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Kipfinger v. G.F. Obstetrical
Citation: Not availableDocket: DA 21-0552
Court: Montana Supreme Court; March 14, 2023; Montana; State Supreme Court
Original Court Document: View Document
Stephanie Kipfinger and Ben Cunningham appeal a summary judgment from the Montana Eighth Judicial District Court that favored Dr. Julie Kuykendall and Great Falls Obstetrical and Gynecological Associates (GFOGA) in a medical malpractice case. The main issue is whether the District Court erred by granting summary judgment due to insufficient expert medical testimony supporting Kipfinger's claim. The Supreme Court of Montana reversed the District Court's judgment and remanded the case for further proceedings. On January 9, 2016, Kipfinger, who was four days overdue, was admitted to Benefis Hospital for labor. Dr. Kuykendall, an independent OB/GYN on-call, reviewed Kipfinger's prenatal records and found no significant issues. During her admission, an external fetal heart rate monitor was placed on Kipfinger, which recorded fetal heart rate and contractions, indicating the fetus's oxygen levels and potential risk of hypoxic injury. The Court noted that determining whether Dr. Kuykendall breached the standard of care required understanding of specific medical terminology and definitions, particularly regarding hypoxia, which refers to inadequate oxygen reaching body tissues. Intrapartum fetal heart rate (FHR) monitoring is essential for assessing fetal well-being during labor. The American College of Obstetricians and Gynecologists (ACOG) outlines guidelines emphasizing its role in detecting fetal hypoxia and preventing conditions like hypoxic-ischemic encephalopathy (HIE), cerebral palsy, and fetal death. Fetal acidosis, characterized by high hydrogen ion concentration and classified as either acute or chronic, can result from tissue hypoxia. HIE occurs when the brain is deprived of oxygen or blood flow, often indicated by fetal distress during labor. Meconium, a substance produced by the fetus, may be aspirated into the lungs during labor, leading to Meconium Aspiration Syndrome (MAS), which is a common cause of respiratory issues in newborns. Significant risk factors for MAS include advanced gestational age, nonreassuring fetal heart rates, and thick meconium. Newborns affected by MAS often require resuscitation and face risks of severe complications, including HIE and mortality. In a deposition, Dr. Kuykendall described a patient, Kipfinger, who was experiencing contractions and managed with medication. She noted that during early labor, it is acceptable for patients to move around rather than remain bedridden, and there was no need for continuous FHR monitoring at that stage. The FHR was recorded at over 140 beats per minute, showing decreased variability but no decelerations after the administration of Nubain. At 12:10 p.m., Dr. Kuykendall examined Kipfinger, noting her cervix was 70% effaced and 2 cm dilated. By 1:40-41 p.m., Pitocin was administered intravenously to induce labor as per Dr. Kuykendall's orders. At 3:08 p.m., concerns arose regarding fetal heart rate (FHR) abnormalities, prompting Dr. Kuykendall to review the electronic fetal monitoring (EFM) tracings but to maintain the current monitoring and treatment approach. At 4:10 p.m., upon reviewing new tracings indicating nonreassuring heart rates, Dr. Kuykendall ordered an urgent primary low transverse cesarean section (C-Section), which began at 4:41 p.m. During the procedure, meconium was observed in the amniotic sac, prompting Dr. Kuykendall to alert the surgical nurse to summon the Neonatal Intensive Care Unit (NICU) team. Although she expected a rapid response, she noted that the necessity for a full NICU team wasn't immediately clear, as most infants with meconium clear it without major intervention. At 4:47 p.m., after rupturing the membranes, E.C. was extracted but was not breathing, had a low heart rate, and displayed limp muscle tone. In the following eight minutes, labor and delivery nurses attempted resuscitation without success. The NICU respiratory therapist (RT) arrived at 4:55 p.m. and struggled to intubate E.C. for airway suctioning until a Certified Registered Nurse Anesthetist (CRNA) assisted and successfully intubated E.C. after an additional 5-6 minutes. Once stabilized, E.C. was transferred to the NICU and later life-flighted to Seattle Children’s Hospital, where he was treated for meconium aspiration syndrome, possible sepsis, pneumothorax, and hypoxic-ischemic brain injury. E.C. was ultimately diagnosed with hypoxic-ischemic encephalopathy (HIE), cerebral palsy, developmental delay, and microcephaly, among other conditions. In October 2019, a pediatric neurologist from Stanford University Medical Center conducted an independent examination of E.C., who was found to be non-verbal, reliant on gastronomy for feeding, profoundly intellectually disabled, fully incontinent, suffering from cortical visual