Birth Injury Hypoxia: Dr Benjamin Viaris de Lesegno Shares His Medico-Legal Expertise

Ardent Expert Chambers Member Dr Benjamin Viaris de Lesegno, Consultant Obstetrician and Gynaecologist, delivered a specialist webinar examining the assessment of hypoxic birth injury and the complex clinical questions that can arise around timing, causation and intrapartum management.

Drawing on his obstetric and medico-legal experience, Dr Viaris de Lesegno explored why these cases rarely turn on a single piece of evidence. Instead, expert analysis may require careful consideration of fetal monitoring, the progress of labour, antenatal factors, escalation decisions and the condition of the baby following delivery.

The session demonstrated the importance of reconstructing the complete clinical pathway when considering whether hypoxic injury occurred, when it is likely to have developed and whether an alternative course of obstetric management would have made a material difference.

Understanding Hypoxic Birth Injury

Hypoxic injury can occur where the fetus or newborn experiences an inadequate supply of oxygen, but determining the timing, severity and clinical significance of that event can be complex.

An adverse neurological outcome does not, by itself, establish that hypoxia occurred during labour or that obstetric management was responsible.

Dr Viaris de Lesegno highlighted the importance of examining the wider clinical evidence when forming an expert opinion.

This may include the pregnancy history, fetal condition before labour, intrapartum events, neonatal presentation and subsequent investigations.

The expert’s task is to establish which conclusions are supported by the evidence while remaining clear about areas where uncertainty remains.

CTG Interpretation in Clinical Context

Cardiotocography (CTG) frequently forms an important part of the evidence in birth injury cases.

Dr Viaris de Lesegno explored how fetal heart rate patterns can provide information about fetal wellbeing during labour, while also emphasising that CTG traces must be interpreted in their clinical context.

Baseline rate, variability, accelerations, decelerations and changes over time may all contribute to the assessment.

An expert reviewing the care retrospectively may need to determine how the CTG should reasonably have been interpreted at a particular point and whether the developing pattern warranted observation, senior review or intervention.

The aim is not simply to identify an abnormal trace with hindsight, but to assess the significance of the information available to clinicians as events unfolded.

Recognising Deterioration and Escalating Care

Labour is a dynamic process, and clinical circumstances can change rapidly.

Dr Viaris de Lesegno examined how concerns identified through fetal monitoring, maternal observations or the progress of labour may influence decisions around escalation and delivery.

Where deterioration occurs, timing can become particularly important.

An expert may need to identify when concern should reasonably have increased, what action would have been appropriate at that stage and how quickly an alternative pathway could realistically have led to delivery.

This detailed reconstruction is often necessary before any meaningful conclusions can be reached about breach of duty or causation.

Antenatal Compromise and Pre-Existing Factors

Not every neurological injury identified after birth begins during labour.

Dr Viaris de Lesegno also considered the importance of antenatal factors when assessing the likely origin of injury.

Evidence of fetal growth restriction, placental dysfunction, infection or other complications may contribute to the clinical picture and potentially affect a fetus's ability to tolerate labour.

For the obstetric expert, distinguishing pre-existing compromise from an acute intrapartum event can be crucial.

It may also help explain why apparently similar labour events can result in very different outcomes between individual pregnancies.

When Would Earlier Delivery Have Made a Difference?

One of the most important medico-legal questions in birth injury cases is not simply whether delivery could have occurred earlier, but whether it would probably have changed the outcome.

Dr Viaris de Lesegno highlighted the need to consider the realistic interval between an alternative clinical decision and actual delivery.

An identified delay of several minutes does not automatically establish causation.

The expert may need to consider the likely timing of the hypoxic insult, how rapidly the fetal condition was deteriorating and whether delivery at an earlier point would have occurred before significant injury had taken place.

This distinction between an opportunity for earlier intervention and a causative delay is fundamental to balanced expert evidence.

Bringing Together CTG, Cord Gases and MRI

Complex birth injury cases often involve evidence from several different clinical sources.

Dr Viaris de Lesegno explored how CTG findings, umbilical cord gases, neonatal observations and MRI evidence may each contribute to understanding the likely timing and mechanism of injury.

No single investigation necessarily provides the complete answer.

Cord gases may offer information about the baby's metabolic state around delivery, while imaging can provide insight into the pattern of neurological injury.

These findings must then be considered alongside the intrapartum records and fetal monitoring.

The expert’s role is to determine whether the different strands of evidence form a coherent clinical picture and to identify where they may point in different directions.

The Importance of Contemporaneous Documentation

Clinical records are particularly important where the timing of deterioration, escalation or delivery is later disputed.

Dr Viaris de Lesegno highlighted the significance of clear documentation surrounding fetal monitoring, clinical assessments, decision-making and communication between members of the obstetric team.

Where records are incomplete, retrospective analysis becomes more difficult.

An expert must then distinguish between what can be established from the evidence, what may reasonably be inferred and what cannot reliably be determined.

That transparency is particularly important in high-value birth injury cases where relatively short periods of time may become central to the medico-legal analysis.

Separating Breach From Causation

A recurring theme throughout the webinar was the need to keep standard of care and causation as separate questions.

An expert may identify an aspect of obstetric management that fell below the expected standard without concluding that it caused the neurological injury.

Conversely, understanding the likely mechanism and timing of injury may help determine whether a particular delay or management decision could realistically have altered the outcome.

Dr Viaris de Lesegno’s approach emphasises the importance of moving logically through the evidence rather than allowing the severity of the eventual outcome to influence the assessment of earlier clinical decisions.

Specialist Expertise in Obstetric Medico-Legal Evidence

As a Consultant Obstetrician and Gynaecologist, Dr Viaris de Lesegno brings specialist expertise in pregnancy, labour and intrapartum decision-making to his medico-legal practice.

His webinar demonstrated how that expertise is applied to complex birth injury cases involving CTG interpretation, antenatal compromise, delayed escalation, hypoxia and questions around the timing and causation of neurological injury.

By considering fetal monitoring alongside clinical records, cord gases, imaging and the wider obstetric picture, Dr Viaris de Lesegno provides a structured assessment of both what happened and what an alternative clinical pathway may realistically have changed.

Dr Benjamin Viaris de Lesegno is a member of Ardent Expert Chambers. View his full member profile to learn more about his specialist expertise and medico-legal practice.

Watch Dr Benjamin Viaris de Lesegno’s webinar, Birth Injury Hypoxia >