Understanding Newborn Strokes

Perinatal strokes, which can result in devastating injuries to newborns, are sometimes caused by medical negligence during labor and delivery. To prove causation, lawyers need to understand how to identify and investigate the injury.

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Strokes that occur at or near the time of encephalopathy (blood and oxygen that—like the liver, heart, and kidneys— birth, which carry a substantial risk for deprivation to the brain), vasospasm, or it depends on adequate oxygen and abnormal neurodevelopment,1 are often obliteration by an inflammatory (infec- nutrients being supplied through a overlooked as a significant contributing tious) process. While PAIS is occasion- dense network of blood vessels. Cere- factor to cerebral palsy. As child advo- ally detected in the posterior, anterior, bral blood flow begins at the heart, and cates, plaintiff attorneys handling these or multiple cerebral arteries, the middle it permeates through the carotid arte- cases must examine the facts closely: cerebral artery is the most common rial system (two blood vessels in the Was the perinatal stroke2 the prevent- blood vessel involved. neck divided into internal and external able result of medical negligence that Plaintiff attorneys must have a general carotid arteries) and the vertebral resulted in the child’s permanent brain understanding of brain perfusion (how arterial system, which consists of two damage? blood passes through the brain) to ascer- arteries that create the basilar artery in Perinatal arterial ischemic stroke tain the potential origin of the injury— a complex called the “vertebrobasilar (PAIS)—a known cause of long-term and its possible causes and effects—to system.” This system supplies blood neurologic impairment3—is caused by better evaluate, investigate, and prove to the brain when the carotid arteries a disruption in blood flow to a major these cases. cannot. The basilar artery and the cerebral artery, resulting in an area internal carotid arteries also join with of damaged cerebral tissue. It can be Arterial Blood Supply to the Brain other arteries to form an arterial ring at the result of thrombosis, embolism, The brain is one of the most highly the base of the brain called the “Circle trauma, compression, hypoxic–ischemic perfused organs in the body, meaning of Willis.” 4 (See Fig. 1, p. 48).5

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The most harmful consequence of CIRCLE OF WILLIS cerebral dissection is ischemia—and BASILAR ARTERY there are reports of middle and cerebral artery ischemia after traumatic delivery INTERNAL CAROTID by forceps.15 There also are high rates of ARTERIES PAIS reported after mechanical deliv- EXTERNAL CAROTID eries.16 In one study, 10 out of 46 infants ARTERIES diagnosed with cerebral infarction in VERTEBRAL ARTERIES COMMON CAROTID the first month of life were delivered by AORTA ARTERIES forceps or vacuum.17 Forceps. Ischemia within the terri- INNOMINATE ARTERY tory of the MCA has been documented SUBCLAVIAN ARTERIES after a stretch injury to the artery that was caused by a failed extraction attempt Figure 1 using forceps.18 Additional studies have documented similar findings of unilat- The internal carotid arteries branch supplied by the internal carotid arteries eral MCA occlusions resulting from to form the anterior cerebral artery may be caused by direct trauma to the trauma by forceps delivery.19 and the middle cerebral artery (MCA), newborn’s head.9 Direct trauma can Practice tip. It is not uncommon which is the largest cerebral artery. The occur during a complicated delivery—for for the delivery record to be vague—or MCA supplies blood to the parts of the example, excessive use of force during a completely silent—as to the placement brain that control the primary motor Zavanelli maneuver10 or from a vaginal, of the forceps, the number of times the and sensory areas of the face, throat, operative, or instrumental delivery. In forceps were used, and the number of hand, and arm—as well as the areas that one case, the obstetrician fractured pulls on the baby’s head. When handling control speech.6 An MCA stroke results the baby’s skull while removing the these cases, it is crucial to question the in a sudden onset of neurological deficits baby’s head from the mother’s pelvis by delivering physician at both deposition related to these areas—such as seizures— hand, causing an intracranial bleed in and trial to discover that information. due to cerebral infarction (an area of the newborn. The newborn suffered a Also ask the client for other sources of necrotic tissue) or ischemia (an area with seizure disorder, feeding difficulty, and this information, such as a birth video or inadequate blood supply) in the parts of respiratory distress. Today, the child has photographs. When explaining forceps the brain supplied by this artery. Nearly cerebral palsy as a direct result of placement and dissection or compres- all unilateral lesions—those occurring in delivery trauma.11 sion of the artery to the jury, be sure to only one hemisphere of the brain—in the Trauma by mechanical delivery. use diagrams and animations. perinatal period involve the MCA.7 Arterial dissection occurs when a small Vacuum. Other medical issues tear forms in the inner lining of the that may lead to mechanical vaginal Mechanisms of Injury arterial wall, allowing blood to collect deliveries are prolonged rupture of Brain imaging shows evidence of brain between the inner and outer linings of membranes, a prolonged second stage lesions in 80 percent of newborns with the artery and causing constriction or of labor,20 cephalopelvic disproportion “neonatal encephalopathy”: full-term complete occlusion. Dissection of the (when the baby’s head is too big to fit infants who show neurological impair- middle and cerebral arteries has been through the birth canal), and otherwise ments within the first few days of birth.8 connected to newborn strokes,12 and the difficult deliveries.21 Early and serial MRI examinations are use of a vacuum or forceps in delivery can Similar to forceps, vacuum-extracted extremely important—they detect not potentially result in arterial dissection. deliveries can result in major fetal only the existence of lesions but also The rate of injury caused by these instru- trauma, including subdural, subgaleal, or when they formed. Several factors ments has been underestimated13 due to a cerebral hemorrhage; shoulder dystocia during childbirth can cause ischemia in lack of clinical signs and specificity (such with a risk for brachial plexus injury; a newborn. as seizure activity), but reports suggest convulsions; central nervous system Direct trauma to an intracranial that they may account for 20 percent of depression; mechanical ventilation; and vessel. Brain ischemia within the regions all causes of childhood stroke.14 cerebral infarction.22 In one study, for

