Obstetric malpractice litigation and cerebral palsy in term infants

doi:10.1016/j.jflm.2010.12.002

Journal of Forensic and Legal Medicine

Volume 18, Issue 3, April 2011, Pages 97-100

https://doi.org/10.1016/j.jflm.2010.12.002 Get rights and content

Abstract

Despite the recognition by many researchers that cerebral palsy (CP) is rarely related to obstetric malpractice, there are many instances where obstetricians face litigation when a child is diagnosed with cerebral palsy following a difficult delivery. The aim of this paper is to review relevant research papers to aid practitioners involved in obstetric malpractice litigation. It is also prudent to question the feasibility of costs for long-term care for children with disabilities being met through the legal process.

Section snippets

Malpractice litigation

Most parents expect to give birth to a healthy, normal baby and are deeply disappointed when their expectation is not fulfilled. Encouraged by earlier research suggesting that EFM (electronic fetal monitoring) in labour could help to deliver a baby in good condition,¹ many also believe that good perinatal outcome is exclusively dependent on a high standard of antenatal and delivery care, which is both the norm and their right.

Advances in medical care in recent decades have led to increased life

The diagnosis of obstetric injury causing CP

It is appropriate to consider the process by which obstetric injury is diagnosed as the cause of CP.

CP is an umbrella term for “permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain”.6, 7 Despite being a permanent and non-progressive brain lesion, the clinical signs can change over time as the child develops. Reviewing the child’s progress is necessary

Risk factors and causation

In total Western Australian population CP data, almost 80% of CP occurs in term or near term infants.¹² In birth years 95–99, 65% of CP was born at term and a further 14.2% was born at 32–36 weeks. The frequency of cerebral palsy in term births is 1.5–2 per 1000 live births.¹³

There are many causal pathways to CP in the term or near term infant¹³ several of which include NE (see Table 1).

The outcomes following these different pathways vary from death to CP to normal development and the outcome

Consensus statements

Consensus statements, based on the best evidence available at the time, were developed to assist clinicians and researchers in determining whether an intrapartum asphyxia event was likely to have caused brain damage.

The consensus statement of the Australian and New Zealand Perinatal Societies was first published in MJA 1995.²⁶ It states that there is no clear evidence that obstetric technologies to avoid or reduce fetal distress, in particular EFM and caesarean section, have reduced the

Compensation and long term care

Learning that one’s child has CP is distressing for parents, particularly when they realize that the condition is long-term and will significantly affect the development of their child, in all but very mild cases. The ongoing financial cost brings further stress. The Australian Medicare system provides for basic medical and allied health care, but the cost of regular therapy and education beyond the Medicare allowance is prohibitive for many families. The option of pursuing a legal path for

Conclusion

Due to the extensive work done by the International Task Force we now have criteria in the international consensus statement that can be applied by experts who provide opinion concerning the association between CP and intrapartum events.

There is still work to be done in relation to compensation for the long-term care of CP patients and others with severe/profound disabilities. This challenge, like that of the Task Force, requires consultation with various agencies, including government and

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Projections of Australian obstetricians ceasing practice and the reasons
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Who will deliver our grandchildren? Implications of cerebral palsy litigation
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Relation between negligent adverse events and the outcomes of medical-malpractice litigation
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(1992)

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Diagnosis, treatment and prevention of cerebral palsy

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The Epidemiology of cerebral palsy in term infants

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A research definition for ’Birth Asphyxia’?

Dev Med Child Neurol

(1993)

Cited by (21)

