• CEREBRAL PALSY
• LOW OXYGEN PROBLEMS
• FETAL DISTRESS 

The pregnancy, labor and delivery, and newborn course mothers and babies can produce problems which doctors and nurses must recognize and treat. Problems with an unborn baby can result from lack of oxygen or blood flow to their brain. This most frequently occurs during labor and delivery when a fetus or unborn baby is undergoing stress from the mother's contractions. Babies of mothers who are diagnosed with high blood pressure, diabetes or other diseases are especially at risk for problems to occur. It is essential for doctors to thoroughly evaluate, monitor and diagnose problems during the pregnancy. If not, babies may not receive adequate oxygen over time in the womb. 

During the birthing process doctors and nurses have the responsibility of making sure the baby does not suffer from lack of oxygen. 

Hypoxemia (which means decreased oxygen in the blood) and ischemia (which means decreased flow of blood) can combine to asphyxiate or suffocate the baby in the womb. If a baby becomes asphyxiated, this can lead to the brain becoming damaged. The injurious process is similar to a child who has nearly drowned in water and suffers brain damage. Doctors have developed electronic fetal monitors to provide information about how a baby is tolerating labor.

The monitor information is printed on a continuous strip of paper next to the laboring mom's bed. It tells the labor and delivery team about the unborn baby's heart rate as well as how the heart is responding to the mother's contractions. When interpreted properly, the labor and delivery team can determine when a baby is getting into trouble from lack of oxygen. Doctors call this fetal distress. 

The labor and delivery team must recognize changes on the fetal monitor tracing which show the baby is suffering from lack of oxygen and blood flow. They must promptly diagnose fetal distress. Once they do, the delivery of the baby must be promptly carried out by cesarean section. The cesarean section removes the baby from a womb which is no longer healthy for the baby; the baby is essentially suffocating in the womb. 

There are situations during pregnancy and the labor which can suddenly effect a baby's oxygen level. Doctors and nurses must promptly recognize and respond to the signs and symptoms of obstetrical emergencies which can cause brain injuries to babies.

These include when the placenta tears and separates from the uterine wall (placental abruption), when the umbilical cord gets pinched if it slips out of the birth canal (cord prolapse); when the uterus splits open (uterine rupture), and sudden, prolonged decrease in the baby's heart rate (fetal bradycardia). In each of these emergencies, there is a dramatic decrease in oxygen and profusion of the blood circulating to the baby's brain. The labor and delivery team must rapidly deliver the baby in minutes by cesarean section before irreversible brain damage sets in. Minutes and seconds are critical in these types of obstetrical emergencies. Delay is inexcusable when doctors and nurses discover any of these complications. . 

If the baby has suffered from lack of oxygen in the womb, the baby will be in a very stressed and depressed condition after birth. The baby may require endotracheal intubation to help him or her breath. They will probably be limp and floppy; they may experience seizure activity, and require a stay in the neonatal intensive care unit. The doctors will observe low Apgar scores and the lab tests will show acidosis, which is a low pH. Often the doctors will use ultrasound to look at the baby's brain, this might be followed up with CT scans or MRIs. 

Days or weeks later the baby will be discharged home. The pediatricians or neonatologists will advise the parents that their child is at risk for developmental problems. The problems may not be obvious until the child is one year of age or older. Ultimately the pediatrician or pediatric neurologist will make the diagnosis of cerebral palsy. Doctors might use the terms hypoxic ischemic encephalopathy, quadriparesis or other medical terms. Often the cerebral palsy could have been prevented had the labor and delivery team properly observed, monitored and acted promptly when the unborn baby demonstrated fetal distress. 

• TRAUMATIC DELIVERIES 
• VACUUM EXTRACTORS AND FORCEPS 

Obstetricians use mechanical instruments to assist in the delivery of babies. There are two types of instruments used in America to assist with deliveries - forceps and the vacuum extractors. Both of them, when used properly, can help safely delivery babies. Unfortunately, both of these powerful instruments can cause trauma to a baby's head and brain. Doctors must be careful in applying and pulling a baby's head with forceps and vacuum extractors. If they are placed incorrectly, if the doctor uses too much pressure, pulls too hard or too often can all injure a baby's brain. There are several different areas of the brain that can be injured by forceps or vacuum extractors. The trauma leads to bleeding within the brain. If the baby's brain has bleeding inside of it, this can lead to the child developing cerebral palsy. If one or both of these instruments are used, the newborn may at first appear to be normal and healthy. But beginning shortly after delivery the newborn may begin to have trouble breathing, turn blue, demonstrate seizure activity and other abnormal neurologic signs. These sick babies often will be transferred to the neonatal or newborn intensive care unit where imaging studies - ultrasound, CT scans, or MRIs - are used to determine the area of the brain which is affected and to what extent.

