Controversial New Article in Obstetrics & Gynecology About C-Section Delivery and Cerebral Palsy

C-Section and Cerebral Palsy: In the News

Obstetrics and Gynecology recently published an article entitled: “Casarean Delivery and Cerebral Palsy: A Systematic Review and Meta-analysis,” in which the conclusion in the abstract was the following: “A review of the literature does not support the use of elective or emergency cesarean delivery to prevent cerebral palsy.”  The authors are Michael O’Callaghan, and Alastair MacLennan.  Since publication of this review, several publications have written dangerous articles.  One article is titled, “Study debunks cerebral palsy: Australian scientists appear to have disproved a theory that a cesarean delivery protects children from cerebral palsy.”  The other alarming article’s title simply reads: “C-sections Don’t Lessen Cerebral Palsy Risk.”

The titles of the last two articles are simply not true, and the conclusion of the main article is misleading and dangerous. A C-section is not only necessary to prevent cerebral palsy, it often is necessary to prevent death of the baby. One condition that can cause cerebral palsy is a lack of oxygen to the brain, called birth asphyxia. There are numerous conditions that occur during labor and delivery that can cause oxygen deprivation in the brain.  When a baby is properly attached to a fetal heart rate monitor, the monitor usually will indicate when the baby is being deprived of sufficient oxygen; this is called fetal distress.

Indeed, a baby could end up with permanent brain damage if O’Callaghan and MacLennan’s conclusions are put into practice.  If a baby is in a shoulder dystocia situation and has umbilical cord prolapse (which is very common when dystocia occurs), she must be delivered immediately.  If a baby’s shoulder is stuck on the mother’s pelvic bone and the cord is compressed, which means some or all the oxygen-rich blood going to the baby is cut off, physicians may lose valuable time if they do not consider a C-section and instead try to maneuver the baby to force a vaginal birth.  The longer the baby remains in the birth canal in this type of situation, the more likely it is that brain damage will occur.  Macrosomia is common in dystocia.  If a baby is macrosomic (large) and is physically unable to pass through the birth canal (called cephalopelvic disproportion), a vaginal birth is impossible.  It is frightening to imagine a physician trying to compel vaginal birth in this situation.

The article is misleading because it strongly implies that a C-section is not necessary in the prevention of cerebral palsy, and that it is good practice for physicians to persist with a vaginal birth because both methods of delivery have the same chance of a child ending up with cerebral palsy.  The fact is, it is not prudent to continue with a vaginal birth when a baby is oxygen-deprived.  This actually would be against medical standards of care in many instances.  When a baby is in distress, she needs to be delivered immediately.  The longer the baby is being deprived of sufficient oxygen, the more likely it is that she will have severe brain damage.  Not much can be done in the womb to alleviate oxygen deprivation; thus, the baby must be delivered in order to get her out of the womb, get her breathing on her own, and get her direct help if needed.  Therefore, the crucial issue with cerebral palsy caused by oxygen deprivation during delivery is how long it takes to remove the baby from the oxygen-depriving conditions.  A study that only compares C-section to vaginal delivery, without examining the crucial factor of length of time from onset of distress to delivery cannot make any substantive claims about the relationship between the type of delivery and the baby’s development of cerebral palsy.

The authors of the review only looked at babies with a confirmed diagnosis of cerebral palsy and whether they were delivered by vaginal birth versus C-section.  They then looked at subtypes of babies: babies born term, preterm, and in a breech presentation.

The authors’ conclusions were as follows:

  • Emergency C-section delivery was associated with an increased risk of cerebral palsy.  Emergency C-section was defined in the study as a C-section that occurs once labor has commenced.
  • There was no significant association between elective C-section delivery and cerebral palsy.
  • Any  type of C-section delivery (elective or emergency) for term newborns was associated with cerebral palsy.
  • There was no association between any type of C-section delivery and cerebral palsy in preterm newborns.
  • C-section delivery did not significantly modify cerebral palsy risk for breech-presenting newborns.

