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Brain Damage and Malpractice at Birth

Some of the largest awards in medical litigation have been made for neurologic impairment in children. Neurologists are often asked to serve as expert witnesses in such cases, to testify concerning causation of the neurologic disability and to assist the court in estimating life expectancy. An especially common topic of contention has been the role of birth asphyxia in the cause of brain damage and cerebral palsey.

The group of congenital neurologic disorders called the Developmental Disabilities includes mental retardation (developmental cognitive disability), cerebral palsy (developmental motor disability), epilepsy, autism, and learning disabilities. The 

In the course of this century, there have been striking declines in maternal and in fetal and infant mortality and injuries, and there have also been declines in diagnosed birth asphyxia. Physical trauma to the fetus during birth is now rare. Neonatal care has also improved drastically. These improvements in 

Causes of Cerebral Palsy

Pure ataxic or dyskinetic CP, especially accompanied by mental retardation, commonly has a genetic basis. Approximately half of spastic CP in term and near-term infants is related to 

Birth Asphyxia

Experimentally, acute deprivation of oxygen can produce motor disability. To do so requires severe hypoxia for an extended period, and most exposed infant animals either die or are later normal; only a

Clinical studies indicate that among infants who have severe and prolonged neonatal depression consistent with birth asphyxia, mortality is high. Among survivors, there is an excess of CP. It has been a repeated observation that the majority of survivors are later normal in neurologic and cognitive function. CP is the neurologic disability most clearly linked with birth asphyxia; other disabilities such as mental retardation and epilepsy, occurring in children who do not have CP, are probably not related to 

Current evidence supports the association of acute interruption of oxygen supply with only one type of CP: spastic quadriplegia, especially if accompanied by dyskinesia. Spastic quadriplegia with dyskinesia


Meconium is common in the amniotic fluid at term, especially in the second stage of labor, and is more frequent with intrauterine infection. The presence of meconium is associated with some increase in

Electronic Fetal Monitoring

In term and near-term infants, multiple late decelerations or decreased beat-to-beat variability but not other electronic fetal monitoring (EFM) findings, were associated with significant increase in risk of CP. Almost three quarters of children who had CP did not have either multiple late decelerations or

Postbirth Observations

Postnatal information used to evaluate if birth asphyxia was present takes into account such factors as low Apgar scores, metabolic acidosis, need for resuscitation and ventilatory support, and other neonatal neurologic signs, including seizures. These findings are compatible with birth asphyxia. It must be


Intrauterine exposure to infection is an important cause of preterm birth, and it apparently contributes to periventricular white-matter lesions visualized on neuroimaging. Such periventricular lesions are the best-known predictors of CP in premature infants. Intrauterine exposure to infection is associated with

Multiple Births

With the development of assistive reproductive technologies and with increasing numbers of births to women at older ages, multiple births are now more common. Twins and triplets are at higher risk of CP than infants born of a singleton pregnancy. Multiple births tend to be lower in birthweight than singletons, an important factor in their greater risk. Risk of CP is higher in twins of normal birthweight than in

Coagulation Factors and Autoimmune Disorders

The factor V Leiden mutation and the antiphospholipid antibody syndrome are associated with strokes in older children and adults. There is recent evidence that such disorders can predispose to 


The neurologist serving as an expert witness in litigation involving neurologic impairment and birth events is likely to be asked a series of

Does This Child Have CP?

Be prepared to offer a definition such as, CP is a chronic motor disorder of cerebral origin and is characterized by abnormality of movement or posture and early (for this purpose, apparently congenital) onset and is not caused by 

Is the Child's CP Caused by Birth Asphyxia?

Does the child have a neurologic disorder that birth asphyxia is known to be capable of producing? Ataxia or dyskinesia without spasticity are unlikely to be caused by asphyxial birth or other birth events; these conditions, especially if accompanied by mental retardation are more likely to be of genetic origin. Note that the existence of hemiplegic CP, spastic diplegia, ataxia, or dyskinesia alone has not been shown to be associated with

Did the Care Given Cause or Fail To Prevent the Patient's Disability?

The neurologist will not be the arbitor of whether the obstetric management met the usual standards of care; that is obviously an issue for obstetricians, as is the interpretation of fetal monitoring strips. Neurologists, however, testifying as

What Is the Current Level of Disability and Expected Life Span?

No assessment of the severity of involvement should be undertaken until a child is at least 3 or 4 years old, since judgment about cognitive level cannot be made well until language has developed; because