The brain is critical for human functioning, serving as the epicentre for the nervous system and the chief control centre for virtually every cognitive and biological process in the body. A baby’s brain is also an organ that can rather easily experience injury during pregnancy, birth and following birth.
Common Causes of Infant Brain Damage
Brain injury in a baby is typically caused by one of the following:
- Oxygen deprivation. Birth asphyxia causes 840,000 or 23% of all neonatal deaths worldwide1,2.
It can be caused by problems during pregnancy, labour and delivery and also complications following childbirth.
- Trauma: Trauma typically refers to damage to the brain through an excessive impact. This could result from the negligent or improper use of equipment such as forceps.
- Infection: infections can sometimes pass from mother to child, particularly during the birthing process or the child may subsequently develop an infection which requires urgent treatment. An example of this is Group B streptococcus (GBS) infections which can be harmful to new-born babies if not treated correctly.
- Failure to monitor the health of the mother and baby throughout pregnancy, labour and delivery and provide the appropriate and timely medical intervention.
Types of brain injuries which can occur during pregnancy, birth and postpartum
1. Oxygen Deprivation
Oxygen is critical to brain functioning. Hypoxic-ischemic encephalopathy (HIE) is one of the most concerning injuries and develops when the brain experiences a shortage of supply of blood and oxygen. The brain requires much more oxygen than any other part of the body; brain cells that die cannot regenerate, which means that any damage from HIE may be permanent.
HIE damage is graded as mild, moderate or severe. When HIE is graded as moderate or severe, long-term disability and possible death could result. These long-term disabilities could result in HIE brain damage could result in permanent disabilities such as cerebral palsy, intellectual/developmental disabilities, and seizures.
What Happens During HIE Injury
“Fetal response to asphyxia illustrating the initial redistribution of blood flow to vital organs. With prolonged asphyxial insult and failure of compensatory mechanisms, cerebral blood flow falls, leading to ischemic brain injury”.
The effects of low oxygen and blood flow can also cause damage to the lungs, liver, heart, bowel and kidneys of the baby.
Brain Damage in a Baby Following a HIE Injury
HIE damages the brain in two phases:
In the first phase, brain cells are damaged when the brain is deprived of oxygen for a period of time. If the oxygen deprivation is severe and prolonged, parts of the brain may die thereby affecting the functions associated with those regions.
In the second phase, the HIE may continue even as the brain regains oxygen. As blood and oxygen return to the damaged areas of the brain, the cells may release toxins such as cytokines which may further damage the brain. This is known as a reperfusion injury and necessitates skilful intervention and monitoring of the baby’s brain.
The full extent of the brain damage resulting from HIE may not be apparent immediately after childbirth. This is due to two reasons:
- Oxygen deprivation creates a chain reaction i.e. as cells die they release toxic substances which damage other cells. Therefore the brain injury may continue to develop for hours or days after birth.
- A child’s developmental and mobility issues may only be noticed as they get older.
The Common Causes of a HIE Injury in a Baby
- Umbilical cord complications
The umbilical cord connects the mother to the child and supplies blood and oxygen. Complications involving the umbilical cord could significantly increase the risk of oxygen deficiency to the child.
Low blood and oxygen delivery to the baby can be caused by the umbilical cord being compressed.
Umbilical cord compression can be caused by a:
- Nuchal cord: When the cord becomes wrapped around the baby’s neck.
- True knot: When the cord becomes tied in a knot.
- Umbilical cord prolapse: When the cord descends the birth canal before or alongside the baby.
- Short umbilical cords: When a cord is unusually short, it is at higher risk of stretching and rupturing, and may lead to placental abruption.
- Vasa previa: Vasa previa is a condition in which umbilical cord vessels migrate out into the amniotic sac membranes, where they are at high risk of rupturing if the baby is delivered vaginally. This condition has the potential to lead to massive fetal blood loss, but can often be managed safely with a planned C-section.
- Oligohydramnios is a complication where a mother has low levels of amniotic fluid. This can cause compression of the umbilical cord, restricting oxygen supply.
Other umbilical cord issues which may affect blood and oxygen supply to the baby include velamentous or marginal umbilical cord insertion. In this condition the blood vessels in the umbilical cord do not fix correctly into the placenta with the risk that the blood vessels may lodge between the fetus and the entrance to the birth canal (cervix) and rupture during pregnancy. This rupture could lead to fetal hemorrhage and possible death. This condition is called vasa previa.
2. Placental complications
These can include:
- Placental abruption: This occurs when the placenta prematurely tears away from the womb, which can reduce or completely eliminate blood flow to the baby.
- Placenta pravia: This is a condition where the placenta is too close to the cervix which can cause oxygen deprivation and excess bleeding during childbirth.
- Placental insufficiency: When the placenta is unable to deliver enough blood (and thereby oxygen) to the baby.