impairment, and entirely dependent on others for care. The neurologist indicated no possibility of reversing these conditions. In October 2017, Kipfinger filed a medical negligence complaint against Benefis Health System, alleging that hospital staff failed to appropriately manage E.C.'s care during a C-section by not timely discontinuing Pitocin, ensuring the presence of a neonatal intubation team, and competently intubating E.C. Benefis denied the allegations and attributed some negligence to Dr. Kuykendall, who was not affiliated with Benefis. Kipfinger amended her complaint in October 2018 to include Dr. Kuykendall and GFOGA, claiming negligence that led to delays in E.C.'s oxygenation, resulting in physical and neurological injuries. Dr. Kuykendall and GFOGA responded with general denials. During discovery, various medical experts were deposed, and Kipfinger disclosed an expert report from Dr. Fred Harlass, who critiqued the obstetric care provided by Dr. Kuykendall and Benefis staff. Dr. Harlass's report identified multiple failures, including misinterpretation of fetal heart monitor tracings, inappropriate continuation of Pitocin administration amid deteriorating fetal conditions, and delays in performing the necessary C-section. Kipfinger later retracted one of the negligence claims in her brief. A failure to ensure the presence of a neonatal response team, including a qualified neonatologist or NICU team member, during a high-risk C-section was highlighted as a critical deviation from the standard of care. This was determined to be a direct cause of injuries to the newborn, E.C., including hypoxic ischemic encephalopathy and seizures. In April 2020, Dr. Kuykendall's counsel deposed Dr. Harlass for over six hours regarding his expert opinions on the care provided on January 9, 2016. In early 2021, Kipfinger settled her negligence claims against Benefis, leading to its dismissal from the case. In June 2021, Dr. Kuykendall and GFOGA filed a motion for summary judgment on Kipfinger's remaining negligence claims, arguing insufficient evidence of negligence regarding the absence of a resuscitation team during the procedure. The motion noted that the need for intubation was only apparent post-delivery, and the attending nurse-anesthetist, who performed the intubation, was present throughout. While the report criticized the initiation of Pitocin under a Category III risk, Dr. Harlass later clarified this as a typographical error, indicating it should have referred to Category II. His deposition did not support the assertion that E.C. suffered intrapartum hypoxic-ischemic injury, as he changed his opinion based on objective criteria. Kipfinger opposed the summary judgment motion, citing genuine issues of material fact, supported by an excerpt of Dr. Harlass’s deposition. The District Court requested and received the complete deposition for review, although it was not formally filed with the court. Subsequently, the court granted summary judgment to Dr. Kuykendall, concluding that the opinions of other medical experts were insufficient to challenge the standard of care and breach elements of the claim since they were not OB/GYNs, thus relying solely on Dr. Harlass’s opinions. The court noted multiple alleged errors and omissions by Dr. Kuykendall in her prepartum care as stated in Dr. Harlass’s Rule 26(b)(4) disclosure report. Dr. Kuykendall was granted summary judgment concerning the standard of care and breach elements of Kipfinger's claim because Dr. Harlass failed to provide an opinion on whether Kuykendall was obligated to have a neonatologist present during the C-Section. Additionally, Dr. Harlass's claims of negligence did not meet the "more likely than not" standard required for admission under M. R. Evid. 702. The District Court noted that Dr. Harlass either acknowledged that his opinions regarding the OB/GYN standard of care lacked a national standard or that he had no opinion at all. Kipfinger subsequently filed a timely appeal. Summary judgment is reviewed de novo, aligned with M. R. Civ. P. 56 standards, which state it is appropriate only when no genuine issue of material fact exists and the moving party is entitled to judgment as a matter of law. A genuine issue of material fact arises only if the factual record contradicts proof of an essential element of a claim or defense. The moving party initially bears the burden of demonstrating the absence of any genuine issue of material fact. The opposing party must then show the existence of such an issue or argue that the moving party is not entitled to judgment. To fulfill this burden, the non-moving party must present specific facts beyond mere speculation or denial. The court evaluates the factual record in favor of the non-moving party, considering all pleadings, discovery materials, and affidavits. On de novo review, the court can examine the entire record and make findings on undisputed material facts, but it is not obligated to foresee or speculate regarding the existence