Neurologic Birth Injury

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Notes

Thomas P. Sartwelle, Defending a Neurologic Birth Injury: Asphyxia Neonatorum Redux, 30 J. Legal Med. 181 (2009).

The medical liability cases referred to are sometimes called cerebral palsy (CP) cases or neonatal or perinatal brain injury cases, or birth asphyxia or birth injury cases. The case Sartwelle targets for defense, consistent with an ACOG focus, is a brain injury alleged to arise during labor (intrapartum) in a full term infant. The variable labels for “the case” may create confusion, as each label does not necessarily mean the same thing. Whatever label is applied, an allegation that a foreseeable complication was a substantial contributing cause of disabling brain injury forms the basis of a meritorious case if a fair preponderance of the credible evidence establishes that such injury was reasonably avoidable by due care.

Sartwelle, supra note 1, at 184 (citing many references and maintaining asphyxia (lack of oxygen) causes only a tiny fraction of CP cases and, more importantly, CP because of asphyxia is not preventable). According to the author, despite research to the contrary, a certain minority of physicians continue to testify that timely caesarean sections (C-sections) prevent neonatal oxygen deprivation damage. This testimony, according to Sartwelle, is false because it allegedly runs counter to worldwide medical information that physicians can rarely prevent “neurologic birth injury.” Sartwelle thus states CP from asphyxia is not preventable and birth injury is rarely preventable.Is it rare or never? Is he talking about the same thing? Neonatal oxygen deprivation is an event occurring after birth. What does he mean by birth injury? Lack of oxygen and asphyxia are related, but not exactly the same thing. As developed below, a lack of oxygen (hypoxia) ultimately can lead to an adaptive decompensation that produces an ischemic brain insult that can cause disabling brain damage.

Sartwelle, supra note 1, at 214.

Alastair MacLennan et al., Who Will Deliver Our Grandchildren? Implications of Cerebral Palsy Litigation, 294 J.A.M.A. 1689 (2005); see also infra note 20 (detailing ACOG's grievance process).

E-mail from the American College of Obstetricians and Gynecologists [hereinafter ACOG] to its members (Oct. 31, 2007) (on file with author).

Richard L. Berkowitz et al., A Proposed Model for Managing Cases of Neurologically Impaired Infants, 113 Ob. & Gyn. 683 (2009).

N.Y. Judiciary Law § 474-a (McKinney 2009) contains a sliding scale fee and allows counsel, subject to court scrutiny, to justify a fee of up to—but no more than—one-third of the recovery. There is not a single instance in which the child and child's family has not received at least two-thirds of the recovery, and almost always a greater percentage.

Berkowitz et al., supra note 7.

MacLennan et al., supra note 5, at 1689.

Sartwelle, supra note 1, at 240-42.

See infra note 52.

See Kenneth R. Niswander, Adverse Outcomes of Pregnancy and the Quality of OB Care, 2 Lancet 827 (1984); Kenneth R. Niswander, Does Substandard Obstetrical Care Cause C.P.?, Contemp. Ob. & Gyn., Oct. 1987, at 42-60.

Sartwelle, supra note 1, at 243.

Mark R. Chassin et al., The Urgent Need to Improve Health Care Quality: Institute of Medicine National Roundtable on Healthcare Quality, 280 J.A.M.A. 1000, 1001 (1998), available at http://jama.ama-assn.org/cgi/reprint/280/11/1000.pdf (citing Medicare: A Strategy for Quality Assurance (Kathleen N. Lohr ed., 1990)).

Institute of Medicine, To Err Is Human: Building a Safer Health System IX-X & 8, 36 (Linda Kohn et al. eds., 2000).

Id. at 3-5.

See, e.g., Pike v. Honsinger, 155 N.Y. 201 (1898); Toth v. Cmty. Hosp. of Glen Cove, 22 N.Y.2d 255, 263 (1968); Bing v. Thunig, 2 N.Y.2d 656, 666 (1957).

Linda Blank et al., Medical Professionalism in the New Millenium: A Physicians’ Charter, 136 Annals Intern. Med. 243 (2002).

Id.

