On Feb. 9, 2015, plaintiff Jayden Bonilla was born at Pacific Alliance Medical Center, in Los Angeles. He was delivered by Dr. Norma Salceda, a board-certified OB/GYN who had been in practice for 40 years. Jayden’s mother, Saret Lopez, a homemaker, previously received primary, prenatal care from other providers, including a perinatologist who diagnosed her with, and treated her for, diabetes. However, Lopez received final prenatal care from Salceda, who had provided family planning for years and had previously provided prenatal care for Lopez before the 2011 delivery of Lopez’s second child, who weighed 8 pounds, 8 ounces. On all of Lopez’s visits with Salceda, prior to the delivery of her third child, Jayden, the fundal height equaled the dates. Lopez also had an outside ultrasound three days before delivery, and Salceda ordered an ultrasound on admission to the hospital so that a current assessment of the estimated fetal weight could be obtained. After Lopez was contacted with the result of the ultrasound, which showed a weight of 3,734 grams (8 pounds, 4 ounces), she was visited by Salceda. After they discussed whether the delivery would be vaginally or using an alternative method, and the risks attendant to each method, Lopez indicated to Salceda that she wanted to proceed with a vaginal delivery. After that discussion, Salceda ruptured the membranes. The nursing staff then did not contact Salceda again until around 9:05 p.m., when Salceda was called for the delivery, which began shortly thereafter. When Jayden’s head was delivered, Salceda saw that there was a cord wrapped tightly around his neck. She immediately cut the cord, but Jayden was not receiving oxygen from that point on. Salceda also observed that Jayden’s shoulder was hung up behind Lopez’s pubic bone. Nurses were present, and Salceda ordered the performance of the McRoberts maneuver with concurrent application of suprapubic pressure in an attempt to dislodge the shoulder. Salceda then cut an episiotomy and performed the Woods maneuver. She ultimately succeeded in delivering the body using a posterior arm delivery. There was uncertainty in the chart about the amount of time that Jayden was without oxygen (7 minutes or 5 minutes). Jayden weighed 3915 grams (8 pounds, 10 ounces) and his left arm was flaccid. Lopez claimed that Jayden suffers from Erb’s Palsy and brain damage. Lopez and Jayden, through his guardian ad litem, sued Salceda; the operator of Pacific Alliance Medical Center, PAMC Ltd.; a medical group that specializes in family medicine, Aghapy Medical Group Inc.; and nurses, Xiaoping Cui, R.N., Elizabeth Kempton, R.N., Cathy Zhou, R.N. and Anju Subedi, R.N. Aghapy Medical Group entered into a settlement with Jayden just prior to trial, and several of the nurses were ultimately let out of the case. Thus, the matter only continued against Salceda, PAMC Ltd., and Subedi. Plaintiffs’ counsel contended that the tracing was sufficiently abnormal (Class III) and that as a result, Nurse Subedi and the hospital should have been summoned Salceda earlier. Counsel also contended that Jayden would not have experienced the complications had there been an earlier delivery. Plaintiff’s counsel further contended that Salceda should have delivered Jayden by cesarean section, that there was no discussion about a C-section versus a vaginal delivery, and that the maneuvers Salceda used were not properly performed. The hospital defendants’ labor and delivery nursing expert testified that the tracing was never a “Category III” and that nurses at the hospital complied with the standard of care in not calling Salceda until just before delivery. Salceda claimed that after the results of the ultrasound came back, which showed the baby’s weight as being 3,734 grams (8 pounds, 4 ounces), she visited Lopez at an appropriate time to rupture the membranes. She claimed that at that time, she discussed with Lopez whether the delivery would be by cesarean section or vaginally, and the risks attendant to each, and that it was Lopez’s decision to proceed with a vaginal delivery. Salceda further claimed attempting a vaginal delivery was not negligent, as the baby was under 9 pounds, and that when difficulties arose during the delivery, he performed the proper techniques and maneuvers. Salceda’s obstetrics and gynecology expert testified that the American Academy of Obstetrics and Gynecology practice bulletin regarding fetal macrosomia recommended consideration of a cesarean section for estimated fetal weights greater than 4,500 grams (9 pounds, 14.73 ounces) in a diabetic mother. The expert opined that the practice bulletin recommendation is an essential basis for recommendations to patients whether to proceed with a vaginal delivery and that following the recommendation complied with the standard of care. (Plaintiff’s counsel objected to the