Cerebral palsy caused by lack of oxygen during or around the time of birth

Cerebral palsy brain injuries caused by oxygen restriction, an interruption to the oxygen supply or short period of total lack of oxygen to the baby’s brain may be described using words such as:

• hypoxia 
• hypoxic ischaemic encephalopathy (HIE)
• asphyxia
• anoxia

The pattern of damage to the brain, sometimes identified after birth on an MRI scan, will indicate whether the injury arose from:

• a profound, acute (of short duration) period of oxygen starvation in the last few minutes of labour; or 
• a chronic (longer duration), partial deprivation of oxygen over a longer period of time; or
• a combination of chronic partial and acute episodes of oxygen deprivation.

These injuries can be caused through:

Delayed delivery of a distressed baby 

When a term (37+ weeks gestation) baby who was known to be in good health at the start of labour shows signs of distress indicating that they are struggling to take in enough oxygen during labour, the baby must be delivered quickly to avoid permanent damage to their brain.

Negligent delays can occur in these circumstances if:

• the fetal heart-rate is not properly monitored;
• signs of fetal distress are not noticed or acted upon;
• the CTG fetal heart monitor trace is misinterpreted or is picking up the maternal heart-rate instead of the baby;
• there is a delay in making or acting upon the decision to expedite delivery (by forceps or caesarean section).

Negligent use of Syntocinon in labour 

Syntocinon or oxytocin is a uterine stimulant which is administered by drip in very small doses to increase maternal contractions to speed up the progress of labour. This is standard treatment in safe, well-monitored circumstances but if used inappropriately can be dangerous for the mother and the baby. 

When the fetus shows signs of distress from oxygen deprivation in labour, Syntocinon should be reduced to reduce uterine pressure on the compromised baby. Failure to do so or, as we sometimes see, commencing or increasing Syntocinon in the presence of fetal distress in an attempt to speed up the labour instead of expediting delivery of the baby, can be a negligent cause of fetal oxygen deprivation, leading to cerebral palsy in the baby. 

Hyperstimulation of the uterus can also cause injury to the mother, particularly when it leads to scar dehiscence (breakdown) or rupture of a uterus weakened by previous surgery, such as caesarean section. Negligent use of uterine stimulants and untreated hyperstimulation in these circumstances can be life-threatening to both mother and baby. 

Delayed resuscitation at birth 

The duration of the oxygen deprivation can extend beyond birth into the neonatal period, i.e. spanning the end of labour and first few minutes of life, if the baby is born needing resuscitation but isn’t properly resuscitated immediately. 

Negligent causes for delayed resuscitation include:

• lack of essential resuscitation equipment;
• the absence of appropriately qualified paediatricians or neonatal staff in the delivery suite or operating theatre at the time of a potentially compromised baby’s birth. 

Failing to act on placental abruption

Placental abruption, when the placenta detaches partially or completely from the uterus, is a life-threatening complication for both the mother and the unborn baby. It must be treated as a medical emergency. 

If this dangerous condition occurs, usually in the third trimester of pregnancy, swift action is needed to deliver the baby to avoid severe haemorrhaging (bleeding) from the mother’s uterus and restriction of oxygen to the baby resulting in permanent brain injury or stillbirth. Cerebral palsy claims can arise when there is a delay in recognising and acting upon the early signs of placental abruption, resulting in severe permanent injury to the baby.

Failing to act on uterine rupture

Uterine rupture is a rare but serious complication that can occur during labour when the muscular wall of the uterus tears.

It is a life-threatening complication for mother and baby. The mother’s life is put at risk from the heavy blood loss and shock which follow rupture of the uterine wall. Meanwhile, the unborn baby is deprived of oxygen leading to severe brain damage with permanent disability including cerebral palsy.

It can occur when there is a trial of vaginal birth after a previous caesarean (VBAC) or where there is hyperstimulation of the uterus through the use of oxytocin. 

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Failing to treat pre-eclampsia 

Medication might be given to reduce blood pressure or to treat or reduce the risk of convulsions, however, pre-eclampsia can only be treated and its serious complications avoided by delivering the (sometimes premature) baby. Cerebral palsy and severe maternal injury claims involving pre-eclampsia usually arise from delays in recognising, properly monitoring and managing the condition and failure to achieve urgent yet safe delivery of the baby.

Shoulder dystocia

Shoulder dystocia is an obstetric emergency which can occur during childbirth, causing injury to the baby. Mothers expecting large babies, or whose babies are disproportionately large for the size or shape of the mother’s pelvis (known as cephalopelvic disproportion), are at higher risk of experiencing shoulder dystocia during delivery.

Shoulder dystocia occurs when the baby’s head has been delivered but delivery of their body is obstructed, usually because the baby’s shoulder has become wedged behind the mother’s pubic bone. Where a mother is known to be expecting a large baby, or is at higher risk, such as from gestational diabetes, she should be advised of the risks and be involved in careful planning of an appropriate time and mode for delivery.

When delivery of the baby is obstructed by shoulder dystocia, the maternity team must act quickly to carry out emergency manoeuvres to free the baby from its stuck position, so that delivery can take place before the baby suffers permanent injury.

Failure to recognise that delivery is obstructed or take action promptly to release and deliver the baby can result in death of the baby or serious injury. The baby’s brain may be damaged from lack of oxygen if the umbilical cord is compressed (squashed) between baby’s body and the mother’s pelvis, or by pressure on the blood vessels in the baby’s neck, or if the placenta becomes separated prematurely. Too much force or traction (pulling) on the baby can cause brachial plexus nerve injury (Erb’s palsy) or fracture the baby’s arm or collar bone. Poor management of shoulder dystocia can also harm the mother, who may suffer bleeding and perineal injury.