The authors’ main conclusion was that meta-analysis showed no overall association of C-section delivery with cerebral palsy.  This overall conclusion is from a very large sample (3,810) that includes elective C-sections.  When the authors break down the study a bit, some relationship between cerebral palsy and C- section delivery can be seen.  This is likely due to the fact that when the decision to perform a C-section is made during delivery, the baby is already in distress and experiencing some oxygen deprivation, which increases the risk of cerebral palsy.

At any rate, the conclusion that C-section does not help prevent cerebral palsy is false and dangerous.  In fact, in response to the main conclusion of the article – that C-section delivery does not help prevent cerebral palsy and that type of delivery does not affect rates of cerebral palsy – O’Callaghan said the following: “The causes of cerebral palsy must lie elsewhere.”

MacLennan, who led the research, added that, “[F]or over a century it was assumed, without good evidence, that most cases of cerebral palsy were due to low oxygen levels or trauma at birth.”

C-section rates have increased from 5% to 33% in Australia and in many other countries over the past 40 years, but cerebral palsy cases remain static at approximately 3.3 per 1000 births. MacLennon said the findings were important to health professionals, and were also legally significant because it had been argued that early C-section delivery could prevent the condition.

“We now need to focus our efforts on finding the antenatal causes of cerebral palsy, which may include genetic vulnerability and environmental triggers such as infection.”

These quotes have been published in multiple news magazines and papers, and the quotes are deceptive and dangerous.  With their statements, the study’s authors are essentially saying that the study shows that oxygen deprivation during labor and delivery cannot be the cause of cerebral palsy that occurs shortly after birth.  It is obvious that this article was written strictly as a tool to defend against lawsuits on behalf of babies and children who suffer brain damage from not being delivered quickly enough.

Indeed, a large study such as this may show that, overall, cerebral palsy occurs just as frequently in babies born vaginally as it does in those who had a C-section birth (including elective C-sections, which is data that merely serves to dilute emergency C-section data).  But this does not mean that the authors can make the conclusion that a C-section birth does not prevent cerebral palsy, and that oxygen deprivation during labor and delivery cannot be the cause of cerebral palsy.

In fact, this study means nothing in terms of causation of cerebral palsy.  The component that should have been examined is the time period from the onset of fetal distress to time of delivery.  This study did not examine how long each delivery took and the time frame from onset of fetal distress to birth of the baby.  Length of time of oxygen deprivation is what causes cerebral palsy (as well as severity of the deprivation and fetal reserve).  It could very well be the case that in many of the vaginal births that resulted in cerebral palsy, the delivery took too long and the baby was oxygen-deprived for a significant amount of time; perhaps physicians spent too much time trying to deliver the baby vaginally when they should have moved on to a C-section delivery.

The authors of the study cannot make the following claim: C-section quickly removes babies from oxygen depriving conditions that can cause cerebral palsy;  since the study shows that C-section does not decrease the likelihood of cerebral palsy, oxygen deprivation during labor and delivery must not be a cause of cerebral palsy.  This line of thinking is grossly inaccurate.  There is not enough data in the study – including length of time from distress to birth –  to support this claim.  It could be the case that the C-section delivery took too long.  The baby could have developed cerebral palsy because the physician spent too much time trying to deliver the baby vaginally, and then moved on to a C-section much too late. Perhaps the C-section would have prevented cerebral palsy if the physician had performed it sooner.  This study does not capture the time it took to move on to a C-section, or the length of time the baby was in distress.

Mistakes could have been made during both delivery types.  Often, during a difficult vaginal birth, physicians use tools to try and facilitate delivery, such as labor inducing drugs (Pitocin and Cytotec) and delivery instruments (forceps and vacuum extractors).  These items increase the risk of oxygen deprivation and cerebral palsy because they make it more likely that dangerous complications (brain bleeding with delivery instruments and oxygen deprivation with labor drugs) will occur.  In certain cases, use of labor drugs and delivery instruments can slow down the process of delivery, especially if the physician is unskilled in their use.  Many times, physicians should not attempt to use these risky items and instead, should move on to a prompt C-section delivery.

