Findings Of Fact Dondraya Wilson was born on December 11, 2011, at Broward Health Medical Center located in Ft. Lauderdale, Florida. Dondraya weighed 3,350 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Dondraya, to determine whether an injury occurred in a hospital due to oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period. Dr. Willis described his findings in pertinent part as follows in an affidavit dated June 2, 2015: I have reviewed the medical records for the above individual, pages 1 through 5357. The mother, Kenia Wilson, was a 29 year old G7 P3 with a history of macrosomia and shoulder dystocia with her prior pregnancy. The mother was admitted at 41 weeks for delivery due to post-dates and suspected fetal macrosomia. Ultrasound on the day of delivery gave an estimated fetal weight of 8 lbs. 6 ozs. Her cervix was long and closed. She was not in labor. The decision was made to delivery (sic) by Cesarean section rather than induction of labor due to prior history of shoulder dystocia. Primary Cesarean section delivery was done with a birth weight of 3,350 grams or 7 lbs 6 ozs. Meconium stained amniotic fluid was present at time of delivery. The baby was not depressed at birth. Apgar scores were 8/9. Umbilical cord blood gas was normal with a pH of 7.29 and a base excess of only -4. The baby was taken to the newborn nursery without apparent problems. Within 24-hours of birth, temperature instability and poor feeding were noted and Neonatology consultation requested. The baby was subsequently transferred to Broward General Hospital on DOL 2. The baby had a complicated and very long newborn hospital course. The initial problems were respiratory distress, poor muscle tone and poor feeding. Respiratory distress was managed with hood and nasal oxygen. Poor muscle tone was a prominent feature. Spinal fluid was obtained for culture. Cultures were no-growth. Feeding tube was surgically placed at about 3 months of age due to poor oral feeding. Seizure activity developed at almost three months of age. EEG was abnormal. Two MRI’s of the brain were done and both were normal. Genetic and metabolic evaluation was done. Chromosome analysis was normal, but microarray identified a deletion in chromosome 16. In summary, the mother was not in labor prior to delivery. Delivery was by Primary Cesarean section. The newborn was not depressed at birth. Apgar scores were 8/9. Umbilical cord blood gas was normal with a pH of 7.29. The baby went from delivery room to the normal nursery. There were no findings to suggest birth hypoxia. Within the first day of life, neurologic problems were suspected. MRI’s of the brain were normal. Genetic evaluation identified a deletion of chromosome 16. There was no apparent obstetrical event that resulted in loss of oxygen or mechanical trauma to the baby’s brain during labor, delivery or the immediate post delivery period. The child was identified with a chromosome abnormality, which most likely explains the neurologic problems. NICA retained Michael S. Duchowny, M.D. (Dr. Duchowny), a pediatric neurologist, to examine Dondraya and to review her medical records. Dr. Duchowny examined Dondraya on March 18, 2015, and opined in pertinent part as follows in his affidavit dated June 4, 2015: In summary, Dondraya’s neurological examination is consistent with severe global neurodevelopment delay with a maturation level of approximating ages 1-2 months. Dondraya evidences hypotonic quadriparesis with microcephaly and a cortical visual impairment. She additionally has a longstanding history of medically resistant seizures, oromotor dysfunction, pseudobulbar palsy and a chronic indwelling gastrotomy tube. There is incidental reactive airway disease. Dondraya therefore has both a substantial mental and motor impairment. Review of medical records reveals that Dondraya’s neurological problems are related to her chromosome disorder and not due to either mechanical injury or oxygen deprivation during labor, delivery or the immediate postnatal period. Dondraya was born at 41 weeks gestation with a birth weight of 7 pounds and had a 1 & 5 minute Apgar scores of 8 & 9. She did not require intubation at birth and there was no evidence of multiorgan impairment. Furthermore, two MRI scans of the brain performed at ages 5 days and 2 months are within normal limits. I therefore believe that Dondraya’s neurological impairment was acquired prenatally and therefore do not recommend her for compensation within the NICA program. A review of the file in this case reveals that there have been no expert opinions filed that are contrary to the opinion of Dr. Willis that there was no apparent obstetrical event that resulted in loss of oxygen or mechanical trauma to the baby’s brain during labor, delivery or the immediate post- delivery period. Dr. Willis’ opinion is credited. There are no expert opinions filed that are contrary to Dr. Duchowny’s opinion that although Dondraya has both a substantial mental and motor impairment, her neurological impairments are related to her chromosome disorder and not due to either mechanical injury or oxygen deprivation during labor, delivery or the immediate postnatal period, but were acquired prenatally. Dr. Duchowny’s opinion is credited.
