In 2003 the American College of Obstetricians and Gynecologists(ACOG), along with the American Academy of Pediatrics, published Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology (“NEACP”). This monograph became more commonly known as “the Green Book” and it has been roundly criticized as an attempt by its authors to use “junk science” to create hard an fast “essential” criteria to diffuse obstetrical malpractice claims against Ob/Gyns. In the more than 10 years since its publications its authors have backed off the allegedly essential nature of its core criteria and physicians have been forced to admit that factors like cord blood ph levels above 7.0 can still occur in births where the fetus experiences perinatal asphyxia that is the result of negligence.
Recently, ACOG published an update to the Green Book titled Neonatal Encephalopathy and Neurologic Outcome, Second Edition. This update changes some of the so-called “essential” criteria that expert witnesses have relied upon to defend causation in birth injury cases.
The update defines Neonatal Encephalopathy as a clinically defined syndrome of disturbed neurologic function in the earliest days of life in an infant born at or beyond 35 weeks of gestation, accompanied by early onset seizures and difficulty initiating and maintaining respiration and depression of fetal tone and reflexes. The update relaxes the criteria which obstetricians and pediatricians feel demonstrate the likelihood of peripartum or intrapartum ischemia playing a role in the pathogenesis of neonatal encephalopathy.
Specifically, the monograph identifies four essential signs and their revised values and includes, Apgar scores of less than 5 at five and ten minutes, cord blood gas pH levels of less than 7.2 (and/or a base deficit greater to or equal to 12 mmol/L), evidence of brain injury shown on MRI at a time early in the childs life (before 21 days of life) and the presence of multisystem organ failure consistent with HIE.
These revised numbers reflect the growing understanding that pH levels above 7.0 can still reflect fetal injury caused by perinatal asphyxia. This is something that we have known and understood for quite some time. It is interesting that the authors of this update have taken a more intellectually honest approach at defining the criteria they use to define asphyxia related neonatal encehalopathy and have become more inclusive in their definitions. As attorneys who routinely face defenses of birth injury cases that are based entirely on Green Book factors, these definitions, while not exactly a breath of fresh air, are a step in the right direction.