How Childbirth Educators Can Respond to Questions about Vaginal Birth Causing Brain Hemorrhages

Talking Points related to: Looney, CB et al. (2007). Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology, 242(2). 535-41. [Abstract]

Summary of the Study: This study reported on 88 healthy full-term newborn babies who underwent magnetic resonance imaging (MRI) within 5 weeks of birth. An experienced radiologist reviewed each MRI to look for intracranial hemorrhage (ICH), which is bleeding into the part of the skull that houses the brain. Seventeen babies were found to have ICH despite having no symptoms. All of these were born vaginally, for a total of 26% of the babies born vaginally showing signs of asymptomatic ICH. There were no associations found between instrumental vaginal delivery (i.e., forceps or vacuum) or birth trauma and the likelihood of ICH. Study authors concluded that ICH is relatively common following vaginal birth and is not necessarily associated with trauma.

What Your Students May Have Heard: Despite its small size and the fact that none of the babies experienced any serious neurological effects, this study received a lot of media attention. Many of the reports about the study were alarmist and/or misleading. Media claims included, “Vaginal Birth Increases Risk of Brain Hemorrhage in Newborns” (from Science Daily, 1/30/07), “Normal Vaginal Births Cause Infant Brain Hemorrhages” (from MedPage Today, 1/30/07), and even, “If you have been delivered to this world the natural way, you may have experienced at that moment one of the worst hemorrhages in your life” (from Softpedia News, 1/30/07).

Important Facts About the Study:

• This study does not compare vaginal birth with cesarean birth.  It compares babies with ICH and babies without ICH.  
• The study shows an association between vaginal birth and ICH but it does not show that vaginal birth causes ICH.
• The study was almost certainly too small to adequately measure the association between ICH and instrumental vaginal birth or birth trauma.  Only 13 babies were born by forceps or vacuum and only 9 had any birth trauma, and this included scalp lacerations (as well as bruising). 
• The researchers did not measure care practices that might have contributed to ICH such as the mother’s position during pushing, whether she was coached or used physiologic pushing, how and when her membranes ruptured, whether Pitocin was used, or how much the doctor or midwife pulled on the baby during the birth.  In fact, the high rates of cesarean surgery, instrumental vaginal delivery, and birth trauma in the study suggest that the care practices that support normal birth were not typical in the study setting.
• The researchers did not find or suggest that any of the babies suffered any short-term or long-term consequences of ICH.  In fact, none of the babies showed any adverse neurological symptoms at all. The study authors themselves say that it is likely that the type of bleeding they observed in the babies they studied “resolve[s] quickly without substantial consequence” (p. 540).
• The amount of blood seen on MRI was small.  Most people understand the word “hemorrhage” to mean large amounts of blood or uncontrollable loss of blood.  In medical terminology, “hemorrhage” just means “bleeding.”  The hemorrhages in this study were measured in millimeters. 
• The study has an important flaw that may affect the reliability of its results.  Babies with ICH underwent MRI an average of a week earlier than those without ICH.  This is important because ICH disappears within a matter of a few weeks.  This significant difference between the groups might make the results invalid if babies born by cesarean had their MRIs later than babies born vaginally.

Suggested Responses to Questions About the Study:

Note: It is suggested that you use the term “bleeding” or “small bleeds” instead of “hemorrhage” because most people understand the word “hemorrhage” to mean large amounts of bleeding or uncontrolled bleeding, neither of which occurred in this study.

Q: Does this study mean that cesarean surgery is safer than vaginal birth?

A: No.  This study did not compare cesarean surgery with vaginal birth. Although it is true that intracranial bleeding was more common in babies born vaginally, it does not mean that vaginal birth caused the bleeding and there were no symptoms, short-term bad outcomes or long-term bad outcomes in any of the babies studied.  On the contrary, cesarean surgery is known to increase risks for the baby (particularly breathing problems), the mother, and the mother’s future babies.

Q: Should I worry about intracranial bleeding?

A: Probably not. The high rate of intracranial bleeding seen in this study suggests that it is probably a common occurrence and the lack of symptoms or bad outcomes suggests that it is not dangerous to babies. Just as bruising clears up on its own, these small bleeds probably do, too. However, it is possible that the bleeding seen in some of the babies may have been caused by harmful care practices in vaginal birth, such as coached pushing with the woman flat on her back aggressive pulling on the baby’s head as it is born or drugs or procedures that stimulate strong contractions. The study did not look at these factors, so it is impossible to know whether any of them are related to intracranial bleeding in babies. The best precautionary advice is to avoid the routine or frequent use of interventions or care practices that may put excessive pressure on the baby during birth. 

Q: Does my baby need to be screened for intracranial bleeding?

A: Healthy babies do not need to be screened for intracranial bleeding. If your baby undergoes MRI for a specific reason and intracranial bleeding is found, it is important to realize that a small amount of intracranial bleeding is common, is not necessarily due to trauma, and is not always associated with long-term poor outcomes.