ACOG's grievance process is triggered when one ACOG Fellow reports that another Fellow has given inappropriate, “egregious” testimony. A plaintiff who is not an ACOG member may not file a grievance against a defense expert. The process involves ACOG designated physicians deciding—without rules of evidence or any legal authority—whether the testimony was “egregious.” Because the process can never benefit a patient's legal rights but only work against the patient, it is intrinsically unethical and a transparent effort to influence the civil justice system to the patient's disadvantage. Charles B. Hammond & Peter A. Schwartz, Ethical Issues Related to Medical Expert Testimony, 106 Ob. & Gyn. 1055 (2005).One ACOG leader maintains that during civil liability trials, “theater often takes precedence over science as a way to impress the jury” and, because “only answers to questions attorneys ask are allowed, the story as depicted is often misleading.” Critical of the “hired guns” who give “biased, outdated or simply wrong” testimony, this author singles out CP testimony as a “particular problem.” James R. Scott, Expert Witness: Perpetuating a Flawed System, 106 Ob. & Gyn. 902 (2005) (citing MacLennan et al., supra note 5).Dr. Scott maintains the civil justice system functions as a “free-for-all.” If this were true, no verdict against an obstetrician would stand, as a “free-for-all” means there was no due process. No one can document a verdict against an obstetrician based on a “free-for-all” or on misleading, outdated, biased, or wrong testimony, because those circumstances would require reversal. Scott maintains that he wants only objective, scientific sources of evidence, such as ACOG Practice Guidelines. Thus, what he wants is experts to endorse what ACOG leaders create. That would allegedly ensure that the medical justice system is reliable and fair. “Reliable and fair” is thus a euphemism to mean no liability in CP cases, because ACOG insists that CP cannot be prevented.

Insitute of Medicine, supra note 16, at 32 & 144-45.

Paul A. Gluck, Patient Safety: A New Imperative, 6 ACOG Clin. Rev. 1 (2001).

John H. Eichhorn et al., Standards for Patient Monitoring During Anesthesia at Harvard Medical School, 256 J.A.M.A. 1017 (1986); American Society of Anesthesiologists, Standards for Basic Anesthetic Monitoring, available at http://www.asahq.org/publicationsAndServices/standards/02.pdf (last visited Oct. 14, 2009).

David M. Gaba, Anesthesiology as a Model for Patient Safety in Health Care, 320 Brit. Med. J. 785 (2000); see generally Jeffrey B. Cooper & David Gaba, No Myth: Anesthesia Is a Model for Addressing Patient Safety, 97 Anesthesiology 1335 (2002).

Sartwelle, supra note 1, at 237-40.

Fred Kubil, Perinatal Events and Brain Damage in Surviving Children 185 (1988).

Richard J. Martin et al., Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant 109 (1997).

Lawrence D. DeVoe, The Future of Intrapartum Care: Navigating the Perfect Storm—An Obstetrician's Odyssey, 201 Am. J. Ob. & Gyn. 100 (2009).

Ralph C. Benson et al., Fetal Heart Rate as Predictor of Fetal Distress: A Report from the Collaborative Project, 32 Ob. & Gyn. 259 (1968).

Emanuel A. Friedman, Labor: Clinical Evaluation and Management (1978).

Edward H. Hon & Kee S. Koh, Management of Labor and Delivery, in Gordon B. Avery, Neonatology: Pathophysiology and Management of the Newborn 120-31 (1982).

Id. at 120-31.

Adré du Plessis, Perinatal Asphyxia and Hypoxic-Ischemic Brain Injury in the Full-Term Infant, in Intensive Care of the Fetus and Neonate 775 (Alan R. Spitzer ed., 2d ed. 2005).

DeVoe, supra note 29, at 3.

Id. at 4.

Louis Weinstein & Thomas J. Garite, On Call for Obstetrics—Time for a Change, 196 Am. J. Ob. & Gyn. 3 (2007).

Louis Weinstein, The Laborist: A New Focus of Practice for the Obstetrician, 188 Am. J. Ob. & Gyn. 310 (2003).

Steven L. Clark et al., Reducing Obstetric Litigation Through Alterations in Practice Patterns, 112 Ob. & Gyn. 1279 (2008).