of contrary material facts. A genuine issue of material fact or a party's entitlement to judgment as a matter of law is reviewed de novo for correctness. Preliminary rulings on evidence under M. R. Civ. P. 56, which determine whether evidence meets relevant rules for consideration, are typically reviewed for abuse of discretion, unless they involve interpretation of legal meanings of evidentiary or procedural rules, which are subject to de novo review. An abuse of discretion happens when a lower court makes an erroneous finding of fact, misapplies the law, or acts arbitrarily, causing substantial injustice. In the context of a medical malpractice claim involving Dr. Kuykendall, the District Court’s grant of summary judgment is questioned based on whether sufficient expert medical testimony was presented. Essential elements of a negligence claim include a legal duty owed by the defendant, a breach of that duty, causation of harm, and resulting damages. The burden of proof lies with the claimant to establish these elements by a preponderance of the evidence, meaning the evidence must show that the claim is more likely true than not. Legal precedents and Montana Code Annotated sections regarding civil burdens of proof support this standard. In Montana law, a negligence claim typically involves factual questions unsuitable for summary judgment unless the defendant demonstrates a lack of any genuine issue of material fact for any element of the claim. If the defendant meets this burden, the claimant must then provide admissible evidence to show a genuine issue remains. Specifically, medical malpractice is a form of professional negligence concerning health care providers, requiring expert medical testimony to establish the applicable standard of care. This standard is determined by national benchmarks for board-certified specialists, regardless of geographical location, contrasting with the standard for non-board-certified practitioners, which is based on local community standards. Board-certified specialists are held to the standard of care of similarly credentialed physicians practicing nationally in their specialty. In Aasheim v. Humberger, the Montana Supreme Court established that, except in specific circumstances, medical malpractice claims necessitate expert testimony demonstrating that a medical professional deviated from the applicable standard of care, supported by a preponderance of evidence. Qualified expert testimony must come from individuals who meet specific criteria, including being a licensed physician actively treating relevant conditions or having recent teaching experience in accredited medical programs. This expert must also demonstrate familiarity with the standards of care relevant to the malpractice claim at the time of the incident. The causation element of a negligence claim requires proof that the alleged breach of duty caused the resulting harm and damages. Relevant statutes and rules, including M. R. Evid. 702-03 and Section 26-2-601, MCA, outline the qualifications and requirements for expert testimony in these cases. In Kitchen Krafters, Inc. v. Eastside Bank of Mont., the court examined the causation standard in negligence claims, particularly in medical malpractice. It established that alleged negligent conduct is a cause-in-fact if the harm would not have occurred "but for" that conduct, requiring a more probable than not standard. This standard, as clarified in Busta, necessitates that qualified expert testimony must demonstrate, on a more likely than not basis, that the breach of the standard of care caused the injury or condition. The court emphasized that the specific language used by medical experts, such as "more probable than not" or "reasonable degree of medical certainty," is less critical than the substantive essence of their opinion, which must convey a reasonable probability supported by rational basis rather than mere speculation. The ruling highlighted the need for expert medical testimony for establishing causation, except in obvious cases where specialized expertise is not necessary. Exclusion of expert medical opinions that used terms like "most likely," "more likely than not," and "unlikely" was deemed an abuse of discretion under Rule 702, which requires a more probable than not standard for causation. The court emphasized that the context of the testimony is crucial, not just the wording. Dr. Harlass, a retired double board-certified OB/GYN and maternal-fetal medicine specialist, provided a Rule 26(b)(4) disclosure, indicating extensive experience treating high-risk patients and familiarity with the applicable national standard of care for such cases. His deposition asserted that his critiques of Dr. Kuykendall's care were based on this national standard, and he expressed his opinions with a reasonable degree of medical probability. Importantly, Harlass's testimony focused specifically on the obstetric care provided by Dr. Kuykendall, suggesting that his opinions were