Causes of brain injury at birth

If your child has suffered a brain injury during birth, there are a number of ways in which this could have occurred. Here, we explain the medical procedures, injuries and conditions which can result in brain injury at birth, and how they could have been as a result of negligence.

You may recognise certain terms, so please click the one that is relevant to your child:

Periventricular Leukomalacia

Periventricular leukomalacia (PVL) describes damage to the brain on either side of the lateral ventricles which are two fluid filled chambers. It is a pattern of injury often seen when premature babies suffer a shortage of oxygen or infection to their brain.

Babies and children with PVL may be affected in different ways, depending on the severity of the injury. While some children may experience minor disabilities in movement, a more severe injury may result in cerebral palsy and/or epilepsy.

Our work with families affected by PVL involves representing children who have sustained PVL as a result of an avoidable brain insult, such as a delay in delivery leading to a shortage of oxygen.

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Brain haemorrhage and IVH

The brain needs an excellent blood supply in order to function. Blood is circulated around the brain through vessels such as arteries, veins and capillaries. If these vessels are damaged, the blood can leak out into the brain where it goes on to cause brain damage.

In babies, a type of brain haemorrhage that occurs more frequently is an intraventricular haemorrhage or IVH.

An IVH describes a bleed that has occurred within the lateral ventricles of the brain. The lateral ventricles act like reservoirs containing cerebral spinal fluid (CSF): fluid that is constantly circulating around the brain and the spinal cord. When a bleed occurs in one or both of the ventricles and the blood then clots it can cause a blockage to the flow of CSF. This can then cause parts of the brain and the skull to swell (hydrocephalus) resulting in further brain damage.

Children who have suffered from intraventricular haemorrhage may experience global developmental delay and/or cerebral palsy.

A brain haemorrhage may have been caused by trauma to the baby’s head during a difficult delivery or as a result of an infection. In some situations, the haemorrhage may have been avoided with adequate care and this is where we can help.

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Intrauterine growth restriction

Intrauterine growth restriction (IUGR) describes the situation when a baby fails to grow properly in the womb.

A developing baby requires oxygen and nutrients in order to grow. Almost everything the baby needs is delivered to the baby from the mother through the placenta. However, when the baby cannot get everything that it needs to grow, their growth may become restricted.

When it becomes apparent that a baby is not growing properly in the womb, regularly checks will be carried out by a doctor or midwife to check on the health of the baby. If the baby is then showing signs that they are beginning to struggle, early delivery may be indicated.

We work with children who have been affected by IUGR that was not picked up early enough in the pregnancy, resulting in brain damage.

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Meningitis is an infection of the meninges: the three membranes surrounding the brain and the spinal cord. Various different types of viruses and bacteria can infect these membranes.

Brain damage can occur in different ways as a result of meningitis. Sometimes the bacteria or virus can release toxins that damage the brain. Sometimes the body’s own inflammatory response to the virus or bacteria can result in brain damage.

Babies and children who have suffered from meningitis may experience a wide range of different types of brain damage, depending on which areas of the brain are affected. These may include cerebral palsy, epilepsy, hearing loss and cognitive difficulties.

Early recognition and treatment of meningitis can save lives. We work alongside families where there has been a delay in treating meningitis or a failure to treat the meningitis appropriately.

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Sepsis, or septicaemia, arises in cases of severe infection. Sepsis can occur around the time of delivery, affecting both mothers and their babies.

Sepsis can lead to organ failure, brain damage and, in some extreme circumstances, death.

Due to the risks from the condition, sepsis needs to be recognised and treated at the earliest opportunity. When initial signs are missed, the window of opportunity for early treatment can be lost, and you or your baby may have been affected more severely as a result. We assist families investigating a claim for a delay in diagnosis and treatment of sepsis.

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Chorioamnionitis arises when the membranes and amniotic fluid surrounding the fetus become infected.

The risk of chorioamnionitis increases once the waters are broken (rupture of membranes), so mothers are often given antibiotics once their waters are broken to prevent infection.

Chorioamnionitis can lead to the baby developing an infection too. For this reason, chorioamnionitis must be treated promptly to prevent infection to the baby. This should involve administering antibiotics and may involve prompt delivery of your baby.

Please do get in touch if you have been affected by chorioamnionitis.

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Induction of labour

Induction of labour describes the process whereby labour is started artificially.

Induction of labour may be required because the pregnancy has gone past the due date or because there are complications in the pregnancy, such as diabetes, that may make earlier delivery the safest option.

