STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
JOSEPH AUGUST SCLAFANI AND REBEKAH LEIGH SCLAFANI, on
behalf of and as parents and natural guardians of JACOB ANTHONY SCLAFANI, a minor,
vs.
Petitioners,
Case No. 15-6196N
FLORIDA BIRTH-RELATED NEUROLOGICAL INJURY COMPENSATION ASSOCIATION,
Respondent.
/
FINAL ORDER
Pursuant to notice, a final hearing was held in this case on December 9, 2016, via video teleconference with sites in West Palm Beach and Tallahassee, Florida, before Barbara J. Staros, an Administrative Law Judge of the Division of Administrative Hearings (DOAH).
APPEARANCES
For Petitioners: Samuel Matthew Yaffa, Esquire
Samuel M. Yaffa, P.A.
301 West Atlantic Avenue, Suite O2 Delray Beach, Florida 33444
For Respondent: Tana D. Storey, Esquire
Rutledge Ecenia, P.A.
119 South Monroe Street, Suite 202 Tallahassee, Florida 32301
STATEMENT OF THE ISSUE
The issue in this case is whether Jacob Anthony Sclafani suffered an injury for which compensation should be awarded under the Florida Birth-Related Neurological Injury Compensation Plan (Plan).
PRELIMINARY STATEMENT
On October 30, 2015, Joseph August Sclafani and Rebekah Leigh Sclafani, on behalf of and as parents and natural guardians of Jacob Anthony Sclafani (Jacob), a minor, filed a Petition for Benefits Pursuant to Florida Statute Section 766.301 et seq. (Petition), with DOAH. The Petition alleged that Jacob suffered brain damage as a result of a birth-related neurological injury, and sought a determination as to compensability under the Florida Birth-Related Neurological Injury Compensation Association (NICA) statutes.
The Petition named Rachel K. Ciaccio, M.D., as the physician who provided obstetric services at Jacob’s birth at Boca Raton Regional Hospital, Inc., in Boca Raton, Florida, on January 3,
2012.
DOAH served NICA with a copy of the Petition on November 6,
2015. On November 12, 2015, DOAH received a return receipt showing that Boca Raton Regional Hospital had been served with a copy of the Petition. The website of the United States Postal Service reflects that a copy of the Petition was delivered to
Rachel K. Ciaccio-Stilwell, M.D, on November 9, 2015. As of the date of this Final Order, neither Boca Raton Regional Hospital nor Dr. Ciaccio-Stilwell has petitioned to intervene into this proceeding.
On January 22, 2016, NICA filed a response to the Petition, giving notice that the alleged injury did not "meet the definition of a 'birth-related neurological injury' as defined in section 766.3021(2), Florida Statutes." NICA requested that a hearing be scheduled to resolve whether the claim was compensable.
The parties filed Motions for Summary Final Order, which were denied, as material facts remained in dispute. Following two continuances, a final hearing was scheduled for December 9, 2016. The case was heard as scheduled. On December 2, 2016, the parties filed a Pre-hearing Stipulation in which they agreed to certain facts as set forth in section E of the Pre-hearing Stipulation.
These facts have been incorporated into this Final Order.
Petitioners’ Exhibits 1 and 2 were admitted into evidence.
Petitioners did not present any live witnesses. Respondent presented the live testimony of Dr. Donald Willis. Respondent’s Exhibits 1 through 3 were admitted into evidence, including the deposition testimony of Dr. Michael Duchowny. Joint Exhibits 1 through 17 were admitted into evidence.
A Transcript of the Final Hearing was filed on December 16,
2016.
Respondent timely filed a Proposed Final Order on January 5, 2017, which has been carefully considered in the preparation of this Final Order. Petitioners did not file a proposed final
order.
FINDINGS OF FACT
Joseph August Sclafani and Rebekah Leigh Sclafani are the natural parents and guardians of Jacob Anthony Sclafani.
Jacob was born a live infant on January 3, 2012, at Boca Raton Regional Hospital, which is a hospital located in Boca Raton, Florida.
Jacob was a single gestation and weighed 3,289 grams at birth.
