OBSTETRIC BRAIN DAMAGE

Prosecuting obstetric negligence has taken a severe beating in the last decade of medical research.

Nevertheless the enormous costs of life-long care for the brain-damaged child encourage vigorous and persistent pursuit of obstetric malpractice suits.

It is true that prolonged and profound oxygen lack during the birth process may result in cerebral palsy, epilepsy, mental retardation and specific learning deficits. Indeed, one in 50 births results in asphyxia[1].

However, most of the affected infants enjoy normal development. Neuropathological research suggests that most asphyxial brain damage occurs before the onset of labour[2].

Review[3] of 10 studies failed to identify either fetal heart-rate patterns which can predict neurological damage, or effective protocols for obstetric intervention.

Entirely healthy newborns may be born after many minutes of profound fetal heart-rate disturbance[4]. Conversely, relatively minor disturbances may be associated with neurological damage[5]: abnormal heart-rate may be the result of fetal brain damage before the onset of labour[4].

The threshold for brain damage is acidic blood (pH less than 7), accompanied by low blood pressure[2]. In mild to moderate oxygen lack, the fetal brain maintains blood circulation to itself, the heart and the adrenal glands at the expense of other body systems. When the oxygen shortage is severe and prolonged, channeling of blood to these vital organs fails and severe brain damage and death rapidly follow[6].

A "thin-skull" argument is tempting. Could not a relatively minor additional insult from substandard obstetric management cause brain damage in a vulnerable fetus? Unfortunately, the natural history of prenatal causes of susceptibility to asphyxia is largely unknown[2].

In the present incomplete state of knowledge, four criteria[7] are required for a robust opinion on causation of cerebral palsy by intrapartum asphyxia:

PRACTICE POINT

Components of a robust opinion on obstetric brain damage:

  1. Severe asphyxia
  2. Newborn symptoms
  3. Typical deficits
  4. Exhaustive investigation

Newborn neurological symptoms will ideally be accompanied by evidence of temporary malfunction of other body systems.

The presence of deficits not normally seen after prolonged and severe birth asphyxia will suggest another cause for the neurological damage and weaken the case.

Even with typical symptoms and an otherwise normal family- and pregnancy history, exclusion of all other causes should be as complete as possible.

Copyright © 2008 Electronic Handbook of Legal Medicine