Giving birth to a healthy baby is the wish for all expectant parents. Mothers can take steps to ensure the health of herself and her baby both before and during pregnancy, but sometimes, factors outside the parents’ control can cause complications that lead to severe injuries to their babies.
One of those complications is brain damage that can lead to a disability known as cerebral palsy. Babies can suffer brain damage for many reasons both before and during birth. One of the main reasons is a lack of oxygen at birth, but a report published more than a decade ago is making it harder for parents to take legal action when their child is born with cerebral palsy due to unforeseen complications during the delivery.
What is cerebral palsy?
Cerebral palsy is a motion disorder that affects a person’s ability to move and maintain balance. It is caused when the part of the brain that controls movement is damaged or does not develop normally. There is no cure for cerebral palsy, but therapy and other treatment options can help children and adults improve their quality of life.
There are several types of cerebral palsy and each affects a person’s ability to move differently. The symptoms of cerebral palsy can range from mild to severe, but the condition does not get worse over time.
As outlined by the American Pregnancy Association (APA), a nonprofit organization that promotes pregnancy wellness, the three types of cerebral palsy are:
- Spastic Cerebral Palsy – Spastic cerebral palsy is the most common type, accounting for about 70 to 80 percent of children and adults with cerebral palsy in the United States. This form of the disability is characterized by stiff muscles which make moving difficult. There are three different forms of spastic cerebral palsy and each depends on the parts of the body affected.
- Spastic hemiplegia – Only one side of the body is affected with spastic hemiplegia and usually the arm is affected more than the leg.
- Spastic deplegia – This type of spastic cerebral palsy affects both sides of the body. In many cases, tightness in the muscles of the hips and legs cause both legs to cross which is called scissoring.
- Spastic quadriplegia – Spastic quadriplegia is the most severe form of spastic cerebral palsy and affects all four limbs as well as the trunk, and oftentimes the muscles that control the tongue and mouth. Spastic quadriplegia is often accompanied with other disabilities including mental retardation.
- Dyskinetic Cerebral Palsy – also called athetoid cerebral palsy, this form of the disability affects about 10 to 20 percent of individuals diagnosed. It is characterized by fluctuations in muscle tone, which can range from too tight to too loose, and uncontrolled movements that can be slow and writhing or rapid and jerky. Children with dyskinetic cerebral palsy often have trouble learning how to control their bodies well enough to sit and walk. It can also affect the muscles in the face and tongue, causing difficulties with swallowing, sucking and speech.
- Ataxic Cerebral Palsy – This is the least common form of cerebral palsy, affecting about five to 10 percent of individuals with the disability. Ataxic cerebral palsy affects a person’s balance and coordination making it difficult to walk. It can also make motions that require precision, like writing, difficult.
How prevalent is cerebral palsy?
About 10,000 babies born in the United States will develop cerebral palsy, making it the most common motor disability in childhood, according to the Centers for Disease Control.
It is estimated that the vast majority of cerebral palsy cases result from events that occur before birth, and a smaller number of cases result from events that occur either during labor and delivery or after birth. In about 85 to 90 percent of cases, brain damage occurred before or during birth. This is referred to as congenital cerebral palsy.
What causes cerebral palsy?
While the exact cause of why a child develops cerebral palsy isn’t always clear, there are many different factors that may contribute to the development of the condition.
According to APA, the following risk factors can increase the chance of a baby developing cerebral palsy:
- Infections during pregnancy
- Certain infections in the mother during pregnancy can cause brain damage and lead to cerebral palsy, including rubella (German measles), cytomegalovirus (usually a mild viral infection) and toxoplasmosis (usually a mild parasitic infection).
- Chorioamnionitis – This is an infection that occurs when bacteria present in the vagina or anus ascends into the uterus and infects the membranes and amniotic fluid surrounding the fetus. According to the Cleveland Clinic, chorioamnionitis occurs in about two percent of births in the United States.
- Prematurity – Babies who weigh less than 3.33 pounds are up to 30 times more likely to develop cerebral palsy. Babies with low birth weights are more likely to suffer from bleeding in the brain or to develop a condition called periventricular leukomalacia, which is characterized by the destruction of nerves around the fluid-filled cavities in the brain. Both of these conditions can lead to brain damage and increase the risk of developing cerebral palsy.
- Blood disease
- Incompatibility between the blood of the mother and the blood of the baby, called Rh disease, can lead to the development of cerebral palsy. Doctors can usually prevent the disease by injecting the mother with Rh immune globulin around the 28th week of pregnancy.