Induction of labour normally starts with a membrane sweep, which involves the midwife sweeping a finger around the cervix. A sweep can stimulate contractions and labour.

The next step may involve the administration of prostaglandins (this often involves the insertion of a pessary), which are compounds that can cause ripening of the cervix.

If neither a membrane sweep nor prostaglandins kick start labour, syntocinon may be given. Syntocinon mimics the natural hormone, oxytocin, which is released in the body to progress labour. Syntocinon is given through a drip.

Both mother and baby require careful monitoring during induction of labour. The process may cause the uterus to be over-stimulated, leading to very intense and long contractions which can cause stress to the baby. As the baby becomes stressed it may deplete its oxygen supply resulting in a shortage of oxygen which, on very rare occasions, can result in brain damage. Normally this is well managed through monitoring and administering medication to slow contractions down if necessary.

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Instrumental or assisted deliveries

An instrumental or assisted delivery describes when forceps or a vacuum cup are used to help deliver a baby.

Forceps look a bit like tongs. They fit around the baby’s head and are used to gently pull the baby during a contraction. A vacuum cup fits to a baby’s head by suction. Just like with forceps, a vacuum cup may be used to apply gentle traction to the baby during a contraction.

In premature babies, the use of a vacuum cup carries a slightly higher risk of causing a brain bleed than forceps. For this reason a vacuum cup should be avoided before the age of 32 weeks gestation, and used cautiously between 32 and 36 weeks gestation.

An instrumental delivery should be discontinued if delivery is not achieved following three gentle pulls.

On rare occasions instrumental deliveries can result in injury to the baby. Sometimes this is very mild such as grazes to the head, but a difficult instrumental delivery can lead to brain damage because of bleeding on the brain.

We advise parents of children who have sustained injuries from instrumental deliveries and will investigate to establish whether the injury was avoidable.

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Caesarean section and impacted fetal head

Difficult delivery of the fetal head during a caesarean section may arise when the baby’s head becomes impacted in the maternal pelvis. As labour progresses the baby’s head descends through the mother’s pelvis. When a caesarean section is required at a later stage of labour, it can become difficult to extract the baby’s head where it has become lodged in the pelvis. In addition, strong uterine contractions can have the effect of clamping the baby’s head within the pelvis, compounding the difficulty of the delivery.

Extraction of the head may be more difficult in situations where there has been a failed attempt to deliver the baby by instrumental delivery; or a failed induction of labour.

There are currently no national management protocols for dealing with an impacted fetal head and, unfortunately, it is affecting an increasing number of babies.

A difficult extraction of the head during a caesarean section can lead to complications for both the mother and the baby. Maternal complications may include a major haemorrhage, tears, or injury to the surrounding organs. Complications to the child may result in brain injury either as a result of a shortage of oxygen during the prolonged delivery or as a result of direct trauma.

An injury caused by a difficult caesarean section can be extremely varied. From skull fractures to widespread brain damage, we support families affected by difficult deliveries.

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Delay in delivery

If a baby is beginning to show signs of distress in the womb, it is often necessary to expedite the birth.

Signs of distress are normally picked up by careful monitoring of the baby’s heart rate in the womb. This might be via intermittent auscultation, when the midwife listens to the baby’s heart at intervals and during and after a contraction, or via continuous monitoring with a CTG which is attached to the mother’s abdomen.

When monitoring the heart rate, the midwife or obstetrician will be looking for changes that indicate that the baby could be in distress. These may include an abnormally fast or slow heart rate, intermittent drops in the heart rate (decelerations), or a reduced variability in the heart rate.

If abnormalities are identified, then the baby may need to be delivered very quickly, particularly when the abnormalities indicate that the baby may be experiencing a shortage of oxygen.

We often represent families affected by a delay in delivering their baby. This is normally because there has been a failure to recognise the baby’s heart rate abnormalities and the baby has suffered from a shortage of oxygen as a result.

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Cord prolapse

A baby’s brain requires oxygen, delivered to the baby via the umbilical cord from the placenta. If this cord is squashed, blood supply to the baby may be interrupted.

Cord prolapse can occur during birth. It occurs when the umbilical cord descends at the same time as the presenting part of the baby and gets trapped between the baby and the birth canal.

When cord prolapse occurs, the baby needs to be delivered very quickly, normally by emergency caesarean section. In addition, steps can be taken to alleviate the pressure from the cord such as the midwife elevating the presenting part of the baby.

