Abstract:
The objective of this study was to establish scientific causality and to devise criteria to implicate intrapartum hypoxia in cerebral palsy (CP)
in low-resource settings, where there is potential for an increase in damaging medicolegal claims against obstetric caregivers, as is currently
the situation in South Africa. For the purposes of this narrative review, an extensive literature search was performed, including any research
articles, randomised controlled trials, observational studies, case reports or expert or consensus statements pertaining to CP in low-resource
settings, medicolegal implications, causality, and criteria implicating intrapartum hypoxia. In terms of causation, there are differences
between high-income countries (HICs) and low-resource settings. While intrapartum hypoxia accounts for 10 - 14% of CP in HICs, the
figure is higher in low-resource settings (20 - 46%), indicating a need for improved intrapartum care. Criteria implicating intrapartum
hypoxia presented for HICs may not apply to low-resource settings, as cord blood pH testing, neonatal brain magnetic resonance imaging
(MRI) and placental histology are frequently not available, compounded by incomplete clinical notes and missing cardiotocography
tracings. Revised criteria in an algorithm for low-resource settings to implicate intrapartum hypoxia in neonatal encephalopathy (NE)/
CP are presented. The algorithm relies first on specialist neurological assessment of the child, determination of the occurrence of neonatal
encephalopathy (by documented or verbal accounts) and findings on childhood MRI, and second on evidence of antepartum and
intrapartum contributors to the apparent hypoxia-related CP. The review explores differences between low-resource settings and HICs in
trying to establish causation in NE/CP and presents a revised scientific approach to causality in the context of low-resource settings for
reaching appropriate legal judgments.
