It’s information the labor and delivery team keep to themselves while the new mom holds her baby; a hidden birth event that can shape the baby’s future.
At age five almost six, my nephew still wasn’t forming complete sentences and couldn’t hold a typical five-year-old conversation — but he wasn’t autistic, either.
When he was three and still mute, I asked my sister-in-law if he’d been tested for autism; she replied, “Yes; he doesn’t have autism.”
I knew something wasn’t right when I saw him (they lived out of state) at nine months completely incapable of rising into a crawl position; I just had a gut feeling.
They moved in with our parents when he was three; for the next two and a half years I clearly saw atypical or delayed development (I was at my parents’ home a lot).
One day I asked his parents about his birth. They didn’t give much detail (seemingly because they couldn’t recollect the medical nuances – neither are “medical people”), but were more than willing to give me a basic scoop — something about his heartbeat.
This was many years ago, so I don’t recall much of what they had said.
The term resuscitation did come up though; his mother said she had heard this term being used during the challenging birth process, but she couldn’t elaborate.
Right off the bat, I’m thinking, His heart stopped; he lost oxygen to his brain; they had to restart his heart.
But his parents couldn’t confirm this, and I could tell that they weren’t up to probing deep into their memories.
Recently a court reporter gave me a transcript to proofread; the case was medical malpractice resulting in a newborn’s death from catastrophic brain injury due to severe hypoxia (oxygen loss) – but her heart had never stopped beating.
As I read a defendant doctor’s testimony, it became increasingly clear that this was what had happened to my nephew – except a less serious version.
The Silent Birth Injury that Shows Up Later
Severe hypoxia to the brain has devastating consequences, but mild hypoxia can also occur from the same birth complication: unstable fetal heart rates.
It’s possible for a newborn to experience mild hypoxia that later results in permanent cognitive difficulties — even when the medical team does not clearly recognize at the time that such injury occurred.
As I read through the defendant’s version of events in the medical malpractice case, I couldn’t tell where this doctor could’ve committed negligence.
Though I’m not a doctor, it’s fairly obvious to me in many of these cases (I’ve read numerous) what the error was, and in fact, the plaintiff attorney will typically drill down on it, page after page after page.
But in this case, everything was described as seemingly medical standard par for the course.
This got me wondering if there was a possibility that my sister-in-law’s medical team botched something along the way involving the baby’s heart rate prior to delivery.
When fetal heart rates are unstable (which can cause reduced oxygen to the brain), how easy is it – or how typical is it – for the medical team to conceal this from the parents when the suspected brain injury is mild?
I did a deep dive and excavated some intriguing information.
The answer is closer to uncertainty and probabilistic risk management than to certainty or concealment.
Can mild hypoxia occur without the team knowing it happened?
Yes, for sure. This happens for several reasons.
Fetal heart rate (FHR) monitoring is an imperfect proxy.
A category 1 tracing shows a normal heart rhythm.
A 2 shows instability, and the heart monitor strip (which is ongoing, monitored via an ultrasound transponder) can oscillate between categories.
A 3 means an abnormal pattern indicating a high risk of severe hypoxia; an emergency C-section is warranted.
The key word is “indicating,” because cat 2’s and 3’s don’t measure oxygen directly.
Instead, they infer risk from rhythm patterns.
An unborn baby can experience intermittent or cumulative hypoxia without a dramatic or prolonged cat 3 pattern. I’m wondering if, indeed, this is what had happened to my nephew.
Here is what the medical team would know for sure:
- There is a risk here.
They would not know:
- Brain injury definitely occurred.
Remember, this is about mild hypoxia; it leaves no immediate, definitive marker.
In fact, standard newborn exams can show as normal or reassuring after delivery if brain tissue sustained mild damage.
But a mild level of hypoxia-inducing brain injury would show up months to even years later (when cognitive demands or expectations increase), rather than in the delivery room.
I don’t know if my nephew’s fetal heart strip showed a cat 3, but let’s look at cat 3.
What are clinicians thinking when the FHR is a category 3?
When the tracing deteriorates, they’re thinking risk escalation, probability and time sensitivity, but not certainty.
It’s “We need to intervene fast to reduce risk,” rather than, “Brain damage is occurring right this moment.”
What does resuscitation mean?
It doesn’t always mean restarting a stopped heart with CPR.
What my nephew’s parents very likely heard was “intrauterine resuscitation.”
In fact, I don’t know what else they could’ve heard under those circumstances.
The term refers to stabilizing the heart rhythm in an already-beating heart, while the baby is still in the womb. This can be done via several measures such as IV fluids and changing mom’s position.
However, establishing stability, or succeeding with intrauterine resuscitation, does not prove success; it would not reverse any brain injury that might’ve already occurred.
