When I'm working through causation in one of these cases, the real question is whether the evidence points to an acute intrapartum hypoxic-ischemic event, something chronic or antenatal, an infection, a stroke, a genetic or metabolic condition, placental pathology, medication exposure, trauma — or some combination of these. No single piece of evidence gets to carry that weight alone. Low Apgar scores, for instance, tell us how the newborn looked and responded to resuscitation in that moment. They don't, by themselves, tell us when an injury happened or why.
A sound causation review has to pull everything together — the fetal tracing, any sentinel events, cord and early neonatal blood gases, how much resuscitation was needed and for how long, whether there was multisystem organ dysfunction, the neurologic exam, when seizures started, the EEG, the MRI pattern and its timing, the placental findings, and any alternative diagnoses that could explain what happened. What matters is whether the whole picture fits together the way we'd expect. Evidence pointing to an acute, near-total event tends to look very different from evidence of a prolonged partial insult, and both look different still from an antenatal condition that predates labor altogether.
For plaintiff counsel, the strongest case is one where the alleged breach, the physiologic mechanism, the timing, and the objective neonatal findings all line up — not just one or two of those, but all of them together. For defense counsel, the question worth asking is whether the alleged delay could actually have produced the injury pattern documented in the records, or whether the record points to something earlier, or whether the record instead supports a non-hypoxic etiology. And honestly, both sides should be wary of an expert who starts with the disability and reasons backward to presumed negligence during labor — that's not how sound causation analysis works.
The distinction that matters most, legally, is between association and causation. A difficult labor and neonatal encephalopathy can occur in the same case without one having caused the other. And on the flip side, a delivery note that reads as technically appropriate doesn't rule out causation if the physiologic record still shows a preventable insult unfolding in real time. None of this can be assessed in pieces — it takes the complete maternal, fetal, placental, and neonatal record together.
Questions for Counsel
- Were umbilical cord blood gases obtained at delivery, and if not, why — and how does the absence of cord gas data affect the causation analysis?
- What is the pattern and timing of injury on neonatal MRI, and is that pattern consistent with an acute intrapartum hypoxic event or with an antepartum or chronic injury?
- Do the EFM strip and clinical record support a sentinel intrapartum event, or does the case involve a more gradually evolving Category II pattern?
- Were the ACOG/AAP essential criteria for establishing intrapartum causation satisfied in this case — and if not, which criteria are missing?
- Has the defense identified any non-hypoxic cause of neonatal encephalopathy (metabolic, genetic, infectious, or antepartum) that should be explored through additional expert review?
Disclaimer: This material is for general educational purposes and does not constitute legal advice, medical advice, or a case-specific standard-of-care or causation opinion. Clinical guidance changes over time. Every matter requires review of the complete record, applicable guidance in effect on the date of care, local resources, and jurisdiction-specific legal standards. For consultation on a specific case, contact OBGYN Peer.