Brain-Related Birth Injuries
The leading brain-related birth injury is Cerebral Palsy (CP). Cerebral is the medical term usually used to describe the brain. Palsy is the medical term used to describe a type of paralysis. In children with CP, parts of the brain that control muscle movement have been damaged by lack of oxygen.
Therefore, the brain can not send and receive the necessary signals for normal muscle movement and body control. Because all body functions depend in some way on muscle movement, children with CP can also have difficulty eating, swallowing, breathing, and speaking. Children with CP can also have cognitive (thought and intelligence) disabilities.
There are several causes of CP. The two causes most related to birth injury are infections and oxygen deprivation. Many times, the brain injuries caused by oxygen deprivation or infection could have been avoided if the physician had used the correct preventative measures. For example, if a physician fails to monitor fetal distress and take the appropriate actions, the infant may develop CP. Other instances include:
- Failure to monitor, detect, and treat maternal infections
- Failure to plan and carry out an emergency C-section
- Failure to identify and treat a prolapsed umbilical cord
- Failure to use birth-assisting tools correctly
In order to understand what doctors and lawyers mean when discussing an infant brain injury, it is important to be familiar with a few key terms:
HYPOXIC ISCHEMIC ENCEPHALOPATHY
Hypoxic Ischemic Encephalopathy (HIE) is a brain injury that occurs from too little oxygen reaching the baby’s brain. Hypoxia is a medical term for too little oxygen in the blood stream. Ischemia is the medical term for cell and tissue damage caused by too little oxygen. Encephalopathy is the medical term used to describe disease, damage or malfunction of the brain.
When doctors and lawyers speak of HIE, they are talking about brain damage that occurred because the baby’s brain received too little oxygen for too long. Often, these babies are diagnosed with Cerebral Palsy.
This term is used to describe an absence of oxygen to the brain. Think in terms of a garden hose. Hypoxia occurs when the water is turned down. Anoxia occurs when the water is turned off. Children who suffer an anoxic event often have a severe form of cerebral palsy because more significant brain cell death has occurred.
This term is used to describe bleeding or blood leaking outside of the blood vessels. There are several circumstances related to birth injury in which a hemorrhage is relevant. While inside the womb, baby and mom share one circulatory system. Mom’s blood gets to her baby from blood vessels between her uterus and the placenta which connects to the baby through the umbilical cord. If there is a disruption anywhere in the system, (a hemorrhage) the baby will receive less blood. If this disruption is too severe, or lasts too long, the baby can suffer injury from lack of blood supply to her brain and other vital organs.
UMBILICAL CORD COMPRESSION
A disruption in blood flow through the umbilical cord can occur from the cord being kinked or squeezed. This stops or blocks blood flow through the umbilical cord leaving the baby with too little blood supply to her brain and vital organs. If the cord is compressed or kinked for too long, this damage can be permanent.
This is the medical term for low amniotic fluid. The amniotic fluid is the “water” that surrounds the baby in his mother’s uterus. If there isn’t enough fluid, several problems can occur, including cord compression from the baby’s own weight pressing down on the umbilical cord.
The placenta is the organ responsible for ensuring blood and nutrients get from mom to baby while baby is growing inside the uterus. The placenta is attached to the inner wall of the uterus through a complex network of blood vessels. At times, part of the placenta can tear away from the uterine wall. This is called an “abruption”, and can disrupt the proper flow of blood and nutrients to the baby.
This occurs when the placenta is not delivering is a complication of pregnancy when the placenta is unable to deliver an adequate supply of nutrients and oxygen to the baby.
The term “uterine rupture” refers to a tear in the uterine wall during pregnancy. It is a rare complication, most associated with women who have had a prior c-section. As the baby grows inside the womb, the uterus stretches. Sometimes, instead of stretching along with the other uterine tissue, the scar tissue from a prior c-section can tear, creating a dangerous situation for both the mother and baby. The tear most often occurs at the end of the pregnancy, when the uterine wall experiences the stresses of labor. Because of this, many women who have had a c-section will choose to forgo a vaginal birth, (also called a “V-BACK”) and opt instead to deliver all of their future babies by c-section.
The symptoms most associated with uterine rupture are:
- Vaginal bleeding
- Sharp pain between contractions
- Contractions that slow down or become less intense
- Unusual abdominal pain or tenderness
- Recession of the fetal head (baby’s head moving back up into the birth canal)
- Bulging under the pubic bone (baby’s head has protruded outside of the uterine scar)
- Sharp onset of pain at the site of the previous scar
- Uterine atony (loss of uterine muscle tone)
- Maternal tachycardia (rapid heart rate) and hypotension
- Abnormal fetal heart tones, variable decelerations
- Bradycardia (slow heart rate)
WHOLE BODY COOLING FOR BIRTH RELATED HIE
Research has concluded that the best predictor of long-term outcome following perinatal injury is the presence of newborn brain swelling. If moderate swelling is present, the risk of death is less than 10% and as many as one-third of the survivors have physical disabilities. With severe swelling, mortality is higher (as much as 60%) and many, if not all, survivors are handicapped. The benefit of whole body cooling (induced hypothermia) in newborns with post-asphyxia brain swelling has been proven in high-quality randomized controlled trials to be safe and has been adopted as standard of care at most of the large hospitals in the United States.
The aim of the cooling protocol is to reduce the newborn’s body temperature to between 33.5°C and 34.5°C within 6 hours of birth. This temperature is then maintained without interruption for 72 hours. The baby is then slowly re-warmed over a period of at least 4 hours at a rate of 0.5°C per hour until the rectal temperature reaches the desired range of 36.5-37°C.
WHICH BABIES CAN BE COOLED?
- First, the baby must have been born at or after 36 weeks of gestation.
- Next, the baby must meet certain physiological and neurological criteria.
- Apgar score 5 or less at 10 minutes of life.
- Need for mechanical ventilation and/or ongoing resuscitation at 10 minutes of life.
- Metabolic or mixed acidosis defined as arterial cord gas, or any blood gas within the first hour of life showing pH of 7 or less, or base deficit of ≥12 mmol/l.
One of the following:
- The presence of seizures
- Evidence of encephalopathy suggested by amplitude-integrated EEG (a-EEG)
- Physical examination consistent with moderate to severe encephalopathy
IF YOUR BABY WAS PLACED IN A COOLING PROTOCOL AFTER BIRTH, YOU SHOULD CONTACT US IMMEDIATELY.
This is a medical term used to describe an infection that gets into the amniotic fluid and the sac surrounding the baby. It is caused when bacteria normally present in the vagina ascend into the uterus. The amniotic fluid and placenta — as well as the baby — can become infected.
Sepsis is the result of infection. It occurs when chemicals released into the bloodstream to fight the infection start to “poison” other parts of the body. Left untreated, these chemicals can damage multiple organ systems, causing them to fail.
Periventricular Leukomalacia (PVL) is a form of brain injury involving the white matter of the brain. Premature babies are especially at risk for developing PVL because their lungs did not have enough time to fully develop before birth. Without proper lung function, the baby cannot get enough oxygen to his brain. This causes parts of the brain to die, leaving the baby with a form of cerebral palsy.