If the baby is not delivered quickly enough and these steps are not taken then the baby can suffer brain damage as a result of oxygen deprivation. Do get in touch to see how we might assist you if your baby has suffered from brain damage following cord prolapse.

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Shortage of oxygen (hypoxia)

Brains require oxygen and a reduction in oxygen (hypoxia) can result in brain damage.

A baby’s brain will cope with a shortage of oxygen for a short time, but within several minutes the parts of the brain with the highest energy demands will begin to get damaged.

A shortage of oxygen may occur if a birth is complicated by shoulder dystocia, cord prolapse or a delay in delivery. Similarly, a baby affected by intrauterine growth restriction may have suffered a prolonged period of partial oxygen deprivation.

Babies affected by hypoxia may suffer from hypoxic ischaemic encephalopathy and go on to develop cerebral palsy, developmental delay or other cognitive difficulties. It is therefore essential that swift action is taken to deliver babies who are showing signs of hypoxia.

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Untreated jaundice (hyperbilirubinemia)

Blood contains red blood cells which carry oxygen around the body. Red blood cells are constantly being created and broken down. When red blood cells break down, bilirubin is released.

Jaundice (sometimes referred to as hyperbilirubinemia) can occur when there is too much bilirubin in the body. This may be because red blood cells are being broken down too quickly, or because the body is unable to dispose of the bilirubin quickly enough.

Babies who are struggling with jaundice will have their bilirubin levels checked regularly. If the bilirubin levels are too high then the baby will undergo phototherapy which uses light to break down the bilirubin. If phototherapy is not enough to break down the bilirubin then a baby may require a blood transfusion, known as an exchange transfusion.

Too much bilirubin is toxic to the brain and can cause brain damage. This is known as kernicterus. Bilirubin-induced brain damage can result in developmental delay, hearing problems and cerebral palsy. We represent children who, sadly, have not received the proper care for jaundice because their raised bilirubin was not spotted quickly enough or the correct treatment was not carried out.

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Hyponatraemia (low sodium)

Hyponatraemia occurs when the levels of sodium in the blood are abnormally low.

Hyponatraemia in the mother can lead to hyponatraemia in the baby, which in turn can lead to the baby’s body holding on to fluid and result in swelling of the brain (cerebral oedema).

Maternal hyponatraemia is thought to be associated with the administration of large volumes of fluids used to deliver drugs that are used in the induction of labour; or excessive drinking during labour. In addition, some of the drugs used in labour have antidiuretic affects which can contribute to the problem. Through accurate fluid balance monitoring and early detection though, the risk of hyponatraemia can be reduced.

Early symptoms of hyponatraemia include nausea, lethargy and a headache. More advanced symptoms include disorientation or agitation. Hyponatraemia can lead to seizures or coma.

If signs of hyponatraemia are identified, then regular blood tests should be carried out to test sodium levels. If the level is too low, then fluids are likely to be restricted and prompt delivery may be indicated. In severe cases, sodium rich fluid will be administered intravenously.

Prompt detection, monitoring and treatment of hyponatraemia are essential. If you or your baby have been affected by hyponatraemia, please contact us to find out more on how we may be able to assist you.

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Hypoglycaemia (low glucose)

Hypoglycaemia is when levels of blood glucose are too low.

At all stages of life, our brains require large amounts of energy. Most of the energy is produced from a chemical reaction involving glucose (sugar) and oxygen.

Under normal conditions, the body carefully maintains levels of blood glucose. When blood glucose levels rise, glucose is turned into glycogen that can be stored in the body. This reduces the amount of glucose in the blood and blood glucose levels are restored. Conversely, when blood glucose levels drop, glycogen is turned back into glucose, and blood glucose levels are maintained.

Babies are particularly vulnerable to low glucose or hypoglycaemia because they do not have good glycogen stores.

Signs of hypoglycaemia in newborn babies include shakiness, low body temperature, lethargy, lack of interest in feeding, floppiness, a blue tint to the skin and lips. In severe cases, seizures and coma can result.

If hypoglycaemia is suspected, blood glucose levels will be carefully monitored and a fast acting glucose source will be administered if required.

Unfortunately, on rare occasions, the signs of hypoglycaemia are not spotted quickly enough. Without enough glucose in the blood, the brain is deprived of energy which can result in brain damage.

The pattern of brain injury in hypoglycaemia will depend on the severity and duration of the insult. Babies who have suffered from hypoglycaemia may go on to suffer from developmental delay, epilepsy and cerebral palsy.

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Contact us if you have any questions about making a claim for brain damage at birth as a result of negligence.