Findings Of Fact Uzziah Walker was born on November 23, 2012, at Sacred Heart Hospital located in Pensacola, Florida. Uzziah weighed in excess of 2,500 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Uzziah. In an affidavit dated May 24, 2015, Dr. Willis described his findings in pertinent part as follows: In summary, there was no apparent fetal distress during labor. Spontaneous vaginal delivery resulted in a large subgaleal hemorrhage with blood loss and poor perfusion. The baby was not hypoxic at birth. Cord blood gas was normal (pH 7.25). However, blood loss from the scalp hemorrhage and poor perfusion resulted in intraventricular hemorrhage during the immediate post delivery period. There was an apparent obstetrical event that resulted in scalp hemorrhage and poor perfusion with loss of oxygen to the baby’s brain during the immediate post delivery period. The poor perfusion resulted in brain injury. I am unable to comment about the severity of the brain injury. NICA retained Michael Duchowny, M.D. (Dr. Duchowny), a pediatric neurologist, to examine Uzziah and to review his medical records. Dr. Duchowny examined Uzziah on March 11, 2015. In an affidavit dated May 29, 2015, Dr. Duchowny opined in pertinent part as follows: Review of medical records and imaging studies sent on February 4 and 6, 2015 was performed. They detail Uzziah’s birth at Baptist Hospital Health System in Pensacola with a forceps assisted delivery after a rapid decent. Uzziah evidenced tachycardia and some retractions at the time of delivery but his Apgar scores were 7 and 8. He was observed to have a subgaleal hematoma; a CT scan of the brain on November 23 revealed a large soft tissue hematoma and a small collection of subdural blood over the right cerebellar tent with a small amount of right ventricular hemorrhage. Of note, there was no cerebral edema or ventricular compression. No skull fractures were noted despite bilateral subgaleal hematomas. The neonatal course was otherwise uncomplicated. In summary, Uzziah’s neurological examination today reveals normal findings. He does not exhibit either mental or physical impairment and his overall development has caught up and is proceeding in an age appropriate fashion. I believe that Uzziah’s perinatal hematomas were resorbed without residual brain injury and his future prognosis is excellent. I explained to his family that Uzziah is doing very well and that his future is favorable from a prognostic standpoint. Given Uzziah’s normal neurological status today, I am not recommending compensation with the NICA program. A review of the file in this case reveals that there have been no opinions filed that are contrary to the opinion of Dr. Willis that there was an apparent obstetrical event that resulted in scalp hemorrhage and poor perfusion with loss of oxygen to the baby's brain during the immediate post-delivery period, and that the poor perfusion resulted in brain injury. Dr. Willis’ opinion is credited. There are no opinions filed that are contrary to Dr. Duchowny’s opinion that Uzziah’s overall development is proceeding in an age appropriate fashion and does not exhibit either mental or physical impairment. Dr. Duchowny’s opinion is credited.