relevant to establishing a genuine issue of material fact regarding the standard of care and breach in Kipfinger’s medical malpractice claim. The initial breach of standard of care was linked to erroneous interpretation of EFM tracings. Dr. Harlass, in his Rule 26(b)(4) report, contends that Dr. Kuykendall misinterpreted E.C.’s prepartum fetal heart rate (FHR) tracings, specifically noting "repetitive late decelerations, decreased variability, a rising baseline, and notable tachycardia." He identifies various deviations from the standard of care linked to these misinterpretations. In the context of FHR assessment, the American College of Obstetricians and Gynecologists (ACOG) published guidelines in 2009 and 2010 that introduced a three-tiered classification system for electronic fetal monitoring (EFM). These guidelines emphasize that they are intended to assist practitioners in clinical decision-making without dictating a fixed course of treatment, allowing for variations based on individual patient needs and institutional capabilities. The ACOG classification includes three categories: 1. **Category I:** Normal tracings indicating no fetal acidemia, which require routine monitoring and no intervention unless Category II or III features arise. 2. **Category II:** Tracings that do not fall into Categories I or III, necessitating evaluation, continued surveillance, and corrective measures when necessary. The details from the ACOG practice bulletins outline the framework for evaluating and managing intrapartum FHR patterns based on this classification system. Tracings classified as Category II require ongoing evaluation, documentation, and surveillance unless they revert to Category I. Category II tracings are indeterminate, not predictive of abnormal fetal acid-base status without sufficient evidence, and necessitate a comprehensive review of clinical circumstances. These tracings may indicate a spectrum from clinically normal to potential acidosis. Abnormalities in Category II can be managed by addressing reversible causes and providing intrauterine resuscitation, such as ceasing uterine-stimulating agents. Category III tracings are abnormal and suggest an increased risk for fetal acidemia, with associations to neonatal complications such as encephalopathy and cerebral palsy. Immediate delivery is often warranted if these tracings do not resolve with interventions. Intrauterine resuscitation strategies should be tailored to the specific clinical situation and the FHR pattern observed. Persistent minimal variability not responsive to resuscitation raises concerns for fetal acidemia, prompting preparatory measures for delivery if the FHR does not improve. The ACOG classification system highlights that tracing patterns reflect the current acid-base status of the fetus, which can change over time. Terminology in Dr. Harlass’s report regarding non-reassuring fetal status signifies suspected fetal hypoxia, intended to replace "fetal distress." Fetal distress indicates progressive hypoxia or acidemia due to insufficient oxygenation, manifesting in altered heart patterns, decreased fetal movement, growth restriction, or meconium-stained fluid. Non-reassuring fetal status serves as a signal of potential conditions leading to oxygen deprivation, which may result in fetal hypoxia and metabolic acidosis. Baseline fetal heart rate (FHR) is defined as the mean FHR calculated over a 10-minute segment, excluding certain variations and changes. Normal fetal heart rate (FHR) is defined as 110-160 beats per minute, with significant deviations over 25 beats per minute indicating potential concerns. The baseline FHR is considered indeterminate unless it is stable for at least two minutes within a ten-minute timeframe. Decelerations in FHR can be categorized as early or late, with the latter occurring after the peak of a uterine contraction. FHR variability is classified into absent (undetectable), minimal (5 bpm or less), moderate (6-25 bpm), and marked (greater than 25 bpm). Fetal tachycardia, defined as a baseline heart rate exceeding 160 bpm for over ten minutes, is a nonreassuring pattern and may indicate fetal hypoxia, particularly when accompanied by minimal variability or recurrent decelerations. Dr. Harlass reviewed the FHR tracings for E.C. and testified that E.C. transitioned from ACOG Category I to Category II between 3:50 and 4:30 a.m., marked by multiple late decelerations, decreased variability, and an increased baseline FHR. He noted that E.C. remained in Category II with fluctuating FHR conditions until 1:41 p.m., when oxytocin was initiated per Dr. Kuykendall's orders. Dr. Harlass stated that initiating oxytocin under these Category II conditions, which already showed signs of fetal tachycardia and decreased variability, constituted a departure from the standard of care. Dr. Harlass's Rule 26(b)(4) report identifies several critical deviations from the standard of care regarding the management of E.C.'s labor. It asserts that the