What is Cerebral Palsy?
Cerebral Palsy (CP) is a common cause of physical disability in children, with an instance of around 2 per 1,000 in the Western world. In Ireland based on 59,796 births per annum (CSO, 2019) there is a CP rate of 1.77 per 1000 births which is approximately 110 CP births each year. The underlying disorder of the brain is not progressive and is permanent, but because CP presents in early childhood the physical limitations do vary with age because the brain is developing so rapidly at this time. The motor disorder of CP, which causes limitation of physical activity, is often accompanied by problems with intellect, epilepsy and behavioural difficulties. Children usually receive input from multi-professional teams including paediatricians, paediatric neurologists, physiotherapists, orthopaedic surgeons, speech and language therapists and benefit from support in primary/secondary school with, where appropriate, a special needs assistant.
Classification of Cerebral Palsy
CP is generally described in terms of the parts of the body which are affected and this can give some indication to the underlying brain disorder. When all four limbs are affected the term ‘quadriplegia’ is used, when an arm and leg on one side are involved, the term ‘hemiplegia’ is used, and when the legs are more affected than the arms the label ‘diplegia’ is often applied.
What causes Cerebral Palsy?
Babies are injured during labour, most often by lack of oxygen but sometimes by haemorrhage. Such babies often give warnings by their conduct, warnings which, if heeded in time, may provide a means for preventing injury. ‘Foetal distress’ is a loose term used to indicate those responses by the baby which alarm medical attendants. Foetal distress in labour is recognised by one abnormality of the baby’s heart to the passage meconium. One recognised cause of CP is the mismanagement of oxytocin. Oxytocin can be administered to induce and augment labour in appropriate circumstances. Contractions in labour of a frequency of more than four in ten minutes are likely to lead to foetal hypoxia (oxygen deprivation) because of the inadequate intervals between the contractions. Therefore, poorly controlled oxycontin infusions which produce excessively frequent contractions can therefore result in foetal hypoxia. It is therefore extremely important when administering oxytocin that it is used to achieve a contraction pattern of the desired frequency and anything in excess can have grave consequences. It is therefore essential that oxytocin is turned off when there is any significant abnormality of the cardiogram (CTG trace) and the contraction frequency exceeds five in 10 minutes. Failure by the medical professionals to turn off oxytocin will inevitably lead to hypoxia and without oxygen the supply of energy will fail and cells will be lost – particularly to the baby’s brain. If the warning signs of foetal heart abnormality and increasing foetal distress are ignored there will be brain damage and cerebral palsy – and eventually death.
Since the baby depends entirely upon the placenta for its oxygen and nutrient supply it follows that any obstruction of the umbilical cord, threatens the baby’s wellbeing, such problems include:
- Abnormalities of the cord (for example knots) and
The risk to the baby is heightened if the contractions are unusually prolonged or abnormally frequent than the incidents of compression of the umbilical cord may begin to interfere with the oxygen supply. The characteristic changes on the CTG then become complex variable decelerations and in these circumstances foetal hypoxia will begin and if not rectified within a short period of time eventually brain damage or the baby’s death will occur. Abnormalities of the cord are rare including two knots in the cord caused by the baby’s movements do have the potential for causing hypoxia and such abnormalities produce changes on the CTG which should be readily picked up by doctors.
Cerebral Palsy – Principal mistakes of obstetric management
The principal mistakes of obstetric management associated with medical negligence claims for Cerebral Palsy are as follows:
Failure to detect or take account of:
- Foetal abnormality
- Intra‑uterine infection
- Maternal hypertension
- Maternal Diabetes
- Special investigations including ultrasound scans
- Abnormal presentations
- Placental abruption
- The need to monitor foetal wellbeing
- Pre-term labour
Failure to detect or take account of:
- CTG abnormalities
- Abuse of Oxytocin
- Umbilical cord complications
- Dysfunctional labour and a secondary arrest of labour
- The need to avoid difficult vaginal delivery, especially in the presence of foetal distress
- Previous injury to the uterus (VBAC)
- The conduct and timing of Caesarean Section
- The need to conduct delivery in an appropriate environment
- The need to have the necessary paediatric and anaesthetic assistance available
- The management of shoulder dystocia
Failure to detect or to take account of:
- The need to reverse the effects on the baby of narcotic drugs given to the mother
- The need to have the necessary paediatric assistance available
- The need to intubate or otherwise effectively resuscitate and provide proper respiratory support for the baby
- The appropriate surroundings and expertise required and necessary for the further care of the baby
Failure on the part of medical staff to understand, interpret and react to an abnormal CTG is probably the most common error in a medical negligence Cerebral Palsy cases. Secondly, the abuse of oxytocin causing excessive contractions and intermittent chronic hypoxia (oxygen deprivation) is also a very common recurrent theme in Cerebral Palsy medical negligence. It is certainly this office’s experience that this is so often a part of the picture that the abuse of oxytocin is so self-evidently the result of negligence that cases taken invariably settle without having to go into court.
Acute near total hypoxia in labour leading to brain damage occurs where for a short period, the baby is almost completely deprived of oxygen, brief periods of acute near total hypoxia are associated with the disasters of labour such as cord compromise, placental abruption, ruptured uterus, or shoulder dystocia. A medical negligence case taken will likely succeed if it can be shown that the disaster should never have been allowed to happen. Delay is a recurrent theme in birth asphyxia (oxygen deprivation) claims, that is to say delay in making observations and also delay in interpreting observations, delay in making decisions to intervene and delay in intervening. Childbirth injuries are not usually achieved by one contributing factor, they are usually as a result of indecisions or incorrect decisions that lead to a cascade of events.
In the most severe forms of Cerebral Palsy the child will require 24 hours care every single day of their life. The compensation awarded for such life altering condition must reflect this huge financial cost and in more recent times in Ireland we are seeing settlements north of 20 million Euro. In medical negligence cases details of the sums and money which will be required to adequately provide for the injured child’s future will have to be very carefully calculated in consultation with numerous experts who will assess in the greatest detail what equipment, nursing, medical and other care the injured child will need. Technologies are constantly developing which are leading to the provision of ever more sophisticated and expensive equipment. This adds to the expense, but more importantly enables injured children to communicate their needs and to have a better quality of life. Experts we would usually engage in Cerebral Palsy cases include experts on life expectancy, care experts, speech and language therapists, physiotherapists, dental experts, rehabilitation consultants, neurophysiologists, educational psychologists, architects for home adaptations as well as quantity surveyors, actuaries and accountants.
If you or a loved one have been affected by injury during birth, our medical negligence solicitors can help you pursue a claim for compensation.