Findings Of Fact Brandon Santiago was born on January 28, 2008, at Health Central in Ocoee, Florida. Brandon weighed 2,750 grams at birth. NICA retained Donald C. Willis, M.D., as its expert in maternal fetal medicine. After having reviewed the medical records of Brandon and his mother, Dr. Willis opined in an affidavit dated June 26, 2013, as follows: The fetal heart rate (FHR) monitor tracing during labor was not available for review. However, the operative report stated “repetitive variable decelerations to the 60’s" were present. Cesarean section delivery was done for the abnormal FHR pattern and failure to progress in labor. Amniotic fluid was clear at delivery. Birth weight was 2,750 grams. The newborn was not depressed. Apgar scores were 7/9/9. Cord blood gas did not suggest acidosis. The pH was 7.26 with abase [sic] excess of only -3. Decreased fetal tone was present after birth and attributed to maternal MgS04 administration during labor. The baby had an uneventful hospital course and was discharged home two days after birth. Subsequently, the baby was noted to have poor muscle tone and developmental delay. Genetic evaluation was done but no obvious genetic condition was identified. In summary, Cesarean section was done for abnormal FHR pattern. The baby was not depressed at birth. Decreased muscle tone was noted, but otherwise the newborn hospital course was uneventful. The baby was discharged home with the mother two days after birth. These findings do not suggest oxygen deprivation during the birthing process. There was no apparent obstetrical event that resulted in loss of oxygen or mechanical trauma to Brandon Santiago’s brain during labor, delivery, or the immediate post delivery period. NICA retained Michael S. Duchowny, M.D., as its medical expert in pediatric neurology. Dr. Duchowny examined Brandon and reviewed his medical records. In an affidavit dated July 9, 2013, Dr. Duchowny opined as follows: Brandon’s neurological examination reveals evidence of severe motor delay with virtually no progress past the newborn level. This disorder affects all limbs in a symmetric fashion and has likely compromised his bulbar musculature, as well. Cognitive testing is difficult to assess due to the profound motor impairment. A review of the medical records confirms his mother’s impression of only transient difficulties at birth and in fact, Brandon was born only with a brief period of absent respirations which responded immediately in the delivery room. His Apgar scores were 7, 9, 9 at 1, 5, and 10 minutes and Brandon’s hospital course stabilized rapidly allowing him to be discharged on the second day of life. These facts do not support the acquisition of a neurological injury to the brain or spinal cord due to oxygen deprivation or mechanical injury during labor or delivery. While Brandon does evidence a substantial motor impairment, he is likely suffering from an unknown neuromuscular disorder. The history of seizures obviously suggests that the underlying diagnosis also involves the central nervous system and is therefore more complex, but his caretakers have so far been unable to ascertain a definitive diagnosis. * * * It is my opinion that BRANDON SANTIAGO does have a substantial motor impairment. However, I do not regard Brandon’s neurological presentation as consistent with a neurological injury to the brain or spinal cord acquired due to oxygen deprivation or mechanical injury occurring during the course of labor, delivery, or the immediate post- delivery period in the hospital during the birth of BRANDON SANTIAGO. I, therefore, do not believe that BRANDON SANTIAGO is compensable within the NICA program. A review of the file does not show any opinions contrary to the opinions of Dr. Duchowny and Dr. Willis that Brandon did not suffer a neurological injury due to oxygen deprivation or mechanical injury during labor, delivery, or resuscitation in the immediate post-delivery period are credited.
Findings Of Fact Antonia was born on March 14, 2012, at Plantation General Hospital located in Plantation, Florida. Antonia weighed 3,665 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Antonia. In an affidavit dated September 19, 2013, Dr. Willis opined the following: It is my opinion that the pregnancy was complicated by poorly controlled Diabetes with a large-for-gestational age baby and resulting in dystocia at delivery. The baby was depressed at birth, but “rapidly improved.” The baby suffered a brachial plexus injury from the shoulder dystocia, but there was no evidence of brain injury. As such, it is my opinion that delivery was complicated by a shoulder dystocia with resulting brachial plexus injury. However, there was no apparent brain or spinal cord injury from loss of oxygen or mechanical trauma. Michael S. Duchowny, M.D., a pediatric neurologist, was retained by NICA to examine Antonia. Dr. Duchowny examined Antonia on August 28, 2013. In an affidavit dated September 18, 2013, Dr. Duchowny opined as follows: It is my opinion that Antonia’s neurological examination reveals evidence of a complete left brachial plexus palsy involving nerve roots C5 to T1. She thus has both an Erb’s and Klumpke’s paralysis which is judged to be severe. There appears to be little benefit from her previous surgery as she most likely had an avulsive type injury. In contrast, Antonia’s cognitive status and motor ability in her other three extremities are well preserved. I had an opportunity to fully review the medical records that were sent on July 25, 2013. The records confirm the family’s history of shoulder dystocia at birth. Antonia’s Apgar scores were 0, 6 & 8 at 1, 5 and 10 minutes. Her brachial plexus palsy was recognized immediately. She was intubated in the delivery room but extubated at 10 minutes of age. Of note, an MRI of Antonia’s brachial plexus performed on June 29, 2012[,] revealed pseudomeningocele formation at the C7 and T1 levels. As such, it is my opinion that Antonia’s brachial plexus palsy places her damage outside the central nervous system as it involves cervical and upper thoracic root segments. Although her injury was likely acquired as a result of mechanical forces during delivery, the location of her impairment is outside the central nervous system (brain and spinal cord). I therefore believe that Antonia should not be considered for compensation with the NICA program. A review of the file does not show any contrary opinions to those of Dr. Willis and Dr. Duchowny. The opinions of Dr. Willis and Dr. Duchowny that Antonia did not suffer a brain or spinal cord injury due to oxygen deprivation or mechanical injury during labor, delivery, and resuscitation during the post- delivery period are credited.