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example, trauma from a vacuum-assisted medical negligence that perinatal injuries. For example, oxytocin delivery caused stretching of the middle or Pitocin, which prepare the cervix for and posterior cerebral arteries, leading resulted in the child’s labor induction, may lead to excessive to skull fracture, ischemia, and cerebral permanent brain damage? uterine activity during labor, as well as infarction.23 In another study, 80 percent abnormal fetal heart rate patterns.30 of perinatal strokes occurred in compli- The mechanisms of injury from cated deliveries, two-thirds of which excessive uterine activity as the fetal occurred in failed vacuum-assisted professional’s or medical facility’s negli- head passes through the mother’s pelvis deliveries.24 gence caused the injury. are the same as for other types of trauma Practice tip. Newborns with infarcts Trauma from head compression injuries.31 Severe molding, bruising, or generally have abnormal neurode - caused by excessive use of Pitocin. fracturing that manifests externally as velopmental and lower cognitive test “Fetal station” is determined by the bleeding may manifest internally as scores compared to newborns with degree of descent of the baby’s head an intracranial hemorrhage that may similar patterns of brain injury without through the birth canal in relation to cause an embolism. 32 Additionally, infarcts.25 As part of your damages argu- the mother’s pelvis. As the baby moves CCIE caused by decreased blood flow ment, have a pediatric neuropsychology down, contraction forces on the fetal resulting from external compression and expert explain to the jury the resulting umbilical cord and cerebral vasculature increased intracranial pressure33 may cognitive deficits that are not apparent impede blood flow. These alterations, also lead to ischemic stroke.34 to the naked eye—such as impaired called “decelerations,” are evaluated by Practice tip. Oxytocin is a naturally concentration, hyperactivity, or poor monitoring the fetal heart rate. Early occurring substance in the human body communication skills. You can turn decelerations—a sign of head compres- associated with childbirth, but Pitocin the results of the expert’s diagnostic sion—are apparent when the lowest tests, such as the Behavior Assessment point of the baby’s heart rate coincides System for Children, into demonstrative with a contraction’s peak. exhibits to use at trial in conjunction Generally, natural labor forces do Online LL.M. with the testimony. For example, use not cause permanent injury to the baby day-in-the-life videos to demonstrate despite compression of the fetal head. in Advocacy to the jury the impact of the injuries on But fetal injury due to prolonged and From the nation’s #1 law the child’s everyday life. excessive uterine activity during labor school in trial advocacy. -U.S. News It is crucial to explain to the jury that has long been documented: It can result health care professionals may violate the in oxygen deprivation to the fetus or • Designed for attorneys in standard of care when they incorrectly fetal cardiac impairment, among other criminal law, civil practice, use an instrument, use the wrong type complications, all of which may ulti- and those who want to teach of instrument, or fail to consider safer mately lead to cerebral ischemia. • Instructors are national leaders in advocacy alternative approaches. For example, to Regional cerebral ischemic injury, education and practice properly apply forceps, the user must however, also can occur from direct • Study any time, any place— know the fetal position and the degree trauma caused by excessive labor complete your degree online 28 of asynclitism (how far a baby’s head is forces. This is known as craniocere- in less than two years tilted to one side).26 And certain condi- bral compression ischemic injury, which • Includes in-person tions—including incomplete cervical can lead to craniocerebral compression workshops dilation, inadequate maternal pelvic ischemic encephalopathy (CCIE).29 This size, and a previously unsuccessful injury occurs when the interval between Learn more. Apply now. vacuum extraction attempt—should the mother’s contractions is less than alert medical professionals that vacuums one minute—a baby requires at least that stetson.edu/advocacyllm or forceps should not be used.27 amount of time to reperfuse his or her 727-562-7317 Carefully review the medical records brain with oxygenated blood. to see if any of these circumstances Drugs commonly used to induce existed: They are essential to support labor are associated with excessive your argument that the health care uterine activity that may result in these