- Placenta accreta: In this condition the placenta does not fully separate from the uterus during labour because it has grown too deeply into the uterine wall. If not detected or treated, it can result in serious blood loss.
In a 2015 study published in the Journal of Maternal, Fetal and Neonatal Medicine, entitled “Hypoxic-ischemic encephalopathy in newborns linked to placental and umbilical cord abnormalities” it was concluded:
“Birth asphyxia (reduction in respiratory exchange) and hypoxic-ischemic encephalopathy (HIE) of the newborn remain serious complications. We present a study investigating if placental or umbilical cord abnormalities in newborns at term are associated with HIE.
Velamentous or marginal umbilical cord insertion was found in 39% among HIE cases compared to 7% in controls. Conclusions: Placental and umbilical cord abnormalities have a profound association with HIE. A prompt examination of the placentas of newborns suffering from asphyxia can provide important information on the pathogenesis behind the incident and contribute to make a better early prognosis”.
3. Uterine complications
Uterine Rupture: Uterine rupture causes haemorrhaging which can drastically reduce blood pressure, resulting in lower blood flow to the baby.
4. Mistakes Made in Monitoring a Fetal Heart Rate Monitor
A heart rate monitor is used to monitor a baby’s heart rate and should provide an indication of fetal distress. If medical professionals are negligent in the use and / or interpretation of the monitor readings, this could delay urgent treatment or intervention such as a C-Section. A delayed emergency C-section could result in further oxygen deprivation to a baby and potential brain damage.
5. Premature Rupture of Membranes (PROM)
In this situation the amniotic sac which surrounds the baby ruptures and the amniotic fluid is expelled i.e. the ‘water breaks’ before labour begins. This condition requires medical intervention and monitoring as the lack of a protective layers means that the baby is at risk for a variety of concerns such as HIE, neonatal encephalopathy, cerebral palsy, developmental issues, Group B Strep and sepsis infections.
6. The occurrence of fetal strokes
Oxygen deprivation to a baby’s brain could result in strokes which further increase the likelihood of permanent brain damage.
Certain medical conditions could increase the likelihood of a fetal stroke eg. preeclampsia, PROM, chorioamnionitis (a bacterial infection of the fetal membranes i.e.amnion and chorion), placental abruption, Fetomaternal haemorrhaging, placental thrombosis (blood clots which occur in the placenta and veins of the uterus, obstructing blood flow), other maternal infections such as pelvic inflammatory disease.
Chorioamnionitis requires immediate medical intervention due to the risk of the baby developing meningitis and brain bleeds.
7. Prolonged and poor management of labour
This could include:
Prolonged or excessive uterine contractions
Uterine contractions compress the placenta and umbilical cord which may lead to a reduction in a baby’s oxygen supply if the labour is prolonged. The failure to take adequate steps to prevent a prolonged labour eg. Carrying out an emergency C-section may be considered.
Oxytocin- induced uterine stimulation
Uterine hyperstimulation (tachysystole) is a birth complication where uterine contractions become excessively strong and frequent. It can result from improper administration of drugs such as Pitocin and Cytotec and can potentially lead to too much pressure in the vessels in the uterus and placenta, which can reduce blood flow to the umbilical cord and baby. The impaired blood flow can lead to severe oxygen deprivation and HIE.
8. Mismanagement of a high-risk pregnancy:
Specific conditions or health concerns may affect the mother and child and these may require additional monitoring throughout pregnancy and birth. Some of these factors could include:
Factors affecting the mother:
- Women with conditions such as preeclampsia, diabetes, gestational diabetes, obesity may require closer monitoring and specialist interventions. Preeclampsia is a condition that can result in oxygen deprivation. This situation occurs when the mother has high blood pressure, which can cause placental abruption or reduce efficacy of the vessels in the placenta.
- HELLP Syndrome
- Vascular disease
- Maternal drug and alcohol abuse.
Factors affecting the baby:
- Macrosomia: The baby is unusually large for gestational age.
- Signs of fetal distress (on CTG) eg fetal bradycardia, late decelerations
- decreased fetal movements
- Thick meconium
- Congenital conditions eg. malformed lungs, cardiac disease
- Congenital infections
- Severe fetal anemia
- Cephalopelvic disproportion (CPD): CPD describes a situation in which the baby’s head is too large to fit through the mother’s pelvis, either because the baby’s head is unusually large or the mother’s pelvis is unusually small/malformed
- Abnormal fetal presentation/lie: These include the following, among others:
- Breech presentation
- Face presentation
- Brow presentation
- Transverse fetal lie
9. Anesthesia errors: Errors in administrating anaesthesia can cause decreased blood pressure in the mother thereby reducing the flow of blood to the baby.
10. Failure to prevent premature birth or mistakes managing a premature birth:
Premature babies may be at a higher risk of developing HIE as their lungs are underdeveloped. Therefore immediate respiratory support may be required following birth.