After discharge from the hospital, the baby may not meet his milestones and demonstrate physical and mental impairment.

INFECTIONS

Maternal infections have the potential to affect a baby. Bacteria which is completely normal and without symptoms to a mother can be devastating to a baby. It is the responsibility of the physicians to diagnose when a pregnant woman has a bacteria which could harm her baby. The doctor must treat the infection and choose the correct route of delivery - cesarean section or natural vaginal delivery. Examples of infections which can injure a baby's brain includes Group B Strep, herpes, and meningitis. 

After a child is born, infections which are left untreated can cause brain damage. One of the most serious infections is meningitis. Meningitis infects and rapidly attacks a child's brain. When a child begins showing certain signs and symptoms of being sick, the doctors must thoroughly investigate the type of infection. A spinal tap or lumbar puncture is required for a doctor to safely rule out this devastating infection. If it is not timely diagnosed and treated by the doctor, it can cause serious and permanent neurologic injuries to a child, including cerebral palsy. 

• BRACHIAL PLEXUS INJURY / ERB'S PALSY
• SHOULDER DYSTOCIA 

Brachial plexus injuries are the result of a traumatic delivery. The brachial plexus nerves are nerves which are attached to the spine and control the use of the upper extremity. This injury is also called Erb's palsy and Klumpke's palsy. Obstetricians using improper delivery techniques can cause the stretching and tearing of these important nerves during delivery. The most common birth situation which leads to the obstetrician causing the injury is a shoulder dystocia. Shoulder dystocia refers to a complication which occurs during the delivery of a baby. It happens after the baby's head is delivered and the baby's upper shoulder gets impacted or stuck behind the mother's pubic bone. 

After the baby's head is delivered, the baby's shoulders are perpendicular to the floor. If the baby's shoulders are too wide or the mother's pelvis is too narrow, shoulder dystocia can result. The brachial plexus injury results from the doctor pulling down on the head to try and disimpact or free the stuck shoulder. While doctors may use gentle traction on the baby's head during a normal delivery, traction or pulling on the head must be avoided when a shoulder dystocia is encountered. Unfortunately the delivering doctor often rushes the delivery and tries to pull the baby out of the birth canal by pulling on the baby's head causing this injury. Doctors and nurses should be trained
in handling this obstetrical complication in a calm and cool manner.

There are multiple accepted maneuvers used to free the baby's shoulder when it is stuck. These include pushing the mother's legs to her chest and having the nurse apply pressure on an angle by the mother's pubic bone. The nurses or delivery room personnel should never apply pressure on a woman's upper abdomen. This can get the baby's shoulder more stuck and stretch the brachial plexus nerves.

This inappropriate maneuver is called fundal pressure. 

There are some women who should not be allowed to have a vaginal delivery because of concerns of birth trauma. Prenatal factors, which should be considered by the doctor, include diabetes in pregnancy, an expected large baby, a small pelvis, excessive maternal weight gain, obstetric history, maternal obesity, and the gestational age. There are a number of factors which can arise during the labor which should lead an obstetrician to consider performing a cesarean section because of the risk of a traumatic delivery. These include a long labor, the need for forceps or a vacuum extractor, and a prolonged descent of the baby down the birth canal. 

If your baby had an arm that was limp after delivery and has not recovered on its own, there is medical treatment and attention which can improve the long-term outcome of brachial plexus injuries. It is essential that physical and occupational therapy begin and a referral to a pediatric neurologist be carried out. Neurosurgeons and plastic surgeons work together in performing surgery to clean and reattach nerve fibers to the injured and effected brachial plexus nerves. The surgery must be conducted at a very young age while there is potential for nerve regeneration. Subsequent surgeries may include muscle and tendon transfers at various age intervals. Ultimately the child may regain some function in their shoulder, arm, elbow, wrist or fingers as the result of these procedures. At Texas Children's Hospital there is the Brachial Plexus Clinic which is dedicated to helping children with brachial plexus injuries. 

Permanent brachial plexus injuries are very significant to the impaired child. They may effect the child's ability to perform basic life functions. The arm may appear shorter and withered; there may be pain and discomfort associated with using and stretching it. Ultimately when the child becomes an adult, he or she may have difficulty finding a job which only requires the use of one hand and arm as sixty percent of American jobs require the use of two arms.

As many parents of children with a brachial plexus injury know, these injuries are severe and permanent. Their impact on the child's future is significant.