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It is crucial for health care providers to understand and recognize abnormal signs and symptoms associated with PAIS in the hours after birth and closely watch at-risk infants.

occiput-posterior position (the back of neonatal records to rule out less likely the baby’s head is against the mother’s causes for arterial cerebral infarction, spine),38 can lead to prolonged labor including congenital heart disease, and traumatic birth.39 CPD also alters bacterial meningitis, and blood clot- the progress of labor, which may be ting disorders. complicated by the baby’s failure to Other factors that increase the descend or the cervix’s failure to dilate— risk of PAIS are oligohydramnios is a synthetic oxytocin that affects all increasing the risk of neonatal arterial (low amniotic fluid); preeclampsia; mothers in a different way. The best ischemic stroke.40 prolonged rupture of membranes; way to determine if Pitocin has caused Practice tip. Attorneys should cord abnormality, such as when it has a excessive uterine activity is by reviewing examine the medical record for descrip- single artery; chorioamnionitis (bacte- the fetal heart monitoring strips. Count tions of the doctor’s vaginal examina- rial infection that moves up the vagina how many contractions the mother is tions during the active phase of labor, to the uterus after a mother’s waters experiencing every 30 minutes: If she is which can demonstrate whether these have broken); and primiparity (when a experiencing more than 15 contractions issues were present during delivery. mother is giving birth to her first child). in that time period, then she is experi- When you suspect arterial cere - encing excessive contractions. Investigating the Injury bral infarction, ask your client about Keep in mind that Pitocin is not a Keep in mind that newborns with PAIS the types of diagnostic imaging taken dose-dependent drug. Each individual usually seem like healthy babies after within the first three to seven days after responds differently to the dosage, so birth, with normal Apgar scores and birth. Then, request original formats a dose of Pitocin that may be appro - cord pH values, and they often remain of those scans so you can send them priate for one patient may be excessive with their mothers in the postnatal to your causation experts—such as a for another. In 2007, the FDA issued ward. But their conditions deteriorate pediatric neuroradiologist—to support a “black-box” warning—the strongest within three days of delivery: Newborns your theories of causation and timing. warning—about Pitocin, recommending may experience seizures (generally You should also retain all subsequent that it only be used when induction of presenting as apnea—episodes of not therapy records. Through expert testi- labor is medically necessary or in select breathing), hypotonia (low muscle tone), mony, you can demonstrate the various cases of stalled labor.35 jitteriness or lethargy, irritability, or cognitive and physical disabilities your Trauma from head compression poor feeding. They may also experience client suffered—and will continue to caused by cephalopelvic disproportion. “dusky episodes,” occasionally turning suffer—throughout his or her life. A disparity between the size of the fetus blue around the mouth. It is crucial for Newborn stroke is a complicated and the maternal pelvis can also result in health care providers to understand and medical issue—and one that is often increased uterine activity, exacerbating recognize abnormal signs and symptoms overlooked as a cause of neurological trauma. A mother who is post-40 weeks associated with PAIS in the hours after deficits. Understanding the biology gestation, for example, or one who has birth and closely watch at-risk infants. behind them will help you hold medical gestational diabetes, a small maternal When handling these cases, it’s professionals accountable for the devas- pelvis, or a large baby,36 may cause a critical to vet for potential risk tating consequences of this injury. mismatch between the fetal head and factors. Focus on clinically and statis- the ischial spines, the narrowest inlet tically significant risk factors—such Lisa B. Weinstein is a of the maternal pelvis.37 This is known as abnormal placenta pathology—to director at Grant & as cephalopelvic disproportion (CPD). overcome anticipated defense testi- Eisenhofer in Chicago. Factors that increase the relative mony as to speculative risk factors. Pay She can be reached at maternal-fetal size mismatch, such as an careful attention to the prenatal and [email protected].