Infants who are premature may encounter a brain injury known as periventricular leukomalacia (PVL). This type of injury frequently causes conditions such as cerebral palsy and epilepsy. In this injury, the brain’s white matter becomes damaged and begins to decay, creating cavities that fill with fluid. It is believed to be caused by a disruption to the oxygen supply during pregnancy. Since white matter assists in the conduction of electrical signals between neurons, PVL can cause a number of related issues including developmental delays.
8. Failure to monitor the baby for deficiencies, abnormalities following birth
A baby’s health and condition needs to be monitored after birth to ensure:
- Congenital conditions are managed correctly eg. cardiac or pulmonary disease
- Infections do not occur or are treated immediately eg. Group B strep, meningitis, sepsis
- Nutrient levels are adequate: eg. glucose levels, calcium and magnesium levels
- Blood pressure is normal i.e. it has not dropped
- Meconium Aspiration Syndrome (MAS) has not developed. Meconium is a mixture of amniotic fluid and the baby’s stool. A baby may inhale this around the time of birth and subsequently develop severe respiratory distress, which can contribute to oxygen deprivation and HIE. MAS can alsobe caused by oxygen deprivation.
- High levels of bilirubin do not develop. Kernicterus is a type of brain damage that can occur if jaundice occurs and is not effectively treated. This condition is caused by excessive levels of bilirubin in the brain. Bilirubin is a substance that accumulates when hemoglobin breaks down. Jaundice is the term for an initial state of high bilirubin levels that can turn into kernicterus. Jaundice is quite common as an infant’s liver is not yet fully developed and can easily be treated. Damage from kernicterus cannot be reversed.
What are the symptoms of Hypoxic Ischemic Encephalopathy
If a baby has experienced oxygen deprivation that may have or display the following characteristics:
- Low heart rate.
- Poor muscle tone; the limbs may be limp.
- Blue skin colour
- Meconium-stained amniotic fluid.
- Born breathing weakly, intermittently, or not at all.
- Depressed or absent newborn reflexes.
- Inability to feed.
- Changes in eye movement; eye movements may be poorly coordinated or shaky.
- Dilated or unmoving pupils.
- Low or irregular blood pressure.
- Unresponsive at birth.
The severity and duration of the oxygen deprivation will determine the extent of the HIE injury. Some possible long-term effects could include:
- Developmental delays
- Learning disorders, such as dyslexia and ADHD, learning difficulties
- Motor and coordination difficulties, cerebral palsy
- Chronic infections, allergies and other immune disorders.
- Seizures and epilepsy.
- Behavioral problems, including impulse control issues and behavior that seems immature for your child’s age.
Improper use of these tools or use by untrained staff can cause brain damage and brain bleeds. This could include the negligent and improper use of forceps and vacuum during birth.
Trauma to the head could result in:
- A brain bleed, which occurs as either a hemorrhage or a hematoma, is an injury typically caused by trauma. A hemorrhage refers to internal bleeding where blood escapes circulatory vessels; a hematoma refers to blood pooling in a particular area.
- A subgaleal hematoma, refers to an accumulation of blood between the skull and the scalp. This is a rare condition which typically results from the incorrect use of forceps or vacuum extractors. While rare, this condition is life-threatening as it can cause permanent brain damage. Hypovolemic shock can also result from this condition.
- Caput succedaneum occurs when the head and scalp of a newborn begins to swell. During childbirth, the baby’s head can face significant pressure from compression. This can be exacerbated by the use of devices to aid in delivery. Mild cases are quite common and go away in a short time without damage however severe swelling can lead to other conditions which can result in brain damage.
- A brain injury where cerebrospinal fluid floods the ventricle cavities in the brain is called hydrocephalus. This is commonly the result of head trauma during childbirth but can also be caused by abnormalities in chromosomes.
Claim Compensation For a Brain Injury to a Newborn
Brain injuries to a baby can have serious consequences to their health and wellbeing. Mistakes made during childbirth or the failure to monitor the health of mother and baby can result in brain damage to the child resulting from oxygen deprivation, infection or even trauma.
If you feel that the care you or your child received prior to, during or after birth was negligent, you may decide to bring a claim in order to secure justice and compensation for your child’s brain injuries. Speak to one of our negligence solicitors who specialise in birth injuries.
Devonshires Claims support victims of medical negligence by providing:
- A free no-obligation case evaluation
- A no win no fee agreement
- A network of medical experts and specialist medical negligence barristers
- Over 20 years’ experience in securing justice and compensation
1.Ferriero DM. Neonatal brain injury. N Engl J Med. 2004 Nov 4. 351(19):1985-95. [Medline].
2.Perlman JM. Brain injury in the term infant. Semin Perinatol. 2004 Dec. 28(6):415-24. [Medline]