Steven L. Clark et al., Improved Outcomes, Fewer Caesarean Deliveries and Reduced Litigation: Results of a New Paradigm in Patient Safety, 199 Am. J. Ob. & Gyn. 105 (2008).

Roger K. Freeman, Medical and Legal Implications for Necessary Requirements to Diagnose Damaging Hypoxic-Ischemic Encephalopathy Leading to Later Cerebral Palsy, 199 Am. J. Ob. & Gyn. 585 (2008).

Physician Insurers Association of America, Neurologic Impairment in Newborns: A Malpractice Claim Study 43 (1998).

Elizabeth S. Draper et al., A Confidential Enquiry into Cases of Neonatal Encephalopathy, 87 Arch. Dis. Child, Fetal, Neonatal F176 (2002).

Freeman, supra note 41, at 586.

Clark, supra note 40, at 105.

MacLennan et al., supra note 5, at 1689.

Wayne R. Cohen, Normal and Abnormal Labor, in Handbook of Clinical Obstetrics: The Fetus and Mother 455 (E. Albert Reece et al. eds., 3d ed. 2007).

Richard P. Perkins, Perspectives on Perinatal Brain Damage, 69 Ob. & Gyn. 807 (1987).

American Society of Anesthesiology, at http://www.asahq.org/safety.htm (last visited Oct. 14, 2009).

Perkins, supra note 48.

See, e.g., First of America Bank v. United States, 752 F. Supp. 764 (E.D. Mich. 1990).

ACOG, Practice Bulletin No. 163: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Policies, 41 J. Ob. & Gyn. 97 (1993).

Gary D. V. Hankins & Michael Spear, Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology, 103 Ob. & Gyn. 628 (2003).

Marie McCullough, A Dispute on Doctor Cerebral Palsy Role, Phila. Inquirer, Feb. 10, 2003, at D01.

See First of America Bank, 752 F. Supp. at 764.

ACOG, supra note 52, at 97.

Robert C. Goodlin, Do Concepts of Causes and Prevention of Cerebral Palsy Require Revision?, 172 Am. J. Ob. & Gyn. 1830 (1995).

Testimony of Gary Hankins, June 6, 2007 & July 9, 2007, Bennett v. Florida Birth-Related Neurological Compensation Ass'n, No. 06-2422N (Fla. Cir. Ct. 2007).

ACOG, supra note 52, at 97.

Hankins & Spear, supra note 53, at 628.

Testimony of Gary Hankins, supra note 58.

Marcus C. Hermansen, The Acidosis Paradox: Asphyxial Brain Injury Without Coincident Acidemia, 45 Dev. Med. & Child Neurol. 353 (2003).

Joseph J. Volpe, Neurology of the Newborn 217, 232 (2001) (noting that typically a brain injury after a longer, less intense insult produces apoptotic cell death at a later time without an associated inflammatory response, while a more intense, acute insult will likely produce necrosis with an inflammatory response). See also id. at 297-98, 302-04, 310-12, 315 & 317 (noting that one neuropathology consequence of the ischemic insult is selective neuronal necrosis because of repeated reversible transient ischemic events, which individually are not sufficient to produce the brain injury).

Testimony of Gary Hankins at 139-97, Apr. 5, 2007, Gould v. Integris Bass Baptist Health Center, No. CJ-2003-138 (D. Garfield Co., Okla. 2007).

Claudine Amiel-Tison et al., Cerebral Handicap in Full Term Neonates Related to the Mechanical Forces of Labor, 2 Baillière's Clinical Ob. & Gyn. 145 (1988); see also John M. Freeman & Karin B. Nelson, Intrapartum Asphyxia and Cerebral Palsy, 82 Pediatrics 240 (1988) (maintaining that, as CP because of birth trauma from prolonged, difficult labor and forcep deliveries became a less frequent cause of CP as obstetrical practice improved, that hypoxic or ischemic injury became blamed more commonly for neurologic deficit). This article was intended to dispose of birth trauma as a nonexistent event of the past. Thus, only intrapartum asphyxia exists to produce an intrapartum hypoxic-ischemic brain injury. Some then used the essential criteria and CP statistics to suggest that intrapartum asphyxia was rare and not preventable as a cause of CP.

Testimony of Gary Hankins, supra note 64, at 149.