Obstetrical services at Jacob’s birth were provided by Rachel K. Ciaccio-Stillwell, M.D., who was a physician participating in the NICA program at the time of Jacob’s birth.
Jacob’s APGAR scores were 2, 5 and 7 at 1, 5 and 10 minutes respectively.
Petitioners contend that Jacob suffered a birth-related neurological injury and seek compensation under the NICA Plan. More specifically, Petitioners contend that Jacob suffered oxygen deprivation during labor and delivery, which resulted in a brain injury, rendering Jacob permanently and substantially mentally and physically impaired. Respondent contends that while there was an event during labor and delivery which resulted in some oxygen
deprivation to Jacob, that any such oxygen deprivation did not result in brain injury, and that any medical conditions of Jacob’s are not birth-related neurological injuries as defined in section 766.302(2), Florida Statutes. Respondent further contends that Jacob is not permanently and substantially mentally and physically impaired.
There is no dispute about the facts and circumstances of Jacob’s birth. Mrs. Sclafani presented to Boca Raton Regional Hospital for induction of labor. Jacob was born via vacuum- assisted vaginal delivery secondary to a non-reassuring fetal heart rate pattern. The delivery was complicated by a shoulder dystocia. Umbilical cord blood gas pH was 6.84. The baby was depressed at birth requiring resuscitation. The baby was intubated and taken to the NICU, and was on room air within 24 hours.
The record reflects that Jacob has received therapy services from Indiana First Steps, including developmental therapy, physical therapy, occupational therapy, and speech therapy. He has also received occupational therapy services from the Rehabilitation Institute of Chicago.
Petitioners retained Paul Gatewood, M.D., to review Jacob’s medical records, as well as the opinions of NICA’s expert witnesses. Dr. Gatewood practices in obstetrics and gynecology in Ohio. Petitioners presented an affidavit of Dr. Gatewood, but did
not present his deposition or live testimony. Dr. Gatewood’s affidavit concludes with an opinion in support of Petitioners’ claim that Jacob suffered a birth-related neurological injury caused by oxygen deprivation which resulted in brain injury.1/
Petitioners presented the affidavit of Dr. Michael H. Kohrman, who is one of Jacob’s treating physicians. Dr. Kohrman is board-certified in neurology, with a subspecialty in child neurology, and practices in Illinois. He also reviewed Jacob’s medical records and rendered an opinion that supports Petitioners’ claim that Jacob suffered a birth-related neurological injury.2/
NICA retained Dr. Donald Willis, a physician who is board-certified in maternal fetal medicine and obstetrics and gynecology. Dr. Willis reviewed the medical records related to Jacob’s birth to determine whether Jacob sustained an injury to the brain or spinal cord caused by oxygen deprivation or mechanical injury in the course of labor, delivery, or resuscitation in the immediate post-delivery period.
Dr. Willis’ report dated December 11, 2015, summarizes the relevant events of Mrs. Sclafani’s labor and Jacob’s delivery in pertinent part:
[The mother] was admitted at term for induction of labor. Her cervix was dilated
1 cm and 75% effaced.
Amniotic fluid was clear at time of rupture of the membranes. The fetal heart rate (FHR) monitor tracing during labor was reviewed.
The baseline heart rate on admission was normal at 140 bpm with normal variability. There was a period of what appears to be uterine hyper-stimulation during early labor with FHR decelerations at about 80 bpm. This resolved and FHR returned to a normal appearing pattern. An abnormal FHR tracing becomes apparent about 90 minutes prior to delivery and continues until delivery.
Vacuum assisted vaginal delivery was done due to the non-reassuring FHR pattern. The presenting part was at +2 to +3 station. Two pop-offs occurred prior to delivery.
Delivery was then complicated by a shoulder dystocia. This was managed with McRobert’s maneuver and supra-pubic pressure. Birth weight was 3,289 grams or 7 lbs 4 oz’s.
The baby was depressed at birth. Apgar scores were 2/5/7. Cord blood gas was consistent with acidosis with a pH of 6.84 and a base excess of -25. Resuscitation began with bag/mask ventilation. Intubation was done shortly after birth due to continued respiratory depression. The first gasp was at about 5 minutes. The baby was taken to the NICU for respiratory depression.
