Category Archives: Causes of Cerebral Palsy

Fetal Heart Monitoring: How Mistakes Happen in Labor and Delivery

By Giles Manley, M.D.
CP Family Network Medical Director

Parents should learn how to read Electronic Fetal Monitoring results so that they'll know when to request medical intervention.Electronic fetal heart monitoring is used in nearly all hospital births in the U.S. The technology has been around for decades. But medical records of brain-injured infants I review each week frequently show that although fetal monitoring was showing the baby was experiencing high levels of distress while still in the womb, nurses or doctors failed to take appropriate action.


What is Electronic Fetal Monitoring?

Electronic Fetal Monitoring (EFM) involves hooking the laboring mother up to a machine that records the baby’s heart rate. Changes to the heart rate, which are indicated on a graph called a tracing that is printed out by the monitor, can indicate that a baby is being deprived of oxygen for some reason, such as the cord wrapped around its neck. If the tracings show unusually high or prolonged stress, it may be critical to take the baby by C-section to avoid brain injury from lack of oxygen.


Why do Mistakes Occur?

Medical best practices are clear about how to interpret tracings and when to take action. But preventable mistakes still happen. There are several reasons for this:

  • Different medical and nursing school programs use different terminology to describe tracings. The American College of OB/GYN is taking steps to prevent this, but old terms have a way of hanging around and can affect communications among people trained differently.
  • Nurses delay alerting doctors to signs of worrisome tracings. They may hesitate to “bother” the doctor, or they may keep trying other techniques, such as turning a laboring mother to her left side or suggesting she squat, to try to alter the situation.
  • A doctor’s order for an emergency C-section isn’t carried out within 30 minutes because of staffing or facility issues or simple miscommunication.

These situations, and others like them, are why I tell parents to learn enough about EFM to know when they ought to be insisting that a doctor be called or that the baby be taken by C-section. It is far better to start insisting on a C-section that later isn’t needed (if tracings return to normal), than to need one and not get it done in time.


Tips for Expectant Parents

In an effort to prevent possible birth injuries, I recommend parents:

  • Tell your labor and delivery team you want to be informed about any evidence that oxygen levels to your baby have dropped and what action is being considered.
  • Confirm that an obstetrician and anesthesiologist are in-house and available to respond in an emergency situation.
  • Know the chain of command in the hospital so that if you feel your concerns are being ignored, you know who to call for a second opinion and intervention. The chain is initiated by getting the charge nurse or nurse manager involved immediately.
  • Encourage expectant couples you know, especially those with high-risk pregnancies, to learn about EFM.

As a board-certified obstetrician for more than 20 years, I know how important it is that parents take an active role in labor and delivery decisions. Learning about fetal heart monitoring should be a part of every expectant parent’s birthing education. To read more about EFM, see my blog Expectant Parents: Pay Attention to Fetal Monitoring During Labor.


Pediatric Stroke and Cerebral Palsy

By John Lehman

View similar stories.

Most people think strokes affect only adults, but they can also occur in children, even before birth. In fact, pediatric stroke is one of the leading causes of death in children. Children who have suffered from a pediatric stroke also have a high chance of developing cerebral palsy. Like cerebral palsy, pediatric stroke is best treated as early as possible to help reduce its side effects and the chance of one occurring again.

Types of Pediatric Stroke

For both children and adults, strokes generally fall into two categories: hemorrhagic and ischemic (though there are many different types of strokes). Hemorrhagic strokes occur when a blood vessel in the brain bursts, resulting in a hemorrhage. Ischemic strokes are usually the result of arteries being blocked by blood clots. While adults are more likely to have ischemic strokes than hemorrhagic, children are equally at risk for both of these types of stroke.


Regardless of the type, it is often difficult for doctors to determine an exact cause for pediatric stroke. Research has revealed common risk factors that can increase the likelihood of a stroke occurring including:

  • Heart conditions
  • Blood disorders

Children with sickle cell disease have a 10 percent chance of suffering from an Ischemic stroke. Hemorrhagic strokes can result from an Arteriovenous Malformation (AVM) or from hemophilia. Roughly 11 out of 100,000 children will suffer a stroke before their 18th birthday, with the greatest risk occurring during the first year of their life.

Signs and Symptoms

Since most pediatric strokes occur in young children less than a year old, they may lack the appropriate communication skills to let you know they need help. Therefore, it falls upon the parent to know the warning signs. For newborns in particular, seizures can be an indication of a pediatric stroke. If the child is old enough to speak coherently, he or she may suddenly begin slurring words and have difficulty speaking. They may also complain about sudden and severe headaches, difficulty maintaining balance or blurred vision, all of which could indicate a stroke.