Frances Cowan et al., Origin and Timing of Brain Lesions in Term Infants with Neonatal Encephalopathy, 361 Lancet 736 (2003).

Karin B. Nelson & Sarah H. Broman, Perinatal Risk Factors in Children with Serious Motor and Mental Handicaps, 2 Annals Neurol. 371 (1977).

Karin B. Nelson & Jonas H. Ellenberg, Antecedents of Cerebral Palsy: Multivariate Analysis of Risk, 315 New Eng. J. Med. 81 (1986).

See David Shier & J. Lee Tilson, The Temporal Stage Fallacy: A Novel Statistical Fallacy in Medical Literature, 9 Med. Health Care & Phil. 243 (2006) (demonstrating how the new consensus in the medical community that lack of oxygen at birth rarely causes CP relies on fallacious reasoning).

Cowan et al., supra note 67.

See Westberry v. Gislaved, 178 F.3d 257 (4th Cir. 1999); Handyman v. N. Fork & W. R.R. Co., 243 F.3d 255 (6th Cir. 2001).

See, e.g., Michael J. Noetzel, Perinatal Trauma and Cerebral Palsy, 33 Clinics in Perinatology 355 (2006).

Sartwelle, supra note 1, at 184; MacLennan et al., supra note 5; Berkowitz, supra note 7.

Richard Naeye, Causes of Perinatal Mortality in the US Collaborative Perinatal Project, 238 J.A.M.A. 228 (1977).

Alan Fried & Roger Rochat, Maternal Mortality and Perinatal Mortality: Definitions, Data and Epidemiology, in Obstetrics Epidemiology 35 (B. Sachs ed. 1985).

Linda L. Wright et al., Perinatal-Neonatal Epidemiology, in Avery's Diseases of the Newborn 1 (Roberta A. Ballard et al. eds., 8th ed. 2005).

Bengt Hagberg et al., Gains and Hazards of Intensive Neonatal Care: An Analysis of the Swedish Cerebral Palsy Epidemiology, 24 Dev. Med. & Child Neurology 13 (1982); Bengt Hagberg et al., The Changing Panorama of Cerebral Palsy in Sweden: Epidemiological Trends 1959-1978, 73 Acta Pediatrica Scandinavica 433 (1984); Kate Himmelmann et al., The Changing Panorama of Cerebral Palsy in Sweden: Prevalence and Origin in the Birth-Year Period 1995-1998, 94 Acta Pediatrica 287 (2005) (noting a decreasing trend in CP rates).

Richard Chamberlain et al., 1970 British Births Cohort Study: A Survey Under the Joint Auspices of the National Birthday Trust Fund and the Royal College of Obstetricians and Gynaecologists 278 (1975).

Steven L. Clark & Gary D.V. Hankins, Temporal and Demographic Trends in Cerebral Palsy, 188 Am. J. Ob. & Gyn. 628 (2003) (noting that the EFM use coupled with an increase in the C-section delivery rate, has eliminated sudden unexpected intrapartum fetal death). The same intrapartum fetal stresses that can in sublethal effect produce disabling brain injury also can produce an intrapartum fetal death. The physicians who wrote this (and similar) articles, which are clearly intended to support legal defenses, must understand that a proper use of statistics actually proves that proper use of EFM and timely C-section delivery can prevent both intrapartum fetal death and brain injury.

Alfred L. Scherzer, The Changing Face of Cerebral Palsy?, 29 Dev. Med. & Child Neurology 550 (1987).

Scott, supra note 21.

Testimony of Gary Hankins, supra note 58.

Sartwelle, supra note 1.

Id. at 185 & 232-35. No case has ever been successful against an obstetrician premised on an allegation that a disabled child's brain injury must have occurred during labor and that the obstetrician was liable because he or she had total control of brain development. These are strawman fallacies connected to the assertion that civil trials are a “free-for-all.”

ACOG, Educational Pamphlet AP015: Fetal Heart Rate Monitoring During Labor (2001). A midwife can manage a normal pregnancy, labor, and delivery. A general surgeon could easily learn how to do a safe caesarean delivery. Nonetheless, ACOG leads women to believe that obstetricians are necessary to ensure delivery of a healthy baby.

