Cerebral Compression and Excessive Head Molding Injuries
Cerebral compression injuries can happen when excessive pressures on the baby’s head cause a baby to have brain damage even without externally visible head trauma or low blood pH. In many cases, this is due to improper administration of Pitocin (Oxytocin), difficult, prolonged or stalled labor, or a mismatch between the size of the baby’s head and the mother’s pelvis. In many cases, cerebral compression is benign, but excessive pressure on the baby’s head can cause blood vessels to collapse, decreasing blood flow to the brain.
We often see injuries caused by hypoxia-ischemia (a lack of oxygen and blood flow to the brain), which can result in babies having signs of acidosis (acidic blood) or decelerations in fetal heart rate on the fetal heart rate monitor during labor and delivery. There has also been a rise in the number of cases where babies show signs of brain damage (such as seizures after birth, fetal stroke, or intracranial hemorrhage), but they do not necessarily show signs of acidosis or fetal heart rate abnormalities. In some cases, babies with ischemic injuries are not identified until after the neonatal period. The commonality between many of these cases is the mechanism of injury – cerebral compression. This has given rise to a new classification of injury called cerebral compression ischemic encephalopathy (or CCIE).
Cerebral compression can occur when a mother has a stalled and/or prolonged labor, and the baby’s head is ‘stuck’ in the birth canal for a prolonged period of time. Because active labor involves pushing and muscle contractions, this can place pressure on the baby’s head. This pressure, when excessive, can cause brain injury.
Cerebral compression injuries can be related to multiple factors, including:
- Excessive uterine contractions
- Prolonged, stalled or dysfunctional labor
- Cephalopelvic disproportion (CPD)
- Marked molding
- Malposition (especially Occiput Posterior ([OP] Position)
- Difficult delivery
- Operative delivery (vacuum extraction and/or forceps delivery)
- Operative delivery (vacuum extraction and/or forceps delivery)
How can excessive uterine activity cause a baby to have brain damage?
During labor, there is a pattern of contraction and relaxation that helps push the baby through the birth canal. During a contraction, the placenta and fetus receive less oxygen as the muscles contract; during the relaxation period, oxygenation resumes to normal levels. If contractions are too long, strong, or frequent, it indicates reduced blood flow to the baby. Under normal circumstances, babies have an array of physiological responses that help them tolerate these variations in perfusion and oxygenation. If excessive uterine activity occurs, however, the baby may not be able to produce a physiological response large enough to respond to the changes in its environment and maintain blood flow to the brain.
One of the factors that can impact its ability to autoregulate is head compression. The following factors can influence the extent of the impact of head compression:
- Increasing frequency/intensity of contractions
- Abnormal shape/resistance of the birth canal
- Cranial molding
- Maternal bearing-down efforts
- Early membrane rupture
- Dysfunctional labor
The impact of mechanical force on the fetal skull can increase the pressure inside the baby’s head, which can in turn cause arteries in the brain to constrict or collapse. When this happens, blood flow (perfusion) to the brain is reduced. When this occurs, the baby may suffer brain damage. It is important to note that a baby who already has low blood pressure is even more susceptible to intracranial pressure-related damage stemming from cerebral compression injuries. This low blood pressure can be caused by the administration of certain drugs, sepsis, or by circumstances that cause the baby to have severe hypoxia.
The pressure on a baby’s head is not uniform, however. Operative deliveries (deliveries where medical professionals use forceps or vacuum extractors) can exert pressure on the baby’s head in certain areas more than others. The baby’s position and station has an impact on cerebral compression as well.
One of the things that studies have shown is that fetal head compression can cause a significant drop in blood flow to the brain, even without significant changes in blood pH or in cardiac performance. MRIs and other imaging sometimes reveal diffuse cerebral ischemia, though a significant number of infants with obvious brain damage do not have any discernable lesions on neuroimaging. In some cases, infants with neurological damage of this type can be admitted to the well-baby nursery, and brain injury is not suspected until after a baby has begun to miss developmental milestones.
