International Cerebral Palsy Task Force Research Articles

Asphyxie perpartum à terme : facteurs de risque de survenue et conséquences à court terme. À propos de 82 cas

Intrapartum asphyxia is a rare yet serious complication during labor with immediate consequences and possible long-term neurological impairment. The international Cerebral Palsy Task Force established criteria that attribute a cerebral palsy to intrapartum asphyxia: metabolic acidemia measured at birth with pH<7and base deficit≥12mmol/L. To determine the risk factors of an intrapartum asphyxia occurring in term live births, to evaluate the short-term consequences. Our retrospective study included all births between 2002and 2010in a level 3maternity of a university hospital center. Inclusion criteria were those of the Cerebral Palsy Task Force associated with a gestational age≥34weeks of gestation. We studied the conventional markers of intrapartum asphyxia: Apgar score at 5minutes, abnormal cardiotogographic recordings whether they occurred after a sentinel hypoxic event or not before and during labor. The duration of expulsive efforts, the amniotic fluid aspects, the delivery mode as well as the preexisting pregnancy pathologies were also evaluated. On the other hand, we studied the short-term consequences at the newborns: death, multiorgan failure and especially the occurring of a neonatal encephalopathy using Sarnat and Sarnat staging. One hundred and twenty-nine newborns (0.43%) out of 29,416live births had a pH<7of whom only 82 (0.27%) presented a real intrapartum asphyxia and were included in this study. A preexisting pregnancy pathology was found in 22% of the women. Hypoxic events were noted in only 9/82of the cases. Abnormal cardiotocographic recordings were present in 97.6% of the cases. The duration of expulsive efforts as well as the amniotic fluid aspects did not interfere with the occurring of a metabolic acidemia. Caesarean rate was at 46.3% and instrumental extraction rate was at 34.1%. Thity-eight newborns (46.3%) were admitted in neonatal intensive care in which we noted 3deaths (3.65%), 2multiorgan failures (2.4%) and 17neonatal encephalopathy (20.7%). The pH value seemed to influence the occurring of an encephalopathy: 50% when pH<6.9vs. 13.6% when pH≥6.9 (P=0.0013), as well as for the base deficit: 50% when BD<-18vs. 15.7% when BD≥-18 (P=0.0068). Apgar score at 5minutes also seemed predictive for a neonatal encephalopathy: 100% when<4, 46% between 4and 6and 11% when>6 (P<0.001). Our results showed an intrapartum asphyxia rate half the one widely recorded of 0.5% of total live births. Our study also validates the commonly used markers to evaluate a high risk of an early neonatal encephalopathy. This study should be continued with the evaluation of hypoxia long-term consequences on the psychomotor development of these kids and especially the occurring of cerebral palsy.

Cerebral palsy: intrapartum causal criteria used in courts.