Ischemic hypoxic encephalopathy: The role of MRI of neonatal injury and medico-legal implication
2021, Forensic Science International
Citation Excerpt :
In addition to allowing the identification of the damage, the neuroradiological data allows to characterize the nature and extent of the damage itself. The acquisition and evaluation of the MRI exam are, in fact, one of the key points for the coroner to define a possible involvement of the obstetrician-gynecologist in the poor management of childbirth [11]. There is a large debate in the literature about the correct timing of MRI study in infants with suspected hypoxic-ischemic encephalopathy.
Hypoxic ischemic encephalopathy is one of the major causes of neonatal death and neurological disability in the child, and represents the most common birth injury claim. Intrapartum asphyxia often leads to several long-term sequalae, such as cerebral palsy and/or developmental delay, epilepsy. Through the neuroimaging it’s possible to identify and define the different lesioned pictures and provide useful elements to establish the moment in which the damage occurred; indeed, timing of injury is a key element in the legal arena. Magnetic resonance imaging (MRI) is emerging as one of the most important tools in identifying the etiologic of neonatal encephalopathy as well as in predicting long-term outcomes.
The aim of this study is to evaluate all MRI tests performed in a group of infants and young patients with possible neonatal encephalopathy, in order to determine the role of MRI in perinatal hypoxic-ischemic damage and the specific patterns that can point towards a diagnosis of the time of the damage’s onset. Another goal is to assess the role of MRI in cases subject to legal-medical ligation. Since the advent of hypothermic neuroprotection, new malpractice allegations have arisen, including the failure to initiate cooling in a timely manner. In all cases, documentation of the status of the baby at birth, including a thorough neurologic exam, can be extremely helpful to the later defence of a malpractice claim, which might occur years later.
Claims about medical malpractices resulting in neonatal and maternal impairment in Iran
2019, Journal of Forensic and Legal Medicine
Citation Excerpt :
Mahmoodian et al. (2012) showed that of 7 medical malpractice claims, 5 were against physicians at the top while midwives received the second most frequent complaints among non-physicians, compared to other health service providers.13 Society's expectations have increased of this specialization21 in line with its advances.22 The smallest violation of scientific standards may cause dangerous and mortal complications in this field, as unlike other groups of medical specialists, obstetricians and midwives should oversee two lives and two human-beings rather than one, and any error can lead to death or permanent injuries in the mother, the fetus or both.23
Today even low incidence of complications for mothers or neonates during pregnancy, delivery or postpartum is unacceptable to the public and can result in claims because of greater expectation from patients and an increase in media coverage. The present study was conducted to investigate the reasons for medical malpractice claims on maternal and neonatal impairment, which are achieved in Iranian Legal Medicine Organization councils.
The present cross-sectional and retrospective study used convenience sampling to collect data of total claims from 31 provinces archived in the supreme council of the ILMO in 2 years. In this article, the medical malpractice claims on maternal and neonatal impairment during pregnancy, labour, delivery and early postpartum were reported. The data were collected through a validated researcher-made checklist and were analyzed in SPSS 16.
Among total of 299 cases of impairment, cerebral palsy (33.34%), Erb's palsy due to shoulder dystocia (24.24%) and Down Syndrome (24.24%) were the main confirmed causes of malpractice for neonatal impairment and Retained Surgical Mass (20.5%), Salpingectomy and/or Oophorectomy Related to EP (17.2%), Hysterectomy (17.2%) and Episiotomy Related complication (17.2%) were the main confirmed causes of malpractice for maternal impairment.
Considering this fact that medical malpractice was confirmed in a large proportion of some preventable and important complications, therefore, results of this study can be used for developing educational programs for related healthcare providers to prevent those complications.
Threshold of metabolic acidosis associated with newborn cerebral palsy: medical legal implications
2019, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Although birth asphyxia-induced cerebral palsy has been associated with neonatal encephalopathy, alternative disorders that include brain malformations, fetal growth restriction, and placental diseases may manifest as neonatal encephalopathy. Furthermore, prematurity,29,30 perinatal infections, prelabor hypoxic events, perinatal stroke,31 congenital or metabolic abnormalities, and neonatal hypoxia or hypoglycemia may or may not exhibit neonatal encephalopathy.32 Thus, it is often challenging to definitively assign a hypoxia-associated cause for neonatal encephalopathy.
