The Records Tell the Story the Delivery Room Didn’t
After a traumatic delivery leaves a baby with cerebral palsy, HIE (hypoxic-ischemic encephalopathy), brachial plexus injury, hypoxia birth injury, or another serious condition, parents often spend weeks or months trying to piece together what happened during those critical minutes. The hospital may offer vague reassurances or clinical jargon, leaving patients without answers. The medical records, all of them, not just the discharge summary, are where the truth lives. Here are the eight categories of documentation that experienced Texas birth injury attorneys prioritize when evaluating a potential case.
1. Apgar Scores: Meaningful, But Not the Whole Story
Apgar scores are assigned at 1 and 5 minutes after birth and rate the newborn on five criteria: Appearance (skin color), Pulse, Grimace (reflex irritability), Activity (muscle tone), and Respiration. A score of 7-10 is normal; 4-6 indicates moderate concern; 0-3 reflects a critical condition requiring immediate resuscitation. Low Apgar scores can support a birth injury claim, but a normal Apgar score does not rule one out. Some injuries manifest after birth, and some physicians subjectively adjust scores. Apgar scores are a starting point, not a verdict.
2. Cord Blood Gas Analysis: The Most Direct Evidence of Oxygen Deprivation
Umbilical cord blood gas values, particularly the arterial pH, base deficit, and lactate level, offer the most objective measurement of whether a baby experienced significant acidemia at the time of birth. A pH below 7.0 or a base deficit greater than 12 mmol/L is associated with severe acidemia that can cause HIE and permanent neurological injury. When cord blood gas values align with an abnormal fetal monitoring strip and a late or difficult delivery, they become highly significant evidence. Many hospitals collect cord blood but do not always run the gases; that omission itself may be relevant.
3. Electronic Fetal Monitoring (EFM) Strips: The Real-Time Record
As discussed in our dedicated EFM article, the fetal monitoring strip is often the backbone of a birth injury case. It provides a continuous, time-stamped record of the baby’s heart rate patterns during labor. Experts analyze the strip alongside nursing notes and physician orders to determine whether warning signs were recognized promptly and whether the response was adequate. Obtaining the actual printed strip, not just an electronic summary, is important because formatting details and annotations matter.
4. Neonatal Resuscitation Records: What Happened in the First Minutes
The neonatal resuscitation record documents exactly what interventions were performed after birth, in what sequence, and when. Was positive pressure ventilation required? Were chest compressions performed? Was epinephrine administered? Was the baby intubated? A detailed resuscitation record showing extensive interventions, combined with cord blood gas values and an abnormal fetal strip, tells a powerful story about the severity of the birth emergency. Conversely, a vague or suspiciously brief resuscitation record may indicate that the documentation was reconstructed after the fact.
5. MRI and Neuroimaging: Mapping the Injury
MRI of the neonatal brain, typically performed within the first week of life using diffusion-weighted imaging (DWI), can identify the pattern and timing of brain injury with significant precision. A watershed injury pattern suggests hypoperfusion from prolonged, partial asphyxia. A deep gray matter injury pattern may indicate a more acute, severe hypoxic event. The pattern of injury on MRI, combined with the timing and the clinical records, helps experts establish whether the injury occurred during labor and delivery or at some other time.
6-8. NICU Records, Maternal Prenatal Records, and Delivery Notes
NICU records document the newborn’s postnatal course, including seizure activity, therapeutic hypothermia (cooling protocol), serial neurological assessments, and response to treatment. These records can help establish the severity and likely timing of the injury. Maternal prenatal records reveal whether risk factors such as gestational diabetes, Group B Streptococcus, preeclampsia, or macrosomia (large estimated fetal weight) were documented and how the obstetric team planned for them. The delivery note, which, in some cases, is brief or dictated hours after the event, describes the provider’s account of the delivery. Comparing that account to the real-time nursing notes and EFM strip often reveals important discrepancies.
📞 FREE CASE REVIEW: If your baby was diagnosed with HIE, cerebral palsy, or another serious injury after birth, do not wait to request the records. The birth injury attorneys at Rasansky | McKenzie Law will review every document and help you understand what the science says about what happened. Call today for a free, confidential consultation.