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Notes Brain Lesions in Term Infants with Neonatal Vacuum Extraction, 21 Am. J. Perinatology 1. Perinatal strokes occur in up to 15 percent of Encephalopathy, 361 Lancet 736 (2003). 15, 17 (2004) (“Mechanical birth trauma has term newborns. Mamdouha Abdab 9. Paul Govaert et al., Traumatic Neonatal been recognized as a direct cause of Barmada et al., Cerebral Infarcts with Intracranial Bleeding and Stroke, 67 Archives intracranial arterial injury leading to Arterial Occlusion in Neonates, 6 Annals of Disease Childhood 840 (1992), adc.bmj. ischemic or hemorrhagic stroke in the Neurology 495, 495–96 (1979). com/content/archdischild/67/7_Spec_ newborn. The trauma could result from the 2. A perinatal stroke is one that occurs No/840.full.pdf. process of natural birth or from assisted between 28 weeks gestation and the first 10. A Zavanelli maneuver involves pushing the instrumentation with forceps or ventouse seven days of life. See Karin B. Nelson & fetal head back into the birth canal in [vacuum]”.) John K. Lynch, Stroke in Newborn Infants, 3 anticipation of a Caesarean section. 17. Con Sreenan et al., Cerebral Infarction in the Lancet Neurology 150 (2004). 11. The baby also suffered from hypoxia as a Term Newborn: Clinical Presentation and 3. This article will not focus on neonatal result of negligence during the intrapartum Long-Term Outcome, 137 J. Pediatrics 351, cerebral sinovenous thrombosis or period. 353 (2000). hemorrhagic strokes. 12. See Clifford I. Mann et al., Posttraumatic 18. Uros Roessmann et al., Thrombosis of the 4. See generally Neuroscience (Dale Purves et Carotid Artery Dissection in Children: Middle Cerebral Artery Associated with Birth al. eds., 5th ed. 2012). Evaluation with MR Angiography, 160 Am. J. Trauma, 30 Neurology 889 (1980). 5. Recreated. Original image from Children’s of Roentgenology 134, 135–36 (1993). 19. See, e.g., Govaert et al., supra note 9, at 843. Hosp. of Wisconsin, PHACE Syndrome 13. See Stéphane Chabrier et al., Ischaemic 20. The second stage of labor starts when the Handbook ch. 3 fig.4 (Yvonne Chiu et al. Stroke from Dissection of the Craniocervical cervix is fully dilated and ends when the eds.), www.chw.org/medical-care/ Arteries in Childhood: Report of 12 Patients, 7 baby is born. Danforth’s Obstetrics and birthmarks-and-vascular-anomalies- Eur. J. Paediatric Neurology 39 (2003). Gynecology 23 (Ronald S. Gibbs et al. eds., center/conditions/phace-syndrome/ 14. Id. 10th ed. 2008). phace-syndrome-handbook/. 15. See, e.g., Govaert et al., supra note 9. 21. See Vijay Ramaswamy et al., Perinatal Stroke 6. See Neuroscience, supra note 4. 16. See Mary A. Rutherford et al., Neonatal in Term Infants with Neonatal Encepha- 7. Joseph J. Volpe, Neurology of the Newborn Stroke, 97 Archives of Disease in Childhood lopathy, 62 Neurology 2088 (2004). 380 (5th ed. 2008). F377 (2012); see also Manoj Kumar et al. 22. See, e.g., Dena Towner et al., Effect of Mode 8. Frances Cowan et al., Origin and Timing of Contralateral Cerebral Infarction Following of Delivery in Nulliparous Women on

