Prenatal and perinatal causal pathways to cerebral palsy in term infants. Distal risk factors exert a pathogenic effect on fetal brain development starting at a time that is remote from the onset of irreversible brain injury. Examples include genetic abnormalities, environmental and sociodemographic factors, and some placental abnormalities. Proximal risk factors exert pathogenic effects on fetal brain development at a time that closely predates or coincides with the onset of irreversible brain injury. Examples include abruptio placentae, chorioamnionitis, and twin–twin transfusion. There are multiple potential causal pathways that lead to cerebral palsy in term infants, and the signs and symptoms of neonatal encephalopathy may range from mild to severe, depending on the nature and timing of the brain injury. A. Intrapartum brain injury that is due to a proximal risk factor may lead to neonatal encephalopathy and subsequent cerebral palsy. B. Intrapartum brain injury may be the result of both distal and proximal risk factors that predispose the fetus to brain injury and cerebral palsy. C. Brain injury or anomaly may occur in the antepartum period as a result of distal and proximal risk factors. When brain injury or anomaly occurs at a time that is remote from the delivery process, neonatal encephalopathy may or may not be seen after birth. D. Brain injury may occur at multiple points during gestation. E. Proximal risk factor and brain injury may occur in the neonatal period following predisposing distal risk factors. Abbreviations: DRF, distal risk factor; PRF, proximal risk factor.