Birth Injuries from Cerebral Compression and Excessive Head Molding

Cerebral compression injuries can happen when excessive pressure on a baby’s head during labor and delivery causes brain damage. This may occur even without externally visible head trauma or obvious signs of oxygen deprivation/birth asphyxia. The baby may experience excess cranial pressure from complications such as uterine hyperstimulation, prolonged or stalled labor, or cephalopelvic disproportion (a mismatch between the size of the baby’s head and the mother’s pelvis). A certain amount of cerebral compression during birth is normal, but excessive pressure on the baby’s head can cause hypoxic-ischemic encephalopathy (HIE) and other birth injuries from reduced blood flow and oxygenation within the brain.

Often, when a baby has hypoxic-ischemic brain damage (hypoxic-ischemic encephalopathy, or HIE), it is caused by a complication or medical error that affects the maternal-fetal circulation. To get to the fetus, oxygenated blood must travel through the mother’s lungs, heart, vasculature, uterus, placenta, and umbilical cord. An interruption in blood flow at any point along this pathway can cause HIE. One common indication of HIE is a low pH, or acidosis, in the umbilical cord blood test administered shortly after birth. However, there are also cases in which babies sustain brain damage even with a normal blood gas score and no external signs of birth trauma (1). In these cases, oxygen deprivation can happen within the brain itself due to excessive cerebral compression restricting blood flow. This may occur even in the absence of brain bleeds. In his book Birth Trauma and Perinatal Brain Damage, Vasily Vasilievich Vlasyuk notes that, “The compression of the brain in labor can occur without any ruptures and hemorrhages, causing hypoxia and ischemia of the brain tissue” (2).

Cerebral compression injuries can be related to multiple factors, including:

• Prolonged, stalled, or dysfunctional labor
• Uterine hyperstimulation/tachysystole(excessively strong or frequent contractions; sometimes this is caused by the misuse of labor-enhancing drugs such as Pitocin and Cytotec) (3)
• Cephalopelvic disproportion (CPD)
• Excessive molding (4)
• Malposition (such as Occiput Posterior ([OP] Position) (5)
• Difficult delivery
• Operative delivery (vacuum extraction and/or forceps use), which often causes brain bleeds in addition to cerebral compression (6, 7)

During labor, there is a pattern of contraction and relaxation that helps push the baby through the birth canal. When the uterine muscles contract, the placenta and fetus receive less oxygen; during the relaxation period, oxygenation resumes to normal levels. Under normal circumstances, babies have an array of physiological responses that help them tolerate these variations in perfusion and oxygenation. However, if contractions are too long, strong, or frequent, this can dangerously reduce blood flow to the baby. When this occurs, the baby may suffer brain damage.

Although cerebral compression injuries can occur without any external signs of birth injury, they are often accompanied by head molding. Newborn babies have more flexible heads than older children or adults because the bones in their skulls need to shift around to accommodate passage through the birth canal. In many cases, head molding is benign. Excessive head molding (even if it is not visually apparent), however, can dangerously increase pressure inside the baby’s skull and cause brain damage.

Many of the cases of excessive molding occur in situations where labor progress is prolonged or difficult. This may be for a variety of reasons:

• The mother has excessive uterine contractions (in some cases this is due to the over-administration of Pitocin/oxytocin or Cytotec). In one study, infants born to mothers who had oxytocin stimulation of labor had more head molding than those who did not, and these differences persisted three days after birth (8). Oxytocin is classified as a high-alert medication (9), and associated with a variety of risks to the mother and baby.
• There is an abnormal fetal presentation/position. This can cause excessive head molding and cerebral compression because the fetus cannot fit safely through the mother’s pelvis. Medical professionals should carefully manage the delivery of any baby not in the vertex presentation (head down with the chin tucked towards the chest), and be prepared to perform a C-section if necessary.
• The medical team uses forceps or vacuum extractors when not indicated. These tools can help to guide a baby through the birth canal, but should only be used under very specific circumstances. Moreover, even when these tools are indicated, they must be used very carefully and by experienced medical personnel. Physicians must follow standard of care and avoid putting excessive pressure on the baby’s head because this can cause molding and brain damage.

To summarize, excessive molding can occur when:

• There is a prolonged labor
• Contractions are too forceful
• The fetal head is malpositioned
• Forceps or vacuum extractors are used improperly

First and foremost, it is important to remember that it is the medical practitioner’s responsibility to ensure labor and delivery is a safe process that does not cause neurological injury in the baby. This means avoiding emergency situations whenever possible and avoiding hypoxic, ischemic, and mechanical stresses.

An important part of reducing the likelihood of injury from excessive cerebral compression may be the Fetal Reserve Index (FRI), which may be more sensitive than the three-category system introduced by the American College of Obstetricians and Gynecologists (ACOG). The FRI takes into account several aspects of the fetal heart rate, uterine activity, and maternal, obstetrical, and fetal risk factors. Eden et al. (2018) found that this system was more effective in detecting injury during labor than ACOG’s system, enabling medical professionals to intervene faster and prevent the need for emergency operative deliveries.

Babies can be injured during birth in ways that aren’t visually or immediately apparent after birth; these injuries may even present without obvious hemorrhaging, superficial trauma, or blood acidemia. In some cases, this can be due to cerebral compression, which in turn can be caused by a prolonged and/or difficult labor, among many other factors.

If your baby sustained brain damage around the time of birth, either from excessive cerebral compression or other factors, we may be able to help. ABC Law Centers was established to focus exclusively on birth injury cases. A “birth injury” is any type of harm to a baby that occurs just before, during, or after birth. While some children with birth injuries make a complete recovery, others develop disabilities such as cerebral palsy and epilepsy.

If a birth injury/subsequent disability could have been prevented with proper care, then it constitutes medical malpractice. Settlements from birth injury cases can cover the costs of lifelong treatment, care, and other crucial resources.

The information presented above is intended only to be a general educational resource. It is not intended to be (and should not be interpreted as) medical advice.

1. Frey, H. A., Liu, X., Lynch, C. D., Musindi, W., Samuels, P., Rood, K. M., … & Landon, M. B. (2018). An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case‐control study. BJOG: An International Journal of Obstetrics & Gynaecology, 125>(11), 1480-1487.
2. Vlasyuk, V. V. (2019). Birth Trauma and Perinatal Brain Damage. Springer.
3. Eden, R. D., Evans, M. I., Evans, S. M., & Schifrin, B. S. (2018). Reengineering Electronic Fetal Monitoring Interpretation: Using the Fetal Reserve Index to Anticipate the Need for Emergent Operative Delivery. Reproductive Sciences, 25(4), 487-497.
4. Jensen, A., & Holmer, B. (2018). White matter damage in 4,725 term-born infants is determined by head circumference at birth: the missing link. Obstetrics and gynecology international, 2018.
5. Yates, S. (2010). Pregnancy and Childbirth: A holistic approach to massage and bodywork. Elsevier Health Sciences.
6. Reiter, J. M., & Plastiras, J. B. S. (2005). Forcep Deliveries: Are They Worth The Risk?. Journal of Obstetrics & Gynecology,192(1).
7. Amar, A. P., Aryan, H. E., Meltzer, H. S., & Levy, M. L. (2003). Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature. Neurosurgery, 52(6), 1470-1474.
8. Freeman, M. (n.d.). Oxytocin and the Hazards of Uterine Hyperactivity[PDF]. Birth Trauma Litigation Group (BTLG) Newsletter.
9. High-Alert Medications in Acute Care Settings. (n.d.). Retrieved February 14, 2019, from https://www.ismp.org/recommendations/high-alert-medications-acute-list