Findings Of Fact Jackson J. Salling was born on February 28, 2008, at Brandon Regional Hospital in Brandon, Florida. Jackson weighed 4,070 grams at birth. NICA retained Michael S. Duchowny, M.D., as its medical expert in pediatric neurology. Dr. Duchowny examined Jackson and reviewed his medical records. In an affidavit dated July 22, 2013, Dr. Duchowny opined as follows: Based upon the history provided to me and my physical and neurological examination of the child, and as further described in my evaluation report, I concluded that the child has a substantial mental impairment but does not evidence a substantial motor impairment. Further the medical records do not provide support for neurological injury of the brain or spinal cord acquired due to oxygen deprivation or mechanical injury. Rather, Jackson’s present neurological problems are prenatal in origin and unrelated to intrapartum or immediate post-delivery events. * * * It is my medical opinion that Jackson Salling has not suffered a birth-related neurological injury as defined by the provisions of Chapter 766, Florida Statutes, and the he therefore is not eligible for compensation under the Florida Birth-Related Neurological Injury Compensation Plan. NICA retained Donald Willis, M.D., as an expert in maternal-fetal medicine to review the medical records of Jackson and his mother. In an affidavit dated July 19, 2013, Dr. Willis opined: Jackson Salling was born by vaginal delivery after elective induction of labor at 39 weeks gestation. Delivery was complicated by a shoulder dystocia lasting three minutes which resulted in a fractured humerus bone. Umbilical cord gas was within normal limits, and did not suggest hypoxia at birth. The newborn was cyanotic, floppy, and without spontaneous respirations at birth. His one- minute Apgar score was 3. Bag and mask ventilation was given and the child quickly improved, with an Apgar score of 9 at five minutes and 9 at 10 minutes. Significant oxygen deprivation during labor and birth would be unlikely with normal Apgar scores of five and ten minutes. The fractured humerus required orthopedic management. No MRI or CT scan of the head was done. Based on my review of medical records, it is my opinion that there was no obstetrical event that resulted in loss of oxygen or mechanical trauma to the baby’s brain during labor, delivery, or the immediate post- delivery period. A review of the file does not show any opinions contrary to the opinions of Dr. Duchowny and Dr. Willis that Jackson did not suffer a neurological injury due to oxygen deprivation or mechanical injury during labor, delivery, or resuscitation in the immediate post-delivery period and that Jackson does not have substantial and permanent mental and physical impairments due to lack of oxygen or mechanical trauma are credited.