Respiratory depression resolved quickly and the baby was on room air within 24-hours of birth during labor, delivery and most likely continuing into the immediate post delivery period. Neurology evaluation immediately after birth described “Perinatal Depression.” Head Ultrasound on DOL 3 was normal.
Cultures were negative. No seizure activity was documented during the newborn hospital stay.
The baby was discharged home on DOL 6. Head MRI was not done during the newborn hospital admission.
In summary, there was an abnormal FHR pattern prior to birth that required vacuum assistance for vaginal delivery. The
delivery was complicated by a shoulder dystocia. The newborn was depressed with Apgar scores of 2/5/7. Umbilical cord blood gas pH of 6.84 would be consistent with acidosis at birth. Respiratory depression for less than 24-hours was the only significant newborn complication. MRI and CT scans were not done during the newborn hospital course.
Labor and delivery were complicated by a non- reassuring FHR pattern prior to birth and delivery was complicated by shoulder dystocia. This resulted in a depressed newborn with cord blood gas consistent with acidosis (pH 6.84). These findings would be consistent with an obstetrical event that resulted in loss of oxygen to the baby’s brain during labor, delivery and most likely continuing into the immediate delivery period. However, no medical records were available to indicate the suspected oxygen deprivation at birth resulted in any actual brain injury.
At hearing, Dr. Willis explained that babies with significant oxygen deprivation during birth that causes brain injury will usually have a complicated hospital course. These complications may include seizures, low platelet counts, abnormal liver function studies, and acute renal failure. He noted that Jacob did not suffer seizures during the newborn hospital course or any of these other conditions typically seen with birth- related oxygen deprivation.
At some point following his initial report, Dr. Willis reviewed an MRI report of Jacob which Dr. Willis believes “firms up” his original opinion that there is no evidence that the
oxygen deprivation resulted in brain injury. He explained that oxygen deprivation can occur during labor and delivery that does not result in any significant brain injury.
He further explained as to why he is of the opinion that the oxygen deprivation that did occur during labor and delivery did not result in brain damage:
Number one . . . the baby did not show any of the clinical signs we see for brain injury, seizures, renal failure, liver function abnormalities. None of these things were present in the immediately born period. The other thing is, the head imaging, the ultrasound that was done, I believe was on day three, but shortly after birth, the head ultrasound was done and then an MRI was done at around 2 years of age, maybe a little under 2 years of age, was completely normal. It showed no abnormalities. So in order to
-- it’s my experience, as well as kind of the standard medical philosophy that if you suffer a brain injury due to oxygen deprivation, significant brain injury due to oxygen deprivation, that there are going to be abnormalities on the MRI. Without abnormalities on the MRI, then you may have suffered some degree of oxygen deprivation, but that oxygen deprivation did not cause any substantial brain injury.
When asked whether a normal MRI scan taken two years post-injury would be sufficient to rule out the presence of an oxygen deprivation injury two years prior, he replied “yes,” noting that any substantial oxygen deprivation that causes brain injury should have abnormal findings that persist. Dr. Willis explained that how quickly the child responds to resuscitation
has a lot to do with the duration of the oxygen deprivation. He noted that Jacob had a fairly quick recovery from respiratory depression which indicates that the oxygen deprivation was probably not long-standing during labor and delivery.
Dr. Willis’ opinion that there was an apparent obstetrical event that resulted in loss of oxygen or mechanical trauma to the baby’s brain during labor or delivery which did not result in brain injury is credited.
NICA also retained Dr. Michael Duchowny to evaluate Jacob. Dr. Duchowny is board-certified in pediatric neurology, with special qualifications in child neurology. He is a senior staff attending at Nicklaus Children’s Hospital and directs the neurology training program. Dr. Duchowny reviewed Jacob’s medical records and performed an independent medical examination of Jacob on January 13, 2016. In a medical report dated January 15, 2016, Dr. Duchowny expressed the following opinions:
In Summary, Jacob’s neurological examination is significant for a complex motor presentation that includes hypotonia, ataxia and distal dystonic posturing. This primarily affects his fine motor coordination but prevents him from grasping objects with thumb-finger opposition. These findings are noted symmetrically in both the upper and lower extremities. Jacob also has a speech articulation deficit. In contrast, Jacob is functioning mentally at age level and his social development is also appropriate for age.