In spite of advances in obstetrics and neonatology, the reported incidence of cerebral palsy in developed countries is about two per 1000 live births (Graham et al. Am J Obstet Gynecol 2008;199:587–95). The linked paper by Leigh et al. suggests that almost one in seven cases are the result of intrapartum hypoxia, and the UK Confidential Enquiry into Stillbirths and Deaths in Infancy (1999) found that 50% of 567 of such cases investigated were possibly or probably preventable. In the UK, during 2000–2010, awards for cerebral palsy judged preventable by better care totalled £1 263 581 324: 41% of all obstetric settlements (Ten Years of Maternity Claims. NHS Litigation Authority, 2012). In the case of McKenzie vs Fife Acute Hospitals NHS Trust [2006] ScotCS_63, the judgment included a ‘threefold test’ for duty of care. The harm must be: (a) reasonably foreseeable; (b) there must be a ‘relationship of proximity’ (duty of care) between the plaintiff/claimant and the defendant; and (c) it must be ‘fair, just and reasonable’ to impose liability. Evidence from the International Cerebral Palsy Task Force (MacLennan BMJ 1999;319:154–9) was used to support a causal relationship between acute intrapartum hypoxia and cerebral palsy. The case met all of the three essential criteria: (a) intrapartum metabolic acidosis (pH < 7.00 and base deficit ≥12 mmol/l); (b) early onset severe or moderate neonatal encephalopathy at ≥34 weeks of gestation; and (c) subtype spastic quadriplegia or dyskinetic cerebral palsy. The case also met four of the five non-specific criteria: (a) sudden, rapid, and sustained deterioration of the fetal heart rate; (b) APGAR score of 0–6 for >5 minutes; (c) early multisystemic dysfunction; and (d) early imaging evidence of acute cerebral abnormality. Only one criterion was difficult to establish: evidence of an identified sentinel hypoxic event, such as (a) listed above. The plaintiff's lawyers successfully argued that the prolonged use of Syntocinon®, compounded by misinterpretation of the cardiotocogram, was sufficient to cause damaging hypoxia, however. The judge was satisfied that, on the balance of probabilities, there was an act of omission, as had steps been taken earlier to discontinue the Syntocinon® infusion and expedite delivery the damage would have been avoided. There was a failure to exercise the due diligence that was expected from a reasonably prudent and skilled professional. A similar finding was reached in the more recent case of Jack Clayton vs Yeovil District Hospital (http://www.dailymail.co.uk/health/article-2218209/Oxytocin-How-drug-used-speed-births-starve-baby-oxygen.html), highlighting the medico-legal cost of using a powerful drug without due diligence. Obstetricians and midwives must remember that although many cases of cerebral palsy have genetic, environmental, and antenatal causes, this does not obviate their duty to avoid substandard care that will result in them being held responsible for damaging intrapartum hypoxia. None to declare.

PLD.32 Audit of Unexpected Term Admissions to SCBU at Liverpool Women’s Hospital

ObjectiveTo review unexpected term admissions to SCBU, identify areas for improvement in care of women in labour and highlight specific cases for learning points.BackgroundBirth asphyxia is a significant cause of...

An Attempt to Discover Antenatal Etiological Factors for Cerebral Palsy: What does 3D and 4D Ultrasonography Add?

Abstract Cerebral palsy (CP) is a nonprogressive condition affecting developing fetal or infant brain resulting in disorders of movement and posture which are sometimes accompanied by disturbances of cognition, sensation, perception, behavior and seizures. The incidence of CP being 2 to 2.5 per 1000 live births did not considerably change in the last decades. Improvement of perinatal care did not result in the decreasing prevalence of CP. Consensus Statement of International Cerebral Palsy Task Force and its modification presented the essential criteria to define an acute intrapartum event sufficient to cause CP. These criteria were not helpful in allocating the time of brain injury, proving that etiology of CP is difficult to investigate. Better markers of acute intrapartum injury should be defined, although much evidence exists that most causes of CP are prenatal. Advances in 3D and 4D ultrasound (US) give opportunities to investigate fetal morphology and behavior. By 4D US, head, body and limb movements can be visualized simultaneously. The earliest phase of development can be studied in detail, making 4D superior compared to 2D. Is applicable neurological test for fetus available? This question is complicated, because even postnatally several neurological methods of evaluation exist, while hardly accessible fetus has less mature brain. Inexistence of reliable neurobehavioral assessment method for the fetuses is discouraging. The scientific community should intensify efforts in finding out simple, clinically applicable, and reproducible fetal neurological test(s), with fair sensitivity and specificity.

Defining the Pathogenesis and Pathophysiology of Neonatal Encephalopathy and Cerebral Palsy

