented as per the unit policy for babies < 27 weeks GA? Small baby protocol includes a set of interventions to reduce cerebral injury in the first 72 hours. Even routine care of the preterm baby during this critical window can affect cerebral blood flow. Interventions like maintaining the baby's head in a neutral, midline position with the head of the bed elevated 30 degrees, avoiding routine suctioning and no routine abdominal girths in the first 72 hours reduces the fluctuations in intracranial pressure and acute brain bleed. Every tertiary NICU has unit policies pertaining to the care of preterm babies which should be obtained to see if the standard of care was followed when reviewing the medical record. This is typically not part of the medical record and needs to be requested. It can be part of the order sets if an audit trail was requested.

7. Did the baby have routine head ultrasounds or MRI/CT scans as per the unit policies to follow up the degree of IVH?

The grade or degree of IVH is important in the prognosis of the baby and neurodevelopmental outcomes.

Legal nurse consultants who have extensive clinical background in neonatology are ideally well equipped to handle such cases. Cangem’s medical legal consulting team have legal nurse consultants (LNCs) with years of medical experience in neonatal ICUs and combined with the years of consulting experience, Cangem is well poised to undertake your next case.

Learn more about us and get in touch here.


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