Findings Of Fact Kayley was born January 26, 2009, at Winnie Palmer Hospital in Orlando, Florida. She weighed 2,928 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records of Kayley. In an affidavit dated July 9, 2012, Dr. Willis opined as follows: Based upon my education and experience, it is my professional opinion, within a reasonable degree of medical probability that Kayley Jazzmine Jimenez-Sanchez did not suffer a "Birth-related Neurological Injury" as defined by Florida Statutes Section 766.302(2) as there was no oxygen deprivation or mechanical injury during labor, delivery, or resuscitation in the immediate post delivery period which resulted in injury to Kayley's brain or spinal cord. Attached to Dr. Willis' affidavit was a report detailing his findings based on the medical records of Kayley as follows: Fetal heart rate (FHR) monitoring on admission shows a normal baseline heart rate of 145 bpm. The pattern is reactive. The FHR monitor strip does not show any fetal distress prior to delivery. Cesarean section delivery was done without difficulty. Birth weight was 2,928 grams (6 lbs 7 oz's). Apgar scores were 4/8. Umbilical cord blood gas was normal with a pH of 7.28 and base excess of -1.9. The baby was taken to the nursery. Difficulty with feeding occurred with emesis after attempting to feed. X-Ray showed a dilated loop of bowel. Gastorgrafin enema was done for evaluation and identified Small Left Colon syndrome. Neurology evaluation at 2 days of age was done for jitteriness. Exam shows abnormal muscle tone. EEG on DOL 2 was normal. Head ultrasound also had normal findings. Skull X-Ray showed asymmetry of the skull bones. MRI on DOL 3 identified dilation of the left lateral ventricle. There were no findings suggestive of hypoxic ischemic encephalopathy. Genetic evaluation was done for the above findings and was negative. Chromosome analysis was normal. Genomic hybridization array was negative. In summary, there was no fetal distress during labor. Delivery was by Cesarean section due to breech presentation. The newborn was not depressed. Umbilical cord blood gas was normal with a pH of 7.28. The baby was identified to have congenital malformations, including Small Left Colon syndrome and dilation of the left ventricle in the brain. MRI did not suggest hypoxic ischemic brain injury. There was no apparent obstetrical event that resulted in loss of oxygen or mechanical trauma to the baby's brain during labor, delivery or the immediate post delivery period. A review of the file in this case reveals that there have been no expert opinions filed that are contrary to the opinion of Dr. Willis. The opinion of Dr. Willis that Kayley did not suffer a neurological injury due to oxygen deprivation or mechanical injury during labor, delivery, or immediate post- delivery period is credited.
Findings Of Fact Alexander Soriano born on July 3, 2011, at Winnie Palmer Hospital in Orlando, Florida. Alexander weighed 3,442 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Alexander. In a medical report dated March 28, 2013, Dr. Willis opined the following: In summary, the mother presented at term with decreased fetal movement and an abnormal FHR pattern. There was no mention of the mother being in labor. Her cervix was not dilated and consistent with no active labor. Cesarean section delivery was required. The baby was severely depressed and had no detectable cardiac activity at birth. The hospital course was consistent with hypoxic ischemic brain injury with multisystem dysfunction, EEG and MRI studies should [sic] brain injury. Available information suggests the patient was not in labor. Oxygen deprivation and brain injury most likely occurred at some time prior to delivery. Although the hypoxia and brain injury may have continued during delivery and into the post-delivery period, the initial brain injury and substantial damage were most likely already present prior to birth. NICA retained Michael S. Duchowny, M.D., a Florida board-certified pediatric neurologist to review the instant claim and to conduct an examination of Alexander, and render an opinion whether a birth-related neurological injury occurred. In a report dated January 23, 2013, Dr. Duchowny opined: While Alexander's birth history documents severe problems resulting from his meconium aspiration syndrome, his present neurological examination reveals neither a permanent nor substantial mental or physical impairment. Essentially Alexander has done remarkably well despite his neonatal course, and I would anticipate continued improvement in the future. I regard his developmental abnormalities as unrelated to the perinatal circumstances and therefore not recommend Alexander for inclusion in the NICA program. A review of the file does not show any contrary opinions, and Petitioners and Intervenors have no objection to the issuance of a summary final order finding that the injury is not compensable under Plan. The opinion of Dr. Willis that Alexander did not suffer a neurological injury due to oxygen deprivation or mechanical injury during labor, delivery, or the immediate postdelivery period is credited. Dr. Duchowny's opinion that Alexander does not have a permanent and substantial mental and physical impairment is credited.