- Blood clotting disorders, called thrombophilias, in either the mother or baby can also increase the risk of cerebral palsy.
- Severe jaundice – Jaundice is caused by the buildup of biliruben in the blood which results in the yellowing of the skin and the whites of the eyes. If the condition goes untreated, it can raise the risk of permanent brain injuries, including cerebral palsy.
- Other birth defects – Babies born with brain malformations, some genetic diseases and other physical birth defects put them at a greater risk for developing cerebral palsy.
- Acquired Cerebral Palsy – Though more rare, a baby or toddler can develop cerebral palsy if he or she suffers a head injury and gets an infection such as meningitis. Only about 10 percent of all cerebral palsy cases are acquired after birth.
Can a lack of oxygen at birth cause cerebral palsy?
Yes. A lack of oxygen puts babies at risk of brain damage which could lead to the development of cerebral palsy. Intrapartum asphyxia, or a lack of oxygen during delivery, occurs in about one out of every 1,000 live births in the United States, according to Seattle Children’s Hospital. There are many factors that could lead to intrapartum asphyxia.
According to Healthline.com, causes of intrapartum asphyxia include:
- The baby’s airway becoming blocked
- If the baby is anemic, his or her blood cells will not carry enough oxygen
- Difficult or long delivery
- The mother does not get enough oxygen before or during birth
- The mother’s blood pressure is too high or low during delivery
- An infection that affects the mother or baby
- The placenta separates from the uterus too quickly, resulting in a loss of oxygen
- The umbilical cord becomes wrapped around the baby
A lack of oxygen during birth was once thought to be one of the main causes of cerebral palsy. When a report written by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) was released in 2003, that viewpoint began to change as the report estimated only about 10 percent or less of cases actually resulted from a lack of oxygen during labor and delivery.
Still, that is 10 percent of cerebral palsy cases that result from a lack of oxygen.
Before the report was published, a large number of lawsuits were filed by parents whose children were born with cerebral palsy. After 2003, it became much more difficult to argue in court that a child’s cerebral palsy was caused by a lack of oxygen during birth.
ACOG/AAP’s 2003 report disputes common asphyxia belief
In its report titled, “Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology to Neonatal Encephalopathy and Neurologic Outcome,” the ACOG and AAP laid out strict guidelines to determine which cases of cerebral palsy would be considered a result of intrapartum asphyxia.
The organizations determined four “essential criteria” that must be met for an intrapartum (occurring during labor or delivery) event to cause cerebral palsy. These criteria included:
- Evidence of a metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH < 7 and base deficit ≥ 12 mmol/L)
- Early onset of severe or moderate neonatal encephalopathy in infants born at ≥ 34 weeks gestation
- Cerebral palsy of the spastic quadriplegia or dyskinetic type
- Exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders
In other words, blood samples taken from the umbilical cord after delivery needed to be unusually acidic; the baby must have displayed signs of severe or moderate brain damage shortly after being born; the baby must have developed only one specific type of the most common form of cerebral palsy, or the second most common type; and no other risk factor could have been present to rule out the possibility of a lack of oxygen during labor and delivery being the cause of cerebral palsy.
These criteria were used as a defense in lawsuits filed by parents whose children were born with cerebral palsy. The fourth criterion was especially difficult for plaintiffs to disprove.
ACOG updates report; asphyxia still hard to prove
In 2014, the ACOG published a second edition of its initial report, titled, “Executive Summary: Neonatal encephalopathy and neurologic outcomes, second edition.” While the 2003 report sought to establish a causal link between intrapartum asphyxia and cerebral palsy, the updated report acknowledges that there are “multiple potential casual pathways that lead to cerebral palsy.”
In the second edition, the authors attempted to use a “broader perspective” when suggesting criteria that would help rule out or determine possible causes of cerebral palsy. “This conclusion reflects the sober recognition that knowledge gaps still preclude a definitive test or set of markers that accurately identifies, with high sensitivity and specificity, an infant in whom neonatal encephalopathy is attributed to an acute intrapartum event,” wrote the assessment’s authors. In other words, there is no one test of set of tests that can say whether or not a baby’s cerebral palsy was caused by a complication during delivery.
Despite this claim, the authors still laid out criteria, similar to that of their original report, which attempted to determine whether a cerebral palsy case was caused by a lack of oxygen during birth, or some other complication. Much like the first set of criteria, they made it harder for parents whose child was born with cerebral palsy to contest in court that it was a lack of oxygen during delivery that caused the disability.