William Little a British doctor, first identified cerebral palsy in the 1860s. Little and generations of doctors after him believed that a difficult labor and delivery were responsible for most cases of cerebral palsy. It was thought that the lack of oxygen during a prolonged delivery caused the brain damage associated with CP. The celebrated Sigmund Freud the founder of psychoanalysis, was a notable opponent of this belief, Freud argued that many of the issues (mental retardation, seizure, vision problems) associated with CP were too profound to have been caused by a brief lack of oxygen at birth. Freud believed that these problems must have arisen from problems during development.
It turns out that Freud was right. In the 1980s, a study funded by the National Institute of Neurological Disorders and Stroke found that less than 10 percent of all cases of congenital cerebral palsy were caused by a problem during delivery. The researchers found that while a lack of oxygen does play a significant role in many cases of cerebral palsy, the lack of oxygen which may occur during a difficult delivery is seldom enough to cause brain damage. Most brain damage from lack of oxygen occurs during the baby’s development.
Significant Delivery Issues
Although the cause of most cerebral palsy is present before birth, the period of labor and delivery is still risky. Over due pregnancies, overly large babies, prolonged labor and breech deliveries increase the risk of injury occurring during birth.
A pregnancy which runs beyond the normal gestational period of 40 weeks is a risk for a difficult delivery because the baby can be larger than normal. Women with pregestational diabetes are also more likely to have larger than normal babies. Larger than average babies have difficulty passing through the birth canal. Sometimes the baby’s head may present or partially present, but then the shoulder is caught under the mother’s pelvic bones (a problem called shoulder dystocia). Being in this position puts the baby at risk for possible prolonged oxygen deprivation, since it may take doctors a long time to extract the child and the umbilical cord may be kinked or squeezed during manipulations to free the shoulder.
Simple procedures like changing the mother’s position and changing the doctor’s grasp on the baby will be tried at first. Sometimes something as simple as pushing the woman’s legs up against her chest can provide extra room for the baby to descend; if this fails, those assisting the birth may help the woman roll over on her hands and knees so that gravity and the change of position will allow the baby to descend. Sometimes special episiotomy incisions are needed to make more room for the child.
The longer a situation like this continues, the greater the risk for both the woman and the child. The woman may bleed excessively or experience tissue damage which will be slow to heal. Nerves in the baby’s shoulder may be stretched or torn causing a condition known as Erb’s palsy.
In extreme situations, where no simpler, less invasive method has worked, the doctors may need to perform a caesarian section to remove a baby who has become stuck in this position; however, a caesarian section at this point is tricky and risky, since the baby may need to be pushed back up the birth canal and then quickly extracted through an incision in the mother’s lower abdomen. Doctors do not like to perform such risky procedures; all possible other procedures will be tried before attempting this form of emergency C-section. During such an emergency C-section, the woman is at greater risk for hemorrhaging and the baby is at risk for oxygen deprivation.
Even with ultrasound and other modern technology, an unborn baby’s weight is difficult to assess. Doctors may not anticipate delivering an overly large baby. Being unable to predict every possible complication is not medical negligence; however, being unprepared to deal with all possible emergencies may be negligence.
Delays in implementing appropriate emergency delivery techniques could lead to the baby being deprived of oxygen long enough to cause brain damage which will lead to cerebral palsy. The doctor should make sure that a special medical team, capable of handling emergency deliveries is available, even when trouble is not anticipated. The delivery room should be always be equipped for all possible emergencies. The doctor should be willing to admit when a delivery is becoming too complex for his or her skills and turn over the patient’s care to the emergency delivery team.
The physician should also explain in advance to the patient and her family, what will happen in the case of an emergency delivery, even in cases where such an emergency is not anticipated. In cases where an emergency is anticipated, the doctor should be even more thorough with the explanation.
In addition, a neonatal intensive care team should be on stand-by to care for the baby should an emergency occur. Proper treatment in the first few minutes after birth can sometimes prevent future problems. Naturally, proper treatment in the first few days after birth is also very important.