Findings Of Fact Te’Yani was born on April 26, 2012, at Plantation General Hospital located in Plantation, Florida. Te’Yani weighed 3,505 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Te’Yani. In an affidavit dated September 16, 2013, Dr. Willis opined the following: It is my opinion that the medical records suggest that baby did not suffer significant oxygen deprivation during labor or delivery. Anemia due to blood loss occurred just prior to delivery and the newborn anemia resulted in oxygen deprivation and multisystem failure. However, there are no studies to indicate the oxygen deprivation resulted in brain damage. As such, it is my opinion that there was an apparent obstetrical event that occurred prior to delivery that caused anemia. The anemia resulted in oxygen deprivation during the immediate post delivery period. There is no documentation in the medical records to suggest the oxygen deprivation resulted in brain damage. Michael S. Duchowny, M.D., a pediatric neurologist, was retained by NICA to examine Te’Yani. Dr. Duchowny examined Te’Yani on August 14, 2013. In an affidavit dated September 18, 2013, Dr. Duchowny opined as follows: It is my opinion that Te’Yani’s neurological examination disclosed no significant findings. She is functioning at age level with respect to her mental and physical abilities and there is little evidence of left-sided motor disability. I had an opportunity to review medical records which were sent to me on June 27, 2103, and supplementary records faxed on July 2013. The records document Te-Yani’s [sic] birth at Plantation General Hospital which was complicated by vaginal bleeding thought to represent placental abruption or a velamentous insertion. Te’Yani was born at 30 weeks gestation and weighed 7 pounds 12 ounces at birth. Her Apgar scores were 4, 5, and 7 at 1, 5, and 10 minutes. Arterial blood gases revealed a pH of 7.17 and a base excess of -17.2. Te’Yani breathed initially then became cyanotic and apneic and required assisted ventilation with CPAP bag and mask. Her neonatal course was complicated by anemia and thrombocytopenia which required transfusions. She was placed on a hyperthermia protocol for three days. Suspected sepsis and pneumonia were both treated vigorously with antibiotics. Cultures were remarkable. As such, it is my opinion that Te’Yani’s normal neurological status documents that she is not suffering from either a permanent or substantial mental or physical impairment. For this reason, I do not recommend that she be considered for compensation with the NICA program. A review of the file does not show any contrary opinions to those of Dr. Willis and Dr. Duchowny. The opinions of Dr. Willis and Dr. Fernandez that Te’Yani did not suffer a brain injury due to oxygen deprivation during labor and delivery are credited. Dr. Duchowny’s opinion that Te’Yani does not have substantial and permanent mental and physical impairments is credited.
The Issue The issues in this case are whether Bill Duke, M.D.; Brenda Harris-Watson; and Lakeland Regional Medical Center provided notice as required by section 766.316, Florida Statutes, and whether Manuel M. Fiesta, M.D., and United Surgical Assistants were required to provide notice pursuant to section 766.316.
Findings Of Fact Elijah was born on May 1, 2010, at Lakeland Regional Medical Center in Lakeland, Florida. Elijah weighed 3,520 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Elijah. In an affidavit dated June 19, 2013, Dr. Willis opined the following: In summary, there was a non-reassuring FHR pattern during labor. Cesarean delivery was done with delivery of a depressed newborn. The baby had low Apgar scores and a cord blood pH<7.0. The baby required resuscitation, including intubation and chest compressions. Hospital course was complicated by multisystem dysfunction. MRI was consistent with diffuse global hypoxic ischemic encephalopathy. There was an apparent obstetrical event that resulted in loss of oxygen to the baby's brain during labor, delivery and continuing into the immediate post delivery period. The oxygen deprivation resulted in brain injury. I am not able to comment about the severity of the brain injury. Raymond J. Fernandez, M.D., a pediatric neurologist specializing in pediatric neurology, was retained by NICA to examine Elijah. Dr. Fernandez examined Elijah on May 31, 2013. In an affidavit dated June 21, 2013, Dr. Fernandez opined as follows: There is ample evidence of substantial mental and motor (physical) impairment due to oxygen deprivation during labor and delivery. Elijah Theard has severe microcephaly that is indicative of poor brain growth and is a reliable predictor of permanent impairment. A review of the file does not show any contrary opinions to those of Dr. Willis and Dr. Fernandez. The opinions of Dr. Willis and Dr. Fernandez that Elijah did suffer a neurological injury due to oxygen deprivation or mechanical injury during labor and delivery and continuing into the immediate post-delivery period are credited. Dr. Fernandez's opinion that Elijah suffered substantial and permanent mental and physical impairment due to oxygen deprivation during labor and delivery is credited.
