Brain injury to a fetus or newborn may result in developmental delays affect that person’s quality of life and capacity to live independently and work productively for a lifetime. In some cases, brain injury can be attributed to genetic or growth abnormalities which occurred during fetal development. However, there are other cases where brain injury may have been preventable during the course of the mother’s labor and delivery. This condition is known as perinatal asphyxia.
Perinatal asphyxia is the result of deprivation of oxygen to a newborn infant long enough to cause injury to the brain and other vital organs. According to the American College of Obstetricians and Gynecologists1, certain conditions must be met for a diagnosis of hypoxic brain injury. First, the records must show that there was a “nonreassuring fetal status”, which means that there was an abnormality of the fetal heart rate and rhythm on the monitor prior to birth, and a delay in managing the fetal heart abnormality. In some cases, where when non-reassuring fetal status cannot be corrected quickly, delivery may be required to prevent brain injury to the fetus.
Second, in order to meet the definition of perinatal asphyxia, the newborn records must show that the Apgar score was low (a score of 0-3 for longer than 5 minutes). The Apgar score is commonly used in evaluating the status of the newborn, and is measured at one minute, five minutes and 10 minutes after birth. The Apgar score measures Activity, Pulse, Grimace, Appearance, and Respiration. A total score of 10 points is the most desirable, meaning the baby is active and healthy. When scores are low at one minute, the standard of care requires that the physician and nursing staff initiate resuscitative interventions. In some cases, the score is not improved. In others, within five minutes, the score improves dramatically. Often the outcome is good.
In some cases though, when the Apgar scores remain low, the clinical course and outcome may be poor. Typically, the records will show that there is profound metabolic acidosis (arterial cord pH below 7.0), meaning that there has been a prolonged period of oxygen deprivation. When this occurs, there are usually neurological abnormalities present soon after birth, including seizures, poor reflexes and tone. Additionally, one or more abnormalities of the vital organs may exist, including respiratory failure, requiring mechanical ventilation, cardiac failure requiring resuscitation, or failure of the kidneys, intestines or blood.
Among infants who survive severe hypoxic brain injury, the most frequent sequelae are mental retardation, epilepsy, and cerebral palsy. In such cases, a detailed review of the medical records of both the mother and infant are recommended to determine whether the conditions for perinatal asphyxia are met, whether the standard of care was followed, and whether the injury was preventable.
Anatomical injuries such as shoulder dystocia or skull injuries can also occur during the birthing process, usually occurring during transit through the birth canal during a difficult delivery where the birth canal is too small or the fetus is too large (as sometimes occurs when the mother has diabetes). Injury is also more likely if the fetus is lying in an abnormal position before birth. Overall, the rate of permanent anatomical birth injuries is low; however, if there is an anatomical injury present which has resulted in permanent dysfunction, a detailed review of the medical records of the mother and infant is recommended to determine whether the standard of care was followed and whether the injury could have been prevented.1 American College of Obstetrics and Gynecology (February 1998). ACOG Committee Opinion #197: Inappropriate use of the terms fetal distress and birth asphyxia, Committee on Obstetric Practice, Washington, D.C.
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