In Brief The topics of neonatal encephalopathy and cerebral palsy, as well as hypoxic–ischemic encephalopathy, are of paramount importance to anyone who ventures to deliver infants. Criteria sufficient to define an acute intrapartum hypoxic event as sufficient to cause cerebral palsy have been advanced previously by both The American College of Obstetricians and Gynecologists (ACOG) and the International Cerebral Palsy Task Force. ACOG convened a task force that over the past 3 years reviewed these criteria based upon advances in scientific knowledge. In this review, we cover the slow but steady progression toward defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Four essential criteria are also advanced as prerequisites if one is to propose that an intrapartum hypoxic–ischemic insult has caused a moderate to severe neonatal encephalopathy that subsequently results in cerebral palsy. Importantly, all four criteria must be met: 1) evidence of metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH less than 7 and base deficit of 12 mmol/L or more), 2) early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks' gestation, 3) cerebral palsy of the spastic quadriplegic or dyskinetic type, and 4) exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders. Other criteria that together suggest intrapartum timing are also discussed. Intrapartum hypoxic–ischemia encephalopathy is only a small subset of the broader category of neonatal encephalopathy and yet an even smaller contributor to cerebral palsy.

Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy.

The topics of neonatal encephalopathy and cerebral palsy, as well as hypoxic-ischemic encephalopathy, are of paramount importance to anyone who ventures to deliver infants. Criteria sufficient to define an acute intrapartum hypoxic event as sufficient to cause cerebral palsy have been advanced previously by both The American College of Obstetricians and Gynecologists (ACOG) and the International Cerebral Palsy Task Force. ACOG convened a task force that over the past 3 years reviewed these criteria based upon advances in scientific knowledge. In this review, we cover the slow but steady progression toward defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Four essential criteria are also advanced as prerequisites if one is to propose that an intrapartum hypoxic-ischemic insult has caused a moderate to severe neonatal encephalopathy that subsequently results in cerebral palsy. Importantly, all four criteria must be met: 1) evidence of metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH less than 7 and base deficit of 12 mmol/L or more), 2) early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks' gestation, 3) cerebral palsy of the spastic quadriplegic or dyskinetic type, and 4) exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders. Other criteria that together suggest intrapartum timing are also discussed.

Cerebral Palsy and Clinical Negligence Litigation: A Cohort Study

The International Cerebral Palsy Task Force has formulated a set of 3 criteria to ascribe cerebral palsy (CP) to an intrapartum hypoxic event. They include evidence of metabolic acidosis, the early onset of moderate or severe encephalopathy in an infant of 34 weeks' or longer gestation, and the spastic quadriplegic or dyskinetic type of CP. In court cases, the argument often revolves around whether or not there is evidence of acute intrapartum hypoxia and, if so, whether timely and adequate care was given. The study cohort included 138 singleton children with CP born in the years 1984-1993. Cases where there was a recognized postnatal cause of CP were not included. A blinded observer reviewed medical records retrospectively. Legal action was considered in 27 cases, 20% of the total. Twelve actions were discontinued, 7 are pending, and 8 were settled in the claimant's favor. Although the presence of all 3 criteria was significantly likelier to lead to a legal claim, all 3 were not fulfilled in 74% of claim cases. Conversely, 36% of cases with no claim met all 3 criteria, and at least 1 criterion was met in 82% of cases with no legal claim. All 3 criteria occurred more often in successful claim cases, but they did not clearly distinguish between successful and unsuccessful claims. A similar pattern was evident for nonspecific criteria such as a sentinel intrapartum event, an ominous cardiotocogram, a 5-minute Apgar score of less than 7, and an abnormal neonatal CT scan. The essential criteria for acute intrapartum hypoxia are more likely to be met when a legal claim is filed, but they do not appear to influence the legal outcome. Even if CP is of intrapartum origin, this does not necessarily imply negligence, and an antenatal cause does not rule out negligence. Litigation may not be a satisfactory and fair means of making certain that families of CP children will be able to care for their disabled children.