I had an opportunity to review the medical records sent on December 29, 2015. They confirm Ms. Sclafani’s recollection of the perinatal events. Jacob’s Apgar scores were 2, 5 and 7 with acidosis noted on his arterial blood gas analyses. There was no accompanying evidence of multi-organ system involvement, and a head ultrasound performed on January 6, 2012 (DOL #4) was within normal limits.
Today’s evaluation and record review do not provide evidence of a substantial mental impairment and Jacob’s pattern of cerebral palsy is more likely to be acquired prenatally, especially in light of his normal MR imaging study. I therefore do not recommend consideration for inclusion within the NICA program.
Dr. Duchowny reaffirmed his opinions contained in his January 15, 2016, report when he was deposed on October 26, 2016. That is, he continues to be of the opinion that Jacob does not suffer from a mental impairment or a substantial physical impairment. And, he is of the opinion that Jacob’s pattern of cerebral palsy was more likely acquired prenatally.
Regarding his physical examination of Jacob,
Dr. Duchowny described Jacob’s level of cognitive functioning to be at or above age level. He described Jacob as a bright child who interacted in a manner that, from a mental standpoint, is quite appropriate for his age. He noted that while Jacob has a “slight motor articulation problem,” his speech was fluent and his communication skills were excellent. He testified that “it is very clear that [Jacob] does not have a substantial mental
impairment. He’s not even close.” Dr. Duchowny’s opinion in this regard is credited.
Regarding Jacob’s physical impairment, Dr. Duchowny acknowledged that it is permanent but not does not consider it to be substantial:
Q: Okay. In your opinion, does Jacob suffer from a physical impairment?
A: Yes, he does.
Q: Is Jacob’s physical impairment permanent? A: I believe it is.
Q: Is Jacob’s physical impairment substantial?
A: I don’t believe so. Q: Why?
A: Jacob does have motor issues and they are related primarily to -- to two areas: One is that he has no muscle tone, and the other is that he has problems with coordination.
I think both of these are important problems, but he is, at the same time, able to walk, despite his incoordination, he did not fall. In fact, he actually can get around and do activities, maybe not as fluently as he should, but he can do them.
I would regard that as not being within a substantial range. Children who have substantial motor difficulties typically are unable to do most functions; they require devices such as wheelchairs and they are just not ambulatory. Jacob, on the other hand, is despite his motor problems.
Dr. Duchowny is also of the opinion that Jacob’s physical impairment is not consistent with a neurological injury to the brain or spinal cord acquired due to oxygen deprivation or mechanical injury at birth. Dr. Duchowny explained that “[t]his kind of finding is not essentially due to mechanical injury or oxygen deprivation. This is a pattern of motor deficit known as either hypotonic or ataxic cerebral palsy. It is well-known to be a prenatally acquired developmental syndrome.”
Dr. Duchowny’s opinions that Jacob does not suffer from a mental impairment, that his physical impairment is not within the substantial range, and that his pattern of cerebral palsy is more likely acquired prenatally are credited.
The dispute in this case centers on whether, more likely than not, any oxygen deprivation to Jacob during labor and delivery resulted in brain injury and, if so, did any such injury result in Jacob becoming permanently and substantially mentally and physically impaired.
The undersigned finds the testimony of NICA’s experts to be compelling. The greater weight of the evidence establishes, through the opinions of Dr. Willis and Dr. Duchowny, that while there was an apparent obstetrical event that resulted in loss of oxygen to Jacob’s brain during labor and delivery, that any such oxygen deprivation did not result in brain injury.
Moreover, the record evidence does not support a finding that Jacob is permanently and substantially mentally and physically impaired. While not minimizing Jacob’s disabilities, Dr. Duchowny’s opinion, following his physical examination of Jacob, that Jacob’s physical impairments are not within the substantial range, is persuasive, and is credited. Moreover, there is no evidence to support a finding that Jacob suffers a mental impairment at all, much less a substantial one.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of this proceeding.
§§ 766.301-766.316, Fla. Stat. (2011).