The biggest C-section mistake is not performing it quickly enough.  When a baby is in distress, a prompt C-section is the only sure-fire way to deliver the baby.  Using items to facilitate vaginal delivery does not ensure that a delivery actually will occur.  Physicians can employ multiple techniques during vaginal delivery, but none will guarantee delivery.

Another C-section mistake is not having proper staff or equipment to quickly carry out a C-section delivery.  The medical team may very well know that a C-section is necessary, but the team cannot implement it due to a lack of resources.  Sometimes the physician or physicians are not in the room, and they take too long to get to the baby for delivery.  The team also may take too long to get the baby to an operating room if the labor room is not equipped for a C-section.

The aforementioned potentially dangerous incidents are just some of the many factors that can cause oxygen deprivation and cerebral palsy in a baby.  The bottom line is that the length of time of oxygen deprivation is the crucial factor, and this issue was not captured in the study – a study that the authors are using to make grandiose and dangerous claims.  And the claims being made are quite simply not true.

Another major problem with the study is that elective C-section delivery was included with the general, overall C-section findings.  Thus, the main finding that the meta-analysis showed no overall association of C-section delivery with cerebral palsy is tainted with inclusion of elective C-section data.  Elective C-sections usually have nothing to do with emergency C-sections because by definition, elective C-sections are planned, which means the baby is not in distress and will be born at a set date.

Although this study is not useful in the way the authors are trying to use it, there actually was an association between emergency C-section delivery and cerebral palsy in a couple of areas in the study.  Nonetheless,  the journal article is dangerous because the authors are using it to make dangerous claims, and the study downplays the importance of C-section delivery.  The study also does not discuss the components of C-section that can prevent cerebral palsy.  It would be extremely dangerous for practitioners to listen to what the authors are saying and, as a result, be less likely to move on to a C-section when the baby is in distress.  It also would be dangerous if the authors’ words cause women to be less likely to consider a C-section delivery when their babies are oxygen-deprived.

Delayed C-Section, Cerebral Palsy and Medical Malpractice

Any condition that causes the baby to be oxygen deprived requires urgent delivery, often by emergency C-section.  Other conditions that may require an emergency C-section in order to avoid cerebral palsy include shoulder dystocia, oligohydramnios (low fluid in the womb), prolonged and arrested labor, and premature rupture of the membranes – especially if the baby hasn’t been delivered within 12 hours of the membranes rupturing, or if the cord has become compressed.

Physicians and the medical team must skillfully and continuously review the fetal heart tracings throughout labor and delivery to ensure that fetal heart tones are reassuring and the baby is receiving sufficient oxygen.  If nonreassuring fetal heart tracings occur, quick delivery must occur, usually by C-section.  An emergency C-section should be performed within 10 – 18 minutes, depending on the circumstance, and sometimes much sooner.

Physicians must continuously monitor the mother and baby and be aware of any problems that may necessitate emergent delivery by C-section.  Physicians should quickly deliver a baby before there is severe oxygen deprivation.  It is crucial for physicians to avoid vaginal delivery when it is not possible or when it is very dangerous.  This requires skill and very close assessment of the mother and baby.  Not only must physicians be prepared for a C-section delivery, but they must also closely monitor the baby’s heart rate.  If a physician or team member ignores the fetal monitor tracings, misinterprets the tracings, or fails to quickly deliver the baby by C-section and the baby develops cerebral palsy, it is medical malpractice.

Award-Winning Birth Injury Attorneys Helping Children with HIE, Cerebral Palsy and Other Injuries

If you are seeking the help of a birth injury lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury cases.  Reiter & Walsh ABC Law Centers is a national birth injury law firm that has been helping children for over 3 decades.

If your child was diagnosed with a birth injury such as hypoxic ischemic encephalopathy (HIE), cerebral palsy, a seizure disorder, intellectual disabilities or developmental delays, the award winning birth injury lawyers at ABC Law Centers can help.  We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent.  Our nationally recognized firm has numerous multi-million dollar verdicts and settlements that attest to our success and no fees are ever paid to our firm until we win your case.  Email or call Reiter & Walsh ABC Law Centers at 888-419-2229 for a free case evaluation.  Our award winning birth injury lawyers are available 24 / 7 to speak with you.

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