Obstetricians and gynecologists belong to 1 of the medical specialties with the highest rate of litigation claims. Among birth injury cases, those cases with cerebral palsy outcomes account for litigation settlements or judgments often in the millions of dollars. In cases of potential perinatal asphyxia, a threshold level of metabolic acidosis (base deficit ≥12 mmol/L) is necessary to attribute neonatal encephalopathy to an intrapartum hypoxic event. With increasing duration or severity of a hypoxic stress resulting in metabolic acidosis, newborn infant umbilical artery base deficit increases. It may be alleged that, as base deficit levels increase beyond 12 mmol/L, there is an increased likelihood and severity of cerebral palsy. As a corollary, it may be claimed that an earlier delivery (by minutes) would reduce the base deficit and prevent or reduce the severity of cerebral palsy. This issue is of relevance to obstetricians as defendants, because retrospective “expert” analysis of cases may suggest that optimal management decisions would have resulted in an earlier delivery. In addressing the association of metabolic acidosis and cerebral palsy, base deficit should be measured as the extracellular component (base deficit_{extracellular fluid}) rather than the commonly used base deficit_blood. Studies suggest that, beyond the base deficit threshold of 12 mmol/L, the incidence and severity of cerebral palsy does not significantly increase (until ≥20 mmol/L), although the risk of neonatal death rises markedly. Thus, among most infants with hypoxia-associated neonatal encephalopathy, the occurrence of cerebral palsy is unlikely to be impacted by delivery time variation of few minutes, and this argument should not serve as the basis for medical legal claims.
Study of financial compensation in rulings against obstetricians and gynaecologists in Spain (1987-2013)
2017, Revista Espanola de Medicina Legal
En indemnizaciones por mala praxis, la obstetricia y la ginecología ocupa un lugar destacado. Analizamos las sentencias de un largo periodo (1987-2013) centrándonos en la cuantía de las indemnizaciones y su evolución. En España existen pocos análisis económicos de esta especialidad y específicamente que muestren aquellos eventos adversos que soportan las indemnizaciones más elevadas.
Se trata de un análisis retrospectivo de las sentencias judiciales en las vías civil y contencioso-administrativa, contra obstetras y ginecólogos tomadas de bases de datos jurídicas en el periodo de estudio. Las variables consideradas han sido las indemnizaciones en los casos de condena, el evento adverso juzgado y el año de la sentencia. El software estadístico SPSS 19.0 permitió obtener tablas de distribución de Fisher, de normalidad y el t test para comparación de diferencias entre grupos.
De 431 casos, 244 terminaron en condena (56,6%). La obstetricia soportó las indemnizaciones más elevadas (p, 0,01) y una probabilidad de ser condenado del 57.5%. Los eventos relacionados con daño o muerte fetal presentaron las indemnizaciones más elevadas y fueron la causa más común entre las indemnizaciones, superiores a 300.000 €. Globalmente, en el 78,7% (193) de los casos con condena, la cantidad fue inferior a 300.000 €. Los máximos, así como la media y la mediana de las indemnizaciones, fueron aumentando a lo largo del periodo de estudio.
Las demandas en el entorno de la obstetricia y los daños relacionados con el feto soportan las indemnizaciones más elevadas, con tendencia a incrementarse. Las indemnizaciones extremas no son infrecuentes.
Malpractice payouts occupy an important place in Obstetrics and Gynaecology. We analysed a long period (1987–2013) of court sentences focusing on compensation amount and the way compensation has changed. In Spain there are not many economic analyses on Obstetrics and Gynaecology, specifically on the main adverse events that lead to catastrophic payouts.
A retrospective analysis of a legal database on court sentences in civil and administrative litigation against obstetricians and gynaecologists during the study period was performed. The adverse event under examination, the year of the ruling, and the payouts for malpractice were the variables analysed. Statistical analysis was performed using SPSS Statistics 19.0, F-distribution and normal distribution tables as well as the Student's t-test to compare differences between groups.
We recovered 431 cases, 244 of which resulted in a conviction (56.6%). Obstetrics involved the highest payouts (p = 0.01) and a 57.5% chance of being convicted. The accusations with the highest payouts involved fetal death or fetal injury, which were the most common cause of payouts exceeding €300,000. Overall, 78.7% (193) of convictions involved a payout below €300,000 and the mean, median and maximum payouts increased steadily during the study period.
Obstetric claims and fetal-related injury involve the highest payouts, with an increasing trend. Catastrophic payouts are common.
Analysis of court claims filed against obstetricians and gynaecologists in Spain. Specific study of the criminal court system (1987-2013)
2016, Revista Espanola de Medicina Legal