The Plan was established by the Legislature "to provide compensation on a no-fault basis, for a limited class of catastrophic injuries that result in unusually high costs for
custodial care and rehabilitation." § 766.301, Fla. Stat. (emphasis added). The Plan applies only to a birth-related neurological injury, which is defined in section 766.302(2) as
follows:
'Birth-related neurological injury' means injury to the brain or spinal cord of a live infant weighing at least 2,500 grams for a single gestation or, in the case of a multiple gestation, a live infant weighing at least 2,000 grams at birth caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate postdelivery
period in a hospital, which renders the infant permanently and substantially mentally and physically impaired. This definition shall apply to live births only and shall not include disability or death caused by genetic or congenital abnormality. (emphasis added).
The injured infant, her or his personal representative, parents, dependents, and next of kin, may seek compensation under the Plan by filing a claim for compensation with DOAH.
§§ 766.302(3), 766.303(2), and 766.305(1), Fla. Stat. NICA, which
administers the Plan, has "45 days from the date of service of a complete claim . . . in which to file a response to the petition and submit relevant written information relating to the issue of whether the injury is a birth-related neurological injury."
§ 766.305(4), Fla. Stat.
If NICA determines that the injury alleged in a claim is a compensable birth-related neurological injury, it may award compensation to the claimant, provided that the award is approved by the Administrative Law Judge to whom the claim has been assigned. § 766.305(7), Fla. Stat. If, on the other hand, NICA disputes the claim, as it has in the instant case, the dispute must be resolved by the assigned Administrative Law Judge in accordance with the provisions of chapter 120, Florida Statutes.
§§ 766.304, 766.309, and 766.31, Fla. Stat.
In discharging this responsibility, the Administrative Law Judge must make the following determinations based upon all available evidence:
Whether the injury claimed is a birth- related neurological injury. If the claimant has demonstrated, to the satisfaction of the administrative law judge, that the infant has sustained a brain or spinal cord injury caused by oxygen deprivation or mechanical injury and that the infant was thereby rendered permanently and substantially mentally and physically impaired, a rebuttable presumption shall arise that the injury is a birth-related neurological injury as defined in
s. 766.302(2).
Whether obstetrical services were delivered by a participating physician in the course of labor, delivery, or resuscitation in the immediate postdelivery period in a hospital; or by a certified nurse midwife in a teaching hospital supervised by a participating physician in the course of labor, delivery, or resuscitation in the immediate postdelivery period in a hospital.
§ 766.309(1), Fla. Stat. An award may be sustained only if the Administrative Law Judge concludes that the "infant has sustained a birth-related neurological injury and that obstetrical services were delivered by a participating physician at birth."
§ 766.31(1), Fla. Stat.
In the instant case, Petitioners filed a claim alleging Jacob did sustain oxygen deprivation resulting in brain injury rendering him permanently and substantially physically and mentally impaired. As the proponent of the issue of
compensability, the burden of proof is upon Petitioners.
§ 766.309(1)(a), Fla. Stat. See also Balino v. Dep't of Health & Rehabilitative Servs., 348 So. 2d 349, 350 (Fla. 1st DCA
1977)("[T]he burden of proof, apart from statute, is on the party asserting the affirmative of an issue before an administrative tribunal.").
The parties have stipulated that Jacob was born a live infant in a hospital licensed in Florida and weighed in excess of 2,500 grams. There is no dispute that the physician who provided obstetric services at Jacob’s birth was a participating physician in the NICA program. The parties disagree as to whether Jacob’s impairments were caused by oxygen deprivation during labor or delivery or whether they were more likely caused by prenatally acquired abnormalities. This is particularly significant in that the above-quoted statutory definition of a birth-related neurological injury expressly excludes those caused by genetic or congenital abnormalities. § 766.302(2), Fla. Stat. Moreover, the parties disagree as to whether, as a result of any such injury, Jacob was rendered substantially mentally and physically impaired.
The undersigned finds Dr. Willis’ expert opinion that while there was an apparent obstetrical event that resulted in loss of oxygen to Jacob’s brain during labor or delivery, such
oxygen deprivation did not result in brain injury to be persuasive.