The Impact of Excessive Uterine Activity on Cerebral Compression
Unfortunately, many medical practitioners ignore and/or fail to recognize excessive uterine activity; the current near-sole focus on hypoxia-ischemia tends to minimize the role that the mechanical forces of labor and delivery have on intracranial pressure, cerebral blood flow, fetal adaptive mechanisms, fetal head molding and descent. Prominent researchers have weighed in that the focus on hypoxia-ischemia alone has given rise to the misguided notion that (1) it is alright to continue pushing oxytocin until abnormal fetal heart tracings occur and (2) that it is acceptable to encourage aggressive maternal pushing in response to concerning fetal heart rate abnormalities in the second stage of labor.
Alarmingly, 98% of women who received oxytocin for labor induction had a diminished relaxation time (less than 60 seconds between contractions), putting the baby at risk for mechanical and hypoxic-ischemic injury. This diminished relaxation time is a metric 3 times more sensitive for identifying excessive uterine activity than the more commonly-used metric of contraction frequency. Notably, excessive uterine activity does not mean that labor will progress more quickly or easily, and it is clearly established that excessive uterine activity is associated with lower fetal blood oxygenation and decreased umbilical cord artery pH, abnormal fetal heart rate patterns and neonatal encephalopathy (NE). Indeed, researchers have found that optimal progress in labor relates to a pattern of evenly-spaced contractions of similar amplitude and duration – not to increased contraction frequency.
Preliminary studies of neonates with neurological injuries during labor associated with prolonged excessive uterine activity and other mechanical factors showed significant cranial trauma (including bruising and molding) at birth. Neuroimaging revealed diverse white matter injuries associated with low blood flow to the brain, and 46% showed signs of brain bleeds (intracranial hemorrhages). Furthermore, the majority showed no umbilical artery acidemia (low blood pH) or evidence of birth asphyxia.
The Impact of Head Molding on Cerebral Compression Injuries
Babies’ heads are susceptible to molding, where the bones of the skull shift around to accommodate the baby’s passage through the birth canal. In many cases, head molding is benign. Excessive head molding (even if it is not visually apparent), however, can lead to injury to a baby’s brain in the form of trauma to the fetal brain, as molding can increase pressure inside the baby’s skull. It is important to note that the head can be compressed for a short time period, causing substantial spikes in intracranial pressure and resulting ischemia, without visually recognizable head molding after birth.
Many of the cases of excessive molding, however, occur in situations where labor progress is slow or stalled and mothers have excessive uterine contractions (in some cases due to the over-administration of Pitocin/oxytocin or Cytotec). 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. This is because oxytocin is a high-alert medication associated with significant risks regarding uterine hyperstimulation, which can cause contractions to be too powerful.
Excessive molding can also occur when:
- There is a prolonged labor
- Contractions are too forceful
- The fetal head is malpositioned
- Forceps or vacuum extractors are used improperly
The Impact of Vacuum Extractor or Forceps Birth on Cerebral Compression
Operative delivery (also known as instrument-assisted delivery is a risk factor for mechanical, traumatic and ischemic injury to the scalp and brain, especially if instruments such as vacuum extractors and forceps are used one after the other. In many cases, an elective C-section is the safest way to deliver a baby, because a C-Section performed too late in labor cannot be expected to protect against injury.
How Can Excessive Cerebral Compression be Avoided?
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. Recent research has provided a roadmap for medical practitioners to follow to avoid these adverse outcomes:
- Avoiding excessive uterine activity at all costs
- Allowing fetal heart rate to return to baseline before continuing to administer oxytocin or encouraging pushing
- Paying close attention to cervical dilatation and descent and recognizing and responding to dysfunctional labor patterns.
- Encouraging maternal bearing-down timed together with contractions, not between contractions.
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.
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Mechanical forces can potentially cause a baby’s brain injury. These forces can cause cerebral compression (due to prolonged labor, excessive head molding, the overuse of Pitocin/Oxytocin, or other factors), a key factor that can play a role in perinatal brain injury.
If your baby was diagnosed with developmental delays, physical, behavioral, or intellectual disabilities, cerebral palsy, or another injury or disability, call Reiter & Walsh ABC Law Centers. We have focused solely on birth injury law since 1997, and would be happy to provide a free consultation regarding the events of your child’s birth.
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