Id.

Id.

Acog.org, New York State's Obstetric Safety Initiative: Providing Excellence in Electronic Fetal Monitoring, available at http://www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=2916 (last visited Oct. 14, 2009).

Id.

ACOG Committee Opinion, Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia, 104 J. Ob. & Gyn. 903 (2004).

Id.

ACOG, supra note 52 (citing Kirkwood Shy et al., Effects of Electronic Fetal Heart Rate Monitoring as Compared with Periodic Auscultation on the Neurologic Development of Premature Infants, 322 New Eng. J. Med. 588 (1990)).

Shy, supra note 93.

ACOG, Practice Bulletin No. 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Policies, 114 J. Ob. & Gyn. 192 (2009).

Frank C. Miller et al., FHR Pattern Recognition by the Method of Auscultation, 64 Am. J. Ob. & Gyn. 332 (1984) (noting that auscultation led to a failure to recognize significant FHR patterns as much as one-third of the time, making it unacceptable in modern obstetrics).

ACOG, supra note 95, at 192.

George A. Macones et al., The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Monitoring, 112 Am. J. Ob. & Gyn. 601 (2008).

Catherine Y. Spong, Electronic Fetal Heart Rate Monitoring, Another Look, 112 Am. J. Ob. & Gyn. 506 (2008).

Julian T. Parer et al., A Framework for Standardized Management of Intrapartum Fetal Heart Rate Patterns, 197 Am J. Ob. & Gyn. 26.e1 (2007).

Testimony of Gary Hankins, supra note 64, at 23-24 & 127-29.

Id.

Id.

Nalder v. West Park Hosp., 254 F.3d 1168 (10th Cir. 2001); see also Karin B. Nelson, et al., Uncertain Value of Electronic Fetal Monitoring in Predicting Cerebral Palsy, 334 New Eng. J. Med. 613 (1996). This article, frequently cited to support the idea that EFM is not useful in predicting CP, used EFM information noted in the birth records. Nobody reviewed any EFM strips to correlate EFM findings with bad outcomes.

See, e.g., Tim Draycott et al., Does Training in Obstetric Emergencies Improve Neonatal Outcome?, 113 Brit. J. Obstet. Gyn. 177 (2006) (finding a six-month course on EFM training for all clinical staff produced a significant reduction in newborns with neurologic symptoms); see also Robert D.F. Keith et al., A Multicentre Comparative Study of 17 Experts and an Intelligent Computer System for Managing Labor Using the Cardiogram, 102 Brit. J. Obstet. Gyn. 688 (1995) (finding consistently good agreement among experts using EFM data concerning the timing of caesarean section recommendations). ACOG guidelines fail to cite these reports to promote a proactive commitment to patient safety.

Robert M. Wachter & Kaveh G. Shojania, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes 322-23 (2005).

Sartwelle, supra note 1, at 243.

Clark et al., supra note 40.

Id. at 105.e2.

Id.

Id. at 105.e3.

Id. at 105.e4.

Id. at 105.e5.

Id.

Id.

Clark et al., supra note 39.

Clark et al., supra note 40, at 105.e4.

ACOG, supra note 53, at 628-36.

Id.

Seetha Shankaran et al., Whole-Body Hypothermia for Neonates with Hypoxic-Ischemic Encephalopathy, 353 New Eng. J. Med. 1574 (2005); Joseph Volpe, Perinatal Brain Injury: From Pathogenesis to Neuroprotection, 7 Mental Retardation & Devel. Disabilities Res. Rev. 56 (2001).

Christopher R. Harman, Fetal Biophysical Variables and Fetal Status, in Asphyxia and Fetal Brain Damage 279-83 (Dev Maulik ed., 1998).

Christopher R. Harman, Assessment of Fetal Health, in Maternal-Fetal Medicine: Principles and Practice 357-402 (Robert K. Creasy et al. eds., 2003).

Id. at 357-403.

Id.

Frank A. Manning et al., Fetal Assessment Based on Fetal Biophysical Profile Scoring: The Incidence of Cerebral Palsy in Tested and Untested Perinates, 178 Am. J. Ob. & Gyn. 696 (1998).

ACOG, supra note 53, at 628.

Id.

Id.