The measures can improve tracing, reduce brain injury risk and buy time. But they do not guarantee:
- Hypoxia didn’t already occur.
- Hypoxia won’t recur.
- Injury was subtle.
So after a recovery, the team might tell the mother, “The tracing improved; that’s reassuring.”
They’re not going to say, “We know nothing bad happened.”
Even when a category 3 episode is brief, this can cause neuronal injury, particularly to the language center. Despite this injury, the baby can look and “act” normal upon delivery and being placed on mom’s belly.
What do the clinicians know?
- There was a period of concern.
- There was non-reassuring physiology.
- There was risk.
What don’t they know?
- Whether hypoxia occurred.
- Whether that injury will be clinically meaningful (e.g., lifelong language deficit)
- Whether later issues will be attributable to that event.
My nephew’s parents may suspect something “happened at birth” to cause their son’s disability, but how could this ever be proven?
Is it negligence when doctors don’t disclose the possibility of permanent brain damage?
If my sister-in-law’s clinical team never disclosed the possibility of reduced oxygen to the brain due to unstable heart rhythms, does this mean negligence and indifference? No.
It means that obstetrics operates under unavoidable uncertainty, and mild hypoxic injury often can’t be confirmed or excluded at the time the fetal heart rate strip shows instability.
Most outcomes from FHR instability, with proper management, are actually good. But doctors also know that delayed consequences can surface later.
Thus, my nephew could have permanent cognitive impairment that was not evident at birth.
It’s not necessarily medical malpractice if the baby ends up with brain damage – because even the best intrauterine resuscitation measures will only reduce risk, not erase possibility.
On the other hand, a severe injury would be obvious at birth due to its global impact. Floppiness, weak crying, seizures and respiratory distress are some immediate signs.
What Clinicians Likely Told My Nephew’s Parents
So when there’s FHR concerns, but the baby seems normal, just what do providers tell the parents ultimately?
Well, it’s a much narrower, calmer and more present-focused approach than the full range of theoretical possibilities that the medical team is actually holding in mind.
They know something might come up later on, but nobody speaks of this to the parents.
This may sound like the clinicians are covering up a medical error and being deceitful. But they’re not; not at all.
It’s about how medicine handles uncertainty, probability and the ethical obligation not to alarm without evidence.
In most cases, the information parents leave with is reassurance anchored to observable outcomes, not to hypothetical future risks.
The medical team will usually explain that there were “some heart rate decelerations” or a “period where the baby didn’t tolerate labor as well,” followed by a description of the interventions used and the fact that the tracing improved.
The emphasis is on what was done and how the baby looked afterward.
Clinicians tend to rely heavily on immediate indicators when talking to parents.
If the baby had an acceptable post-birth assessment score, normal muscle tone (rather than limpness) and a reassuring general exam, these facts become the backbone of what the parents are told.
My nephew’s parents may have heard, “Your son did well,” or, “He responded appropriately,” or, “He showed no distress after birth.”
Why is a discussion of possible brain injury avoided?
What my nephew’s parents, and those in similar situations, don’t get is a discussion of long-term but low-probability impaired developmental outcomes tied to mild hypoxia (remember, in most cases of FHR challenges, the baby develops normally).
This impairment, again, is not diagnosable at birth when it’s mild.
From the physican’s standpoint, raising the probability proactively — without evidence of injury — can cause significant anxiety, undermine bonding with the baby and create fear around normal developmental variations.
The medical team is in a difficult position. They are balancing being truthful with avoiding causing harm through unnecessary fear.
Keeping their demeanor calm isn’t just for show; it reflects that, medically, the situation has moved from acute risk to watchful normal follow-up.
But the long-term uncertainty is real, though it lives mostly in the background of medical knowledge rather than in the discharge conversation — unless the parents raise the issue (e.g., mom is a nurse or dad always wants to know all the details).
Update on My Nephew
My siblings and I became estranged from his parents shortly after the boy turned six, though the estrangement is not related to the child.
His older sister couldn’t speak a single word when she was two years, five months.
Though this is late, it’s still within an acceptable developmental range; the range is roomy.
Next time I saw her, she was four and a half with normal speech.
However, her brother literally could not speak in sentences when he was closing in on his sixth birthday. In fact, he hardly talked at all.
Plus, his sister once told me, “I think he has a developmental disability.”
As for academics, all we know is that his mother once reported he was doing well in kindergarten, but then she was homeschooling him after that (along with their third, younger child). By then, the estrangement was underway.
He’s 12 now; my brother stays off social media, and his wife posts only occasional family pictures – which of course, wouldn’t reveal a cognitive disability.
Sources
ACOG Clinical, Oct. 2025
StatPearls, March 2023
Fetal Diagnosis and Therapy, Dec. 2021