Treating a Pediatric Stroke

Once a child has had a stroke, there are several treatments available to help reduce the chance of a another stroke occurring. In some cases, medications are taken to prevent overgrown blood clots. In other cases, surgery can be performed to relieve blood pressure on the brain or to remove build up in the arteries. Although many adults take tPA compounds to treat stroke, its use for children is the subject of some controversy.  Talk to your doctor about which treatment may best suit your child’s needs.

Relationship to Cerebral Palsy

Children who have suffered from pediatric stroke have a chance of developing hemiplegia, a spastic form of cerebral palsy that typically renders one side of a child’s body weakened or paralyzed. Other effects of hemiplegia include issues with attention, memory, speech, seizures and mood swings. Like other forms of cerebral palsy, there are many treatment options available to improve your child’s condition and quality of life.

Pediatric strokes can be a frightening experience for both you and your child. Although they may face long-term challenges, the majority of children affected by stroke adapt well and will go on to live long and healthy lives.

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National Stroke Association

American Heart Association/American Stroke Association

Children’s Hemiplegia and Stroke Association

Understanding the Risks of Misdiagnosed Fetal Position

At the time of delivery, the position of an unborn child in a woman’s uterus is considered normal only if it presents itself head-first and face down (known as the occiput anterior position). If the baby presents itself in any other position such as feet first, buttocks first or sideways, it is termed a breech presentation or breech birth and considered abnormal. If a woman’s doctor misdiagnoses a breech delivery or fails to respond appropriately, injury to the baby, including brain damage and cerebral palsy, may occur.

Determining the Position of the Fetus

Throughout a pregnancy, the fetus can change positions many times, but between week 32 and week 38 (accepted full term), the percentage of fetuses in breech position reduces naturally from 25% down to approximately 3%. A number of factors can contribute to a fetus remaining in breech: a multiple pregnancy (two or more fetuses), prior Cesarean sections (C-section), an unusual volume of amniotic fluid (too much or too little), as well as any abnormalities of the uterus, placenta or fetus.

Whether premature or full-term, it is the health care provider’s responsibility to determine the fetal position at the time of labor and delivery. He or she may accomplish this by feeling the baby’s positioning through the abdomen using a procedure known as Leopold’s Maneuvers or by performing a vaginal exam in which they feel for the suture lines along the baby’s skull. In some situations, an ultrasound may be performed late in the pregnancy or even during early labor to determine the baby’s positioning.

Delivery Options for Breeched Babies

In the event of a breech, there are options for delivery. Because breech presentations make it very difficult, if not impossible, for the baby to safely pass through the birth canal, many result in C-sections. If the fetus is known to be in breech, the health care provider may first attempt to rotate the baby into the occiput anterior position by pushing on the mother’s abdomen (a procedure known as External Cephalic Version or gently twisting the baby through the vaginal opening and cervix using their hands and/or forceps (Internal Cephalic Version). When attempting either or both Versions, it is imperative that the baby’s vital signs be closely monitored through ultrasound and fetal heart monitoring. If at any point during the procedure the fetus appears in distress, such as a sudden drop in heart rate, the procedure is terminated until the fetus is stabilized. If the fetus does not stabilize, an emergency C-section may be performed.

Risks of Breech Deliveries

Attempts at vaginal deliveries of beech presentations are not uncommon, but can be difficult and present a higher risk of fetal distress, birth defects or suppression of the umbilical cord. “Fetal distress” is a term the OBGYN community is moving away from, preferring practitioners now use terminology more specific to the situation. Historically, however, “fetal distress” has referred to any situation in which the baby is not coping well with the demands of labor. While occurrences of “fetal distress” are considered rare, any number of contributing factors could be in play, including the mother’s medical history, her health and lifestyle during pregnancy or circumstances specific to labor and delivery. A “birth defect” refers to any physical, mental or biochemical abnormality present at birth. “Umbilical cord suppression” refers to cutting off the flow of the oxygenated, nutrient-rich blood prior to the baby drawing its first actual breath. Any of these complications can lead to temporary or even permanent health problems for the newborn.

Advice for Expectant Parents

For all we don’t know about the causes of cerebral palsy, we do know that it reflects an abnormality or disruption in brain development, often during pregnancy or childbirth. Misdiagnosing the fetal position or attempting a risky vaginal birth increases the possibility that something can go wrong.
The key to protecting the health of your child is to get regular prenatal care which should include conversations with your doctor about the positioning of your unborn child and a game plan in the event of a breech presentation.

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