En España las reclamaciones judiciales contra ginecólogos resueltas por vía penal son escasas, menos del 3%. Esta vía conlleva sanción económica y penas de cárcel y de inhabilitación. El objetivo es estudiar las sentencias resueltas por vía penal, por ser de consecuencias más graves y obtener un perfil del condenado.
Análisis retrospectivo de las sentencias judiciales penales contra ginecólogos desde 1987 hasta 2013. Hemos utilizado tablas de distribución de Fisher, de normalidad y el t-Test para comparación de diferencias entre grupos y la prueba no paramétrica de Mann-Withney para comparación de muestras independientes. Para la caracterización de dos grandes grupos, el de «condenado» y «no condenado», realizamos estudio multivariante mediante análisis de correspondencias múltiples seguidas de análisis de conglomerados para agrupar.
De 85 casos el 54,6% de las reclamaciones judiciales procedían de actos médicos del sector público, aunque el mayor número de condenas, el 59,3%, lo fue por demandas sobre hechos ocurridos en el ámbito de la sanidad privada. La probabilidad de condena en sucesos relacionados con el parto fue del 36,6% (20 de 55) frente al 16,6% (5 de 30) de episodios de otro origen. En el 69,2% de los casos de procedimientos penales por daño neurológico (encefalopatía neonatal) la sentencia fue condenatoria y con las indemnizaciones más elevadas. El tiempo medio trascurrido entre el incidente y la condena fue de 5,7 años. Con una condena previa, la posibilidad de confirmación en instancias superiores fue del 71,9%. Una absolución se confirmó en el 96,2% de las ocasiones.
Aunque es elegida para iniciar el procedimiento pocas reclamaciones se resuelven en vía penal. La mayoría se deben a complicaciones durante el parto y en un tercio se condena. Lo más probable es que se confirme la sentencia previa cuando esta fue absolutoria.
Court claims against gynaecologists in the Spanish criminal court system are a rare occurrence (less than 3%). These can lead to financial penalties, imprisonment and disqualification. Our aim is to study the court sentences issued in such cases, as these involve the most serious convictions, and to obtain a profile of those convicted.
A retrospective analysis of the sentences against gynaecologists during the period from 1987 to 2013. We used F-distribution tables, normal distribution tables and Student's t-test to compare differences between groups, and the Mann-Whitney nonparametric test for comparison of independent samples. In order to define two broad groups, those of “convicted” and “not convicted,” we performed a multivariate study analysis followed by cluster analysis to determine similar sentences.
Of the 85 cases, 56.4% of complaints came from procedures in the public sector, but the highest rate of convictions (59.3%) was based on complaints originating in the private healthcare sector. The likelihood of conviction in events related to childbirth was 36.6% (20 out of 55) versus 16.6% (5 out of 30) in incidents of another origin. 69.2% of cases of criminal proceedings for permanent neurological damage (neonatal encephalopathy) concluded in a criminal conviction and had the highest financial compensation. The average time elapsed between the incident and the sentence was 5.7 years. With a prior conviction, the possibility of confirmation at higher levels was 71.9%. An acquittal was confirmed in 96.2% of cases.
Of the court claims filed against gynaecologists based on their professional activity, very few are decided upon in the criminal courts. Most are due to complications during childbirth, and one-third ends with a conviction. A judgment of acquittal is most likely to be confirmed when this was the case with the previous one.
Intrapartum asphyxia: Risk factors and short-term consequences
2016, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Établir les facteurs de risque de survenue d’une asphyxie perpartum et évaluer les conséquences néonatales précoces.
Il s’agit d’une étude rétrospective observationnelle ayant inclus toutes les naissances vivantes entre 2002 et 2010 dans une maternité de type 3 de CHU. Les critères d’inclusion étaient ceux de la Cerebral Palsy Task Force associés à un âge gestationnel ≥ 34 SA. Nous avons étudié les marqueurs de l’asphyxie perpartum, tels que le score d’Apgar à 5 minutes et les anomalies du rythme cardiaque fœtal faisant suite à un éventuel évènement hypoxique sentinelle survenant avant ou pendant le travail. Ont également été évalués la durée des efforts expulsifs, l’aspect du liquide amniotique, le mode d’accouchement ainsi que les pathologies gravidiques préexistantes. D’autre part, nous avons étudié les conséquences à court terme chez ces nouveau-nés : décès, défaillances multiviscérales et la survenue d’une encéphalopathie hypoxo-ischémique précoce basée sur la classification de Sarnat.
