Director's Forum

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Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient to Cause Cerebral Palsy

by David B. Troxel, MD, Medical Director, Board of Governors

The report “Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology” was published in 2003 by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics. It significantly broadened our understanding of this problem and provided the necessary information for evaluating the newborn with encephalopathy. An executive summary of the report entitled “Neonatal Encephalopathy and Cerebral Palsy: Executive Summary” (Obstetrics and Gynecology, 2004 103:780–81) is an important reference.

As noted in the forward of this report, “Until recently, four nonspecific clinical signs: 1) meconium-stained liquor, 2) nonreassuring fetal heart rate patterns, 3) low Apgar scores, and 4) neonatal encephalopathy were often assumed to be adequate evidence of birth asphyxia and hypoxic-ischemic neonatal encephalopathy in the absence of objective criteria to show that a de novo acute hypoxic event actually occurred during labor and delivery.” In reality, these four nonspecific signs often are the results of pathological insults to the newborn that occurred before labor and delivery.

Dr. R. Gibbs, et al., at the University of Colorado felt that applying the evidence contained in this report had great implications for risk management; however, the report did not make specific recommendations for clinical practice. Therefore, Dr. Gibbs, et al., wrote “Suggestions for Practice to Accompany Neonatal Encephalopathy and Cerebral Palsy” (Obstetrics and Gynecology, 2004 103:778–79).

Both of these articles are available on the ACOG Web site (www.acog.org).

The Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient to Cause Cerebral Palsy was developed by Drs. Henry Galan and Ronald Gibbs at the University of Colorado. It summarizes the “Suggestions for Practice” and provides a practical guideline to follow when faced with this difficult problem. Documenting the presence or absence of the 4 Essential and 5 Suggestive Criteria should be done in all cases of potential neonatal encephalopathy and cerebral palsy.

The Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient to Cause Cerebral Palsy is available on our Web site at http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_000310.

Please consider:

• Sharing this information with your entire perinatal team, including Pediatrics, NICU Staff, Anesthesia, L&D Personnel, etc.
• Developing written guidelines and pro­tocols to apply the 12 “Suggestions for Practice” in your institution.
• Developing an interdisciplinary nomen­clature at your institution that avoids nonspecific terms such as “fetal distress” and “birth asphyxia.”

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  About the Author

  David B. Troxel, MD, is medical director of The Doctors Company. Dr. Troxel is clinical professor emeritus in the School of Public Health at the University of California at Berkeley. He is past president of the American Board of Pathology and the California Society of Pathologists.

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