Neurologic injury, and cerebral palsy, in particular, can be a devastating result of poor care during labour and delivery. However, some babies are vulnerable to injury before labour begins. This may be a result of a problem with the mother’s health, the baby’s health or the environment in which the fetus develops. Where these conditions exist, an injury may be unavoidable, even with the best medical care.
On the other hand, the presence of these conditions does not make injury inevitable. Poor obstetrical care can still cause or contribute to newborn neurologic injury for these vulnerable babies.
What Causes Newborn Injury?
Determining the cause of newborn injury where conditions of risk exist can make the causation analysis quite complex. Special help is needed from highly qualified causation experts, including obstetricians, neonatologists, and neuroradiologists to identify the likely cause and timing of the injury. Fortunately, these tragic outcomes are rare. Despite its rarity, doctors, nurses, midwives, and others providing obstetrical care must be diligent in recognizing babies that may be vulnerable to injury and must respond with proper clinical action to avoid or mitigate injury where possible.
Identifying the fetus at risk begins with antenatal care and maternal health history and conditions. Some maternal health issues can impact fetal wellbeing, leading to increased risk of injury. Some of the more prominent maternal conditions that can cause added risk for the fetus include high blood pressure (including preeclampsia), heart disease, kidney dysfunction, and diabetes. These maternal conditions must be assessed at regular antenatal visits and treated to reduce the risk posed to the baby.
With regard to the fetus, growth restriction is a condition that more commonly poses added risk to the baby. There is a clear relationship between low birth weight and newborn neurologic injury. There may also be abnormalities of the placenta, issues with infection or genetic anomalies that can cause or contribute to a bad outcome. Multiple gestations are also associated with a higher incidence of injury. Prematurity is an important risk for a higher rate of poor outcomes. Post-term births also have a higher incidence of neurologic injury, particularly those occurring after 42 weeks of gestation.
Importantly, as stated above, both maternal and fetal conditions that add risk do not necessarily mean that injury is inevitable. Properly managed by the obstetrical team, there may be an opportunity to avoid or mitigate injury associated with these conditions. Certainly, where adverse conditions contributing to fetal risk are present, the recognition of special vulnerability to injury should lead to timely clinical responses to evidence of potential harm.
Avoiding Newborn Injury
The techniques for monitoring and evaluating fetal wellbeing antenatally and during labour and delivery are and will be extensively covered in other Birth Injury Alliance articles. The information obtained from fetal surveillance techniques must be used to assess the potential for harm and must be used to inform the obstetrical team about action that might be taken to reduce or eliminate risk. Where there is reason to believe a fetus is more vulnerable to injury, the tolerance for signs of distress must be lower, as must the threshold for action or intervention. Injury to the fetal brain is mostly due to impaired perfusion of oxygenated blood to the brain (ischemia). An otherwise healthy baby has considerable capacity to compensate for some impairments of oxygenation.
A vulnerable baby, on the other hand, will be less resilient, calling for a quicker response to reduce the effects of an environment where oxygenation is an issue or for rescue from that environment.
Cases involving the fetus at risk demand a very careful analysis of all the clinical circumstances and predispositions that might have contributed to the injury. Some of these injuries are not preventable, but some are preventable. Where there is some concern that an injury was preventable, it is essential to engage highly qualified professionals to review the matter, ask the right questions, engage the appropriate experts, and perform the proper analysis.