VOLUNTARY MEMBERSHIP ASSESSMENT THE STAKES COULD NOT BE HIGHER Fight back at www.justice.org/fightback

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46-53 Weinstein_FINAL.indd 52 4/7/17 2:36 PM Neonatal Intracranial Injury, 341 N Engl. J. Dystocia, 60 Obstetrics & Gynecology 417 Perinatal Arterial Stroke: A Study of 60 Med. 1709 (1999). (1982). Mother-Child Pairs, 37 Pediatric Neurology 23. C.M. Y. Choy et al., Skull Fracture and 37. See Danforth’s Obstetrics and Gynecology, 99 (2007). Contralateral Cerebral Infarction After supra note 20, at 28 fig.2.8. 40. See Janyne E. Althaus et al., Cephalopelvic Ventouse Extraction, 108 Brit. J. Obstetrics & 38. Susan E. Ponkey et al., Persistent Fetal Disproportion Is Associated with an Altered Gynaecology 1298 (2001). Occiput Posterior Position: Obstetric Uterine Contraction Shape in the Active 24. 83.3 percent of the newborns had arterial Outcomes, 101 Obstetrics & Gynecology 915 Phase of Labor, 195 Am. J. Obstetrics & infarcts. See Ramaswamy et al., supra note (2003). Gynecology 739 (2006); see also Towner et 21, at 2089. 39. See Cynthia J. Curry et al., Risk Factors for al., supra note 22. 25. Ramaswamy et al., supra note 21. 26. See Joong Shin Park et al., Rotational Forceps: Should These Procedures Be Abandoned? 27 Seminars Perinatology 112 (2003). 27. Id.; see also Dena R. Towner & Mary C. Ciotti, Operative Vaginal Delivery: A Cause of Birth Injury or Is It? 50 Clinical Obstetrics & Gynecology 563 (2007). 28. Barry S. Schifrin et al., Cranial Compression Ischemic Encephalopathy: Fetal Neurological Injury Related to the Mechanical Forces of Labor and Delivery, in Stress and Develop- mental Programming of Health and Disease: Beyond Phenomenology (Public Health in the 21st Century) 651 (Lubo Zhang & Lawrence D. Longo eds., 2014). 29. See id. 30. Danforth’s Obstetrics and Gynecology, supra note 20, at 159, 454; see also Cara C. Heuser et al., Tachysystole in Term Labor: Incidence, Risk Factors, Outcomes, and Effect on Fetal Heart Tracings, 209 Am. J. Obstetrics & Gynecology 32 (2013); Kathleen R. Simpson & Dotti C. James, Effects of Oxytocin- Induced Uterine Hyperstimulation During Labor on Fetal Oxygen Status And Fetal Heart Rate Patterns, 199 Am. J. Obstetrics & Gynecology 34 (2008). 31. In animals, damage to a single vessel has been attributed to fetal head compression in the pelvic inlet. See Stephen Ashwal & William. J. Pearce, Animal Models of Neonatal Stroke, 13 Current Opinion Pediatrics 506 (2002). 32. Govaert et al., supra note 9, at 844–45. 33. See Andrew P. Harris et al., Efficacy of the Cushing Response in Maintaining Cerebral Blood Flow in Premature and Near-Term Fetal Sheep, 43 Pediatric Research 50 (1998). 34. Leon I. Mann et al., The Effect of Head Compression on FHR, Brain Metabolism and Function, 39 Obstetrics & Gynecology 721, 726 (1972) (suggesting further research is warranted). 35. Food & Drug Admin., Prescribing Informa- tion as of March 2007: Pitocin (Mar. 26, 2007), www.accessdata.fda.gov/drugsatfda_ docs/label/2007/018261s028lbl.pdf. 36. Houchang D. Modanlou et al., Macrosomia— Maternal, Fetal, and Neonatal Implications, 55 Obstetrics & Gynecology 420 (1980); see also Houchang D. Modanlou et al., Large-For-Gestational-Age Neonates: Anthropometric Reasons for Shoulder

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