Cerebral palsy and criteria implicating intrapartum hypoxia in neonatal encephalopathy – An obstetric perspective for the South African setting

The science surrounding cerebral palsy (CP) indicates that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway to brain injury and later CP. It is therefore simplistic to base causation of CP on only an intrapartum perspective with radiological ‘confirmation’, as is often the practice in medico-legal cases in South African courts. The present modalities (magnetic resonance imaging (MRI) and cardiotocography (CTG)), when available, that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) is taken into account, success for the plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this article to implicate intrapartum hypoxia in hypoxic-ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medico-legal setting.