reliance on the American Academy of Obstetrics and Gynecology practice bulletin, but the court accepted it as a reliable authority.) The defense expert also disagreed with the plaintiffs’ obstetrics and gynecology expert in his assertion that head circumference/abdominal circumference ratio (which was not 1:1 in this case) was a significant, overriding factor for that recommendation. The defense’s OB/GYN expert further testified that his literature search found an article that stated that head circumference/abdominal circumference ratio was not sufficiently predictive to be useful in a clinical setting. Salceda’s OB/GYN expert also supported the position of Salceda that there was a discussion about undergoing a C-section, as there was a history and physical-referenced discussion of “alternatives.” The expert testified that the only alternative to a vaginal delivery is cesarean section. The expert further testified that shoulder dystocia was the only significant risk to be discussed regarding a vaginal delivery, but that there were different, significant risks to undergoing a C-section. He concurred that those risks were discussed and documented with Lopez stating that risks had been discussed. In addition, Salceda’s OB/GYN expert opined that the maneuvers undertaken were proper, that they may be done in any order, and that there was significant time lost and possible earlier delivery lost due to the lack of pushing by Lopez at the end of each maneuver. He also supported the delivery time, which showed five minutes without oxygen from the time of removal of the fetal scalp electrode, and provided a broader interpretation of the standard of care, one in which Salceda clearly fit., Lopez claimed that Jayden suffered Erb’s palsy and brain damage due to the period of time without oxygen. The plaintiffs’ pediatric neurology expert testified that Jayden’s pH was reported as 6.97 and Apgar scores of 1, 5, and 8, which he opined showed organic encephalopathy and organic behavioral syndrome. The expert also opined that Jayden will need physical therapy for two decades and that Jayden’s life expectancy will be shortened by 10 to 15 percent. The plaintiffs’ expert life care planner opined that Jayden will require $211,000 worth of future care and the plaintiff’s expert economist testified to projected lifetime earnings of a child that is Jayden’s age. (Defense counsel noted that before Lopez testified, her claim for her son’s loss of earnings was withdrawn, as she was a citizen of Mexico with no green card and no citizenship. However, defense counsel added that the court reversed a prior order on the day of closing arguments, allowing plaintiffs’ counsel to argue lost earnings, despite there being allegedly no specific testimony and no testimony beyond age three.) Thus, Jayden, through his guardian, sought recovery of past medical costs, future medical expenses, and future loss of earnings. Lopez claimed that she suffered from emotional distress as a result of the incident. Thus, she sought recovery for her emotional pain and suffering. The defense’s pediatric neurology expert testified that that the level of return of function to Jayden’s affected arm was significant and that, to a medical probability, no surgery was indicated for Jayden. She also opined that there was no indication of any brain injury. Defense counsel noted that Jayden’s lifetime pediatrician testified that Jayden has met his milestones, displays no cognitive deficit or behavioral issues, and has resolved, or nearly resolved, issues with his arm and shoulder. Counsel further noted that Jayden’s pediatrician testified that the last time he saw Jayden, if he had not been following him for a shoulder/arm issue, he would not have appreciated any limitation. As to the testimony of the plaintiffs’ pediatric neurology expert, defense counsel noted that the plaintiffs’ expert had a report of an evaluation of Jayden, but had no memory of the child. Defense counsel also noted that although the plaintiffs’ expert claimed that Jayden’s pH and Apgar levels showed organic encephalopathy and organic behavioral syndrome, the expert had not performed any formal, objective testing on Jayden. Defense counsel further contended that the plaintiffs’ pediatric neurologist had a practice of having children stay awake all night before an evaluation so that they can sleep for an EEG, which may have made Jayden cranky during his evaluation. In addition, defense counsel contended that the plaintiffs’ expert testified that Jayden will need physical therapy for two decades, but could not explain how two decades of that therapy would benefit a young man with allegedly resolved, or nearly resolved, shoulder and arm issues. Thus, the defense’s expert life care planner opined that if Jayden did need future medical care, it would not total more than $48,000.