Many guidelines are aimed at practitioners in a particular field, with limited appeal to those outside. Ocasionally a specialist paper contains something so important that it deserves wider consideration.
One such paper is the statement from the International Cerebral Palsy Task Force published recently in the BMJ.1,2 The statement contained two clear messages:
|Contrary to popular belief, only a minority of cerebral palsy cases begin in labour|
Criteria can be applied to individual cases to determine whether an acute intrapartum hypoxic event is the likely cause.
The statement contains three essential diagnostic criteria for defining intrapartum hypoxia: evidence of a metabolic acidosis in intrapartum fetal, umbilical arterial cord or very early neonatal blood samples; early onset of neonatal tncephalopathy in infants of 34 weeks gestation; and cerebral palsy of the spastic quadriplegic or dyskinetic type. There are also five weaker indicators which may provide circumstantial evidence. These are based on major intrapartum events, cardiotocograph (CTG) evidence, Apgar score, early abnormalities on examination, and brain imaging abnormalities.
The Task Force provides evidence to support the contention that most cerebral palsy originates long before labour. Its criteria for diagnosing cases resulting from intrapartum hypoxia discount reliance on CTG interpretation.
It suggests how cases might be assessed medicolegally in the light of new knowledge. Despite the public's incorrect perception of cerebral palsy as a common consequence of mismanaged labour, the authors do not claim that the statement will see the end of difficult legal cases concerning the condition. At many births the necessary measurements will not be available, and there is still debate around some of the softer supporting imaging criteria.
Medicolegally this must be a landmark paper. In the UK it may help a shift from an adversarial, negligence-orientedlapproach to a 'no fault' system compensating parents with handicapped children. Obstetrics has always been seen as a high-risk specialty by medical defence organisations. The increasing level of awards to support children handicapped from birth trauma increases the premiums for all doctors.
Defensive medical practice is said to be responsible for the rising rates of caesarean sections. Any generally accepted framework to assess whether intrapartum asphyxia has contributed to handicap should be welcomed by public and professionals alike.
GPs are rarely involved in litigation surrounding labour, although many have experienced the discomfort of trying to care for a family with a handicapped baby who are also pursuing redress through the courts. Hostile feelings towards the medical profession are sometimes transferred to the GP. There may be a general loss of faith in medical advice, making it difficult to offer routine postnatal care and continuing support.
Modern Western society no longer regards death or accident as commonplace, and is more likely to view it as somebody's fault than a natural event. Doctors, articularly, have suffered in this culture of blame. In two generations we have moved from GPs performing complicated deliveries in the home with all the attendant risks accepted, to a hospital-based system with little tolerance of any adverse outcome.
The public needs to appreciate that certain courses of action, even natural ones such as starting a family, carry inherent risks. Appreciation of this would allow better understanding of the strengths and weaknesses of medical practice. This paper and its broader messages deserve to be widely publicised and discussed.
- See also News story Guidelines help define cause of cerebral palsy in this issue.
- Bakketeig LS. Editorial. Br Med J 1999; 319: 1016-7.
- MacLennan A for the International Cerebral Palsy Task Force. Br Med J 1999; 319: 1054-9.