Sur 29 416 naissances vivantes, 129 nouveau-nés (0,43 %) avaient un pH au cordon < 7 et seuls les 82 (0,27 %) présentant une asphyxie perpartum ont été inclus dans l’étude. Une pathologie gravidique précédant l’accouchement était présente chez 22 % des patientes. Les évènements hypoxiques n’étaient présents que dans 9/82 cas. Les anomalies du rythme cardiaque fœtal étaient présentes dans 97,6 % cas. La durée des efforts expulsifs et l’aspect du liquide amniotique ne semblaient pas influencer la survenue d’une asphyxie perpartum. On notait 46,3 % de césariennes et 34,1 % d’extractions instrumentales. Trente-huit enfants (46,3 %) ont été hospitalisés en néonatologie avec 3 décès (3,65 %), 17 encéphalopathies hypoxo-ischémiques précoces (20,7 %) et 2 défaillances multiviscérales précoces (2,4 %). La valeur du pH semblait influencer la survenue d’une encéphalopathie : 50 % si pH < 6,9 contre 13,6 % si pH ≥ 6,9 (p = 0,0013). Il en était de même pour le déficit de base avec 50 % si BD < –18 contre 15,7 % si BD ≥ –18 (p = 0,0068). Le score d’Apgar à 5 minutes semblait lui aussi prédictif d’une encéphalopathie hypoxo-ischémique avec 100 % quand il était < 4, 46 % entre 4 et 6, 11 % si > 6 (p < 0,001).
Nos chiffres montrent un taux d’asphyxie perpartum après 34 SA deux fois inférieur à celui de 0,5 % décrit dans la littérature. Notre étude semble confirmer la validité des marqueurs utilisés pour lesquels il existe un risque élevé d’encéphalopathie précoce. Ce travail se poursuit par l’évaluation des conséquences de l’hypoxie sur le développement psychomoteur chez ces enfants et notamment la survenue d’une paralysie cérébrale à long terme.
Intrapartum asphyxia is a rare yet serious complication during labor with immediate consequences and possible long-term neurological impairment. The international Cerebral Palsy Task Force established criteria that attribute a cerebral palsy to intrapartum asphyxia: metabolic acidemia measured at birth with pH < 7 and base deficit ≥ 12 mmol/L.
To determine the risk factors of an intrapartum asphyxia occurring in term live births, to evaluate the short-term consequences.
Our retrospective study included all births between 2002 and 2010 in a level 3 maternity of a university hospital center. Inclusion criteria were those of the Cerebral Palsy Task Force associated with a gestational age ≥ 34 weeks of gestation. We studied the conventional markers of intrapartum asphyxia: Apgar score at 5 minutes, abnormal cardiotogographic recordings whether they occurred after a sentinel hypoxic event or not before and during labor. The duration of expulsive efforts, the amniotic fluid aspects, the delivery mode as well as the preexisting pregnancy pathologies were also evaluated. On the other hand, we studied the short-term consequences at the newborns: death, multiorgan failure and especially the occurring of a neonatal encephalopathy using Sarnat and Sarnat staging.
One hundred and twenty-nine newborns (0.43%) out of 29,416 live births had a pH < 7 of whom only 82 (0.27%) presented a real intrapartum asphyxia and were included in this study. A preexisting pregnancy pathology was found in 22% of the women. Hypoxic events were noted in only 9/82 of the cases. Abnormal cardiotocographic recordings were present in 97.6% of the cases. The duration of expulsive efforts as well as the amniotic fluid aspects did not interfere with the occurring of a metabolic acidemia. Caesarean rate was at 46.3% and instrumental extraction rate was at 34.1%. Thity-eight newborns (46.3%) were admitted in neonatal intensive care in which we noted 3 deaths (3.65%), 2 multiorgan failures (2.4%) and 17 neonatal encephalopathy (20.7%). The pH value seemed to influence the occurring of an encephalopathy: 50% when pH < 6.9 vs. 13.6% when pH ≥ 6.9 (P = 0.0013), as well as for the base deficit: 50% when BD < –18 vs. 15.7% when BD ≥ –18 (P = 0.0068). Apgar score at 5 minutes also seemed predictive for a neonatal encephalopathy: 100% when < 4, 46% between 4 and 6 and 11% when > 6 (P < 0.001).
Our results showed an intrapartum asphyxia rate half the one widely recorded of 0.5% of total live births. Our study also validates the commonly used markers to evaluate a high risk of an early neonatal encephalopathy. This study should be continued with the evaluation of hypoxia long-term consequences on the psychomotor development of these kids and especially the occurring of cerebral palsy.

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ReviewObstetric malpractice litigation and cerebral palsy in term infants

Abstract

Section snippets

Malpractice litigation

The diagnosis of obstetric injury causing CP

Risk factors and causation

Consensus statements

Compensation and long term care

Conclusion

Obstetrics Gynecol

The Lancet

Hum Pathol

Clin Perinatology

Am J Obstetrics Gynaecol

Fetal Monitoring: is it worth it?

Obstetrics Gynecol

Projections of Australian obstetricians ceasing practice and the reasons

MJA

Who will deliver our grandchildren? Implications of cerebral palsy litigation

JAMA

Relation between negligent adverse events and the outcomes of medical-malpractice litigation

New Engl J Med

A report: the definition and classification of cerebral palsy

Dev Med Child Neurol

Birth injury and the obstetrician

Recent Adv Obstetrics Gynaecol

Diagnosis, treatment and prevention of cerebral palsy

Clin Obstetrics Gynecol

The Epidemiology of cerebral palsy in term infants

Ment Retard Dev Disabilities Res Rev

A research definition for ’Birth Asphyxia’?

Dev Med Child Neurol

Review
Obstetric malpractice litigation and cerebral palsy in term infants