The acidosis paradox: asphyxial brain injury without coincident acidemia

The acidosis paradox: asphyxial brain injury without coincident acidemia

Cerebral palsy and clinical negligence litigation: a cohort study

To compare the prevalence of criteria suggesting acute intrapartum hypoxia in children with cerebral palsy who have and have not been the subjects of clinical negligence legal claims. Nested cohort study within a geographically defined cohort. The former Oxfordshire Health Authority. Singleton children with cerebral palsy born between 1984 and 1993, excluding cases with a recognised postnatal cause for cerebral palsy. Retrospective review of medical records by blinded observer. Three 'essential' criteria defined by the International Cerebral Palsy Task Force which identify acute intrapartum hypoxia. One-fifth (27/138) of all singleton cerebral palsy children were the subject of a legal claim. The presence of all three criteria was significantly more likely to lead to a legal claim (P < 0.01), but in 74% (20/27) of claims, all three were not fulfilled and 36% (4/11) of those satisfying all three criteria did not claim. At least one of the three criteria was met in 82% (91/111) of the cases where there was no claim. Data on fetal or neonatal arterial blood gases were available in only 57% (78/138). Of the 27 claims, 12 were discontinued, 8 were settled and in 7 the legal process is still pending. The presence of the three essential criteria for acute intrapartum hypoxia did not increase the likelihood of a legal claim being settled. The prevalence of the 'template essential' criteria is high in all cases of cerebral palsy. Although the presence of all three essential criteria was more likely in the claims group, this did not appear to influence the outcome of a claim. It remains to be seen whether the existence of the template leads to change in the pattern of decisions made by the courts.

Cerebral palsy and clinical negligence litigation—a cohort study

We set out to compare the characteristics of children with cerebral palsy who have and have not been the subjects of clinical negligence legal claims. This involved a nested cohort study within a geographically defined cohort of a former Health Authority. Participants were singleton children with cerebral palsy born between 1984 and 1993, excluding cases with a recognised postnatal cause for cerebral palsy. The main outcome measures were the three ‘essential’ criteria defined by the International Cerebral Palsy Task Force which identify acute intrapartum hypoxia. One-fifth (27/138) of all singleton CP children were the subject of a legal claim. The presence of all three criteria was significantly more likely to lead to a legal claim (P < 0.01), but in 74% (20/27) of claims all three were not fulfilled and 36% (4/11) of those satisfying all three criteria did not claim. At least one of the three criteria was met in 82% (91/111) of the cases where there was no claim. Data on fetal or neonatal arterial blood gases were available in only 57% (78/138). Of the 27 claims, 12 were discontinued, eight were settled and in seven the legal process is still pending. The presence of the three essential criteria for acute intrapartum hypoxia did not increase the likelihood of a legal claim being settled.

Cerebral palsy and clinical negligence litigation: a cohort study

Objective To compare the prevalence of criteria suggesting acute intrapartum hypoxia in children with cerebral palsy who have and have not been the subjects of clinical negligence legal claims. Design Nested cohort study within a geographically defined cohort. Setting The former Oxfordshire Health Authority. Population Singleton children with cerebral palsy born between 1984 and 1993, excluding cases with a recognised postnatal cause for cerebral palsy. Methods Retrospective review of medical records by blinded observer. Main outcome measures Three ‘essential’ criteria defined by the International Cerebral Palsy Task Force which identify acute intrapartum hypoxia. Results One-fifth (27/138) of all singleton cerebral palsy children were the subject of a legal claim. The presence of all three criteria was significantly more likely to lead to a legal claim ( P < 0.01), but in 74% (20/27) of claims, all three were not fulfilled and 36% (4/11) of those satisfying all three criteria did not claim. At least one of the three criteria was met in 82% (91/111) of the cases where there was no claim. Data on fetal or neonatal arterial blood gases were available in only 57% (78/138). Of the 27 claims, 12 were discontinued, 8 were settled and in 7 the legal process is still pending. The presence of the three essential criteria for acute intrapartum hypoxia did not increase the likelihood of a legal claim being settled. Conclusion The prevalence of the ‘template essential’ criteria is high in all cases of cerebral palsy. Although the presence of all three essential criteria was more likely in the claims group, this did not appear to influence the outcome of a claim. It remains to be seen whether the existence of the template leads to change in the pattern of decisions made by the courts.

Analysis of cord blood gas at delivery: questionnaire study of practice in the United Kingdom

A consensus statement from the International Cerebral Palsy Task Force outlined essential criteria to define an acute perinatal hypoxic event; criteria included evidence of a metabolic acidosis in fetal umbilical...