Even if the undersigned were persuaded that Jacob suffered oxygen deprivation during labor and delivery that resulted in his disabilities, it must be established that those disabilities are permanent and substantial in nature as both are required to establish compensability. Fla. Birth-Related Neurological Injury Comp. Ass’n v. Div. of Admin. Hearings, 686
So. 2d 1349 (Fla. 1997). The greater weight of the evidence, in particular Dr. Duchowny’s opinion, establishes otherwise. There is no evidence that Jacob suffers from a mental impairment.
Additionally, while not minimizing his physical disabilities, the evidence does not establish that these disabilities are “substantial” as contemplated by the NICA statutes. Thus, Jacob is not entitled to benefits under the NICA Plan.
CONCLUSION
Based on the foregoing Findings of Fact and Conclusions of Law, it is ORDERED that the Petition filed by Joseph August Sclafani and Rebekah Leigh Sclafani, on behalf of and as parents and natural guardians of Jacob Anthony Sclafani, is dismissed with prejudice.
DONE AND ORDERED this 8th day of February, 2017, in Tallahassee, Leon County, Florida.
S
BARBARA J. STAROS
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 8th day of February, 2017.
ENDNOTES
1/ The affidavit is admissible in that it contains hearsay evidence which supplements or explains information contained in the medical records in evidence, but Dr. Gatewood’s opinion contained within the affidavit is not sufficient in itself to support a finding as contemplated by section 120.57(1)(c), Florida Statutes, and does not come within the hearsay exception contained in section 90.803(6)(a), Florida Statutes.
2/ The affidavit is admissible in that it contains hearsay evidence which supplements or explains information contained in the medical records in evidence, but Dr. Kohrman’s opinion contained within the affidavit is not sufficient in itself to support a finding as contemplated by section 120.57(1)(c) and does not come within the hearsay exception contained in section 90.803(6)(a).
COPIES FURNISHED:
(via certified mail)
Kenney Shipley, Executive Director Florida Birth Related Neurological
Injury Compensation Association
2360 Christopher Place, Suite Tallahassee, Florida 32308 (eServed) | 1 | ||
(Certified Mail No. 7016 0910 | 0001 | 7980 | 4346) |
Samuel Matthew Yaffa, Esquire Samuel M. Yaffa, P.A. Suite O2 301 West Atlantic Avenue Delray Beach, Florida 33444 (eServed) (Certified Mail No. 7014 2120 | 0003 | 1053 | 1972) |
Tana D. Storey, Esquire Rutledge Ecenia, P.A. Suite 202 119 South Monroe Street Tallahassee, Florida 32301 (eServed) (Certified Mail No. 7014 2120 | 0003 | 1053 | 1989) |
Amie Rice, Investigation Manager Consumer Services Unit Department of Health
4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275
(Certified Mail No. 7014 2120 0003 1053 1996)
Justin Senior, Secretary Health Quality Assurance
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 1
Tallahassee, Florida 32308 (eServed)
(Certified Mail No. 7014 2120 0003 1053 2009)
Rachel K. Ciaccio-Stilwell, M.D. Suite 301
6853 Southwest 18th Street Boca Raton, Florida 33433
(Certified Mail No. 7014 2120 0003 1053 2016)
Boca Raton Regional Hospital Attention: Risk Management 800 Meadows Road
Boca Raton, Florida 33486
(Certified Mail No. 7014 2120 0003 1053 2023)
NOTICE OF RIGHT TO JUDICIAL REVIEW
Review of a final order of an administrative law judge shall be by appeal to the District Court of Appeal pursuant to section 766.311(1), Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings are commenced by filing the original notice of administrative appeal with the agency clerk of the Division of Administrative Hearings within 30 days of rendition of the order to be reviewed, and a copy, accompanied by filing fees prescribed by law, with the clerk of the appropriate District Court of Appeal. See
§ 766.311(1), Fla. Stat., and Fla. Birth-Related Neurological Injury Comp. Ass'n v. Carreras, 598 So. 2d 299 (Fla. 1st DCA 1992).
| Issue Date | Document | Summary |
|---|---|---|
| Feb. 08, 2017 | DOAH Final Order | Child did not sustain an injury to the brain during labor or delivery. Physical and mental impairments not substantial. The child does not have a mental impairment. |
