Preventable neonatal deaths and brain injury at birth

This work takes a multidisciplinary medical approach, combining obstetrics, paediatrics and neuroimaging. Its aim is to alert professionals and authorities to the failure to consider certain well-established scientific data on brain trauma in newborn babies during childbirth. The majority of these traumas occur in full-term newborns. They can be detected during labour and are therefore potentially preventable. The associated events mainly consist of intracranial haemorrhage, which is most often associated with retinal haemorrhage, or cerebral asphyxia, which may lead to resuscitation with therapeutic hypothermia. Cerebral and retinal haemorrhages may affect up to half of all children born vaginally, yet they are not currently subject to systematic screening or organised surveillance. The authors wish to make clear that no perinatal caregiver or administrator in any country has ever sought to endanger the health of children or mothers. Nevertheless, it is possible that certain current obstetric practices, due to various cognitive biases, contribute to preventable maternal and neonatal morbidity and mortality. Two major biases are at work. The first stems from the belief that the placenta is the main cause of fetal asphyxia, whereas cerebral compression during childbirth is more often the cause of the anoxic encephalopathies observed in full-term newborns. Even when caregivers identify cerebral compression, they do not necessarily recognise the link with neuronal asphyxia. They may then be led to intensify or accelerate skull moulding (using drugs or instruments) to speed up delivery rather than performing a caesarean section earlier. The second bias is assuming that cephalopelvic disproportion is always expressed as obstructed labour, when in fact fetal head compliance is a key factor in understanding the diversity of cases. There are low-compliance and high-compliance disproportions. The former can lead to stalled labour, while the latter can cause fetal pain and cerebral contusion to varying degrees without any overt blockage of labour. The authors recognise that this information may be unsettling and destabilising for colleagues caring for labouring women who strive to provide the best possible care. The data presented here suggest the possibility of a collective cognitive bias among perinatal professionals worldwide, due to an incomplete understanding of the mechanisms of fetal distress and obstetric biomechanics. The authors share the same concern for quality of care and wish to involve their colleagues in the process of evaluating and revising knowledge, as this work calls for. This book aims to provide the necessary perspective to assess the relevance of trials of labour with the child's brain and the maternal perineum in view.