Cerebral palsy after caesarean section

There’s not a lot of fetal monitoring research that explores long-term outcomes. When a new paper by Gutvirtz et al. (2026) appeared in my inbox with the title of “Long-term neurological health of the term offspring born via caesarean section for non-reassuring fetal monitoring”, I was optimistic that it would be a useful addition to the knowledge base. Having read it, sure it adds to what we know. But I find myself disagreeing with the authors conclusions.

How was the research done?

The aim of the research was to look at the rate of brain injuries diagnosed up to 18 years after birth among babies born by unplanned caesarean section during labour, who had a “non-reassuring” fetal heart rate pattern. To do this, the authors looked at records of babies born between 1991 and 2021 at one hospital, where basically all women had CTG monitoring in labour. The first group of children they included were those born by caesarean section during the labour where the fetal heart rate pattern was classed as “non-reassuring”. They don’t specifically say what framework was used for CTG interpretation, and given the duration of the study, this may have changed over time.

The second group of children (and this is an important point) were those born by caesarean section due to delayed progress in labour. Babies born vaginally, with or without assistance, or caesarean for other reasons were not included. They also included babies born preterm – which is a little unexpected as brain injury is much more common in this group, and would increase the statistical power of the study.

Having decided on the groups, the hospital records for these babies were then searched, up to when the child turned 18, looking for diagnoses relating to the nervous system. They also looked at a few outcomes close to birth, like Apgar scores and birth weight. Statistical testing adjusted for confounding variables (maternal age, gestation, hypertensive disorders, diabetes, induction, oligohydramnios, low birth weight).

What did they find?

They identified 8,455 babies born due to fetal heart rate changes and 5,878 due to non-progressive labour. Babies born because of heart rate changes were more likely to have a low Apgar (3.4% vs 1.4%), or weigh less than 2,500 g (10.4% vs 2.7%). Perinatal mortality rates were also higher (1.1% vs 0.4%). These rates are on the high side for term babies (in the Australian Birthplace study by Homer et al., 2014 the rate was 0.1%). Once the controlled for the woman’s age and gestation at the time of birth, this was no longer statistically significant.

Cerebral palsy rates were 0.5% in the abnormal heart rate group and 0.3% in the non-progressive labour group, which came close to but was not statistically significant. There was also no difference in other developmental disorders (1.2% vs 1.0%), or in having ANY neurological condition (8.3% vs 8.8%).

What was their conclusion?

This is what they authors concluded –

Our study found that non-reassuring fetal heart rate indication for caesarean delivery did not affect the offspring neurological health, and was not related to higher rates of cerebral palsy in childhood or adolescence, most probably due to prompt intervention by the obstetric teams. These results underscore the fact that survival and neonatal outcome is highly dependant on timing and mode of intervention following a prenatal diagnosis of non-reassuring fetal heart rate.
p. 7

Here’s what I think…

The study does show that the incidence of neurological conditions, and in particular cerebral palsy and developmental disorders, were no different to the group of babies born by caesarean section for heart rate changes than the ones born by caesarean section for a non-progressive labour, when all the women in both groups used CTG monitoring. However, the authors didn’t collect any information about the timing of birth after the onset of the heart rate abnormality. So they really shouldn’t be making assumptions that “timely intervention” is the reason for the absence of difference in the two groups. I’d be stunned if 100% of the caesarean births at a single hospital over a 30 year period were all managed in a timely manner.

There are other possible explanations for the findings in this study. The authors do touch on some of these, but ultimately dismiss them. The decision to record the indication for caesarean section as either due to fetal heart rate concerns or non-progressive labour is arbitrary, as the anticipated time to achieve birth is typically part of the decision making to proceed to caesarean section. As someone with decades of clinical experience, I know the messiness of this distinction. The absence of difference in the outcomes may reflect this.

The sample size could have been too small to provide statistical accuracy. There was after all a 66% higher rate of cerebral palsy and a 20% higher rate of developmental disorders, and they are both rare outcomes. It might be that a study with 25,000 babies might have the power to show a difference.

On the other hand, we know that abnormal fetal heart rate patterns are poorly predictive of poor short-term (Reynolds et al., 2022) and long-term neurological outcomes (Nelson et al., 1996). The lack of difference in outcomes in this study could reinforce these earlier findings, providing more evidence that the premises on which CTG monitoring are based are unsound.

What this study should NOT be used for, but I fear it will be, is proof that CTG monitoring is a useful labour tool. This is vaguely the direction the authors were heading in their conclusion. The study design means that this study was never able to show whether CTG monitoring led to better long-term neurological outcomes.

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References

Gutvirtz, G., Pariente, G., Wainstock, T., & Sheiner, E. (2026, Jan 6). Long-term neurological health of the term offspring born via cesarean section for non-reassuring fetal monitoring. Archives of Gynecology & Obstetrics, 313(1), 13. https://doi.org/10.1007/s00404-025-08258-2

Homer, C. S. E., Thornton, C., Scarf, V. L., Ellwood, D. A., Oats, J. J. N., Foureur, M. J., Sibbritt, D., McLachlan, H. L., Forster, D. A., & Dahlen, H. G. (2014). Birthplace in New South Wales, Australia: an analysis of perinatal outcomes using routinely collected data. BMC Pregnancy and Childbirth, 14(1), 206. https://doi.org/10.1016/j.wombi.2011.10.003

Nelson, K. B., Dambrosia, J. M., Ting, T. Y., & Grether, J. K. (1996, Mar 7). Uncertain Value of Electronic Fetal Monitoring in Predicting Cerebral Palsy. New England Journal of Medicine, 334(10), 613-619. https://doi.org/10.1056/nejm199603073341001

Reynolds, A. J., Murray, M. L., Geary, M. P., Ater, S. B., & Hayes, B. C. (2022, Jun). Fetal heart rate patterns in labor and the risk of neonatal encephalopathy: A case control study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 273, 69-74. https://doi.org/10.1016/j.ejogrb.2022.04.021