ordering of oxytocin occurred in the presence of a Category II fetal heart rate (FHR) tracing, which is deemed inappropriate, especially as it may lead to adverse outcomes such as fetal hypoxemia or acidemia. Harlass criticizes the failure to apply a fetal scalp lead monitor despite concerning FHR abnormalities, which would have facilitated the earlier detection of meconium in the amniotic fluid. He states that Dr. Kuykendall did not identify meconium until the C-Section, although she could have done so earlier if the fetal scalp lead had been used when E.C. exhibited concerning tracings. Harlass emphasizes that a fetal scalp lead is indicated in such scenarios to better define the FHR category, and that E.C. was born with meconium-stained fluid, which likely resulted from events during labor. The report underlines that the physician's inaction regarding the fetal scalp lead monitor and meconium diagnosis constitutes a significant deviation from accepted medical practices. Dr. Harlass's deposition indicates that he provided qualified expert medical opinions suggesting that Dr. Kuykendall deviated from the national standard of care for OB/GYNs. Specifically, Harlass identified three primary failures: (1) incorrect interpretation of E.C.’s external Fetal Heart Rate (FHR) tracings, (2) inappropriate administration of oxytocin at 1:41 p.m., and (3) failure to use a fetal scalp lead for internal electronic fetal monitoring in a timely manner, which delayed the diagnosis of meconium presence and the associated risks of meconium aspiration. Harlass classified E.C.’s FHR tracings as transitioning from ACOG Category II to Category III at 3:20 p.m., based on published ACOG criteria, personal expertise, and nurse documentation of abnormal tracing patterns noted earlier. He highlighted the significance of repetitive late decelerations, decreased variability, and fetal tachycardia as indicators of fetal distress. These conditions, he argued, suggested an increased risk of lactic acidosis due to inadequate oxygen for glucose metabolism during labor. Harlass asserted that oxytocin administration should have been ceased by 3:20 p.m. and, at the latest, by 3:15 p.m. He further noted that there were periods in E.C.’s tracings with no discernible readings, contrasting these findings with ACOG guidelines on normal perinatal outcomes. His testimony emphasizes that the failure to discontinue oxytocin was a significant deviation from the expected standard of care. Recurrent variable decelerations that deepen and prolong indicate a higher risk of fetal acidemia. Dr. Harlass stated that oxytocin administration should have been stopped by 3:20 p.m. and that Dr. Kuykendall should have ordered a C-section at that time due to the worsening Category III fetal heart rate (FHR) tracings. Despite attempts at intrauterine resuscitation failing, Dr. Kuykendall delayed the C-section until 4:10 p.m., during which E.C. exhibited ongoing late decelerations, increased heart rate (tachycardia), and worsened variability. Dr. Harlass’s deposition indicated that these actions deviated from the national standard of care for obstetricians, as timely intervention could have mitigated risks. Additionally, Dr. Harlass highlighted that the C-section was a high-risk procedure requiring immediate neonatal resuscitation capabilities, which were not present as no NICU team members were available at the start of the procedure. Benefis Hospital protocols necessitate a qualified medical professional for immediate neonatal intubation during such high-risk deliveries, yet the required Neonatal Response Team was not in attendance, violating established guidelines for emergency resuscitation. The document outlines the protocols for high-risk deliveries as per established guidelines, which necessitate the presence of a neonatologist, a neonatal nurse practitioner (NNP), a NICU registered nurse (RN), and a NICU respiratory therapist (RT), with at least one member possessing complete resuscitation skills. Criteria for categorizing a delivery as high-risk include fetal compromise unresponsive to interventions and the potential need for an emergency C-section. It emphasizes the importance of consulting Neonatology whenever there is uncertainty. Nurse Carrie Etcheberry's testimony indicates that the decision to call for NICU team assistance during a C-section rests with the attending OB/GYN. In this case, Dr. Kuykendall delayed calling for the NICU team until after making the initial incision and observing meconium in the amniotic fluid, resulting in a NICU RT arriving approximately eight minutes after the delivery of a non-responsive newborn, E.C. Additional time was required for a non-NICU certified registered nurse anesthetist (CRNA) to successfully intubate E.C., leaving the newborn without an airway for about 12-14 minutes. Dr. Harlass's deposition suggested that it was Dr. Kuykendall's duty to ensure the presence of a qualified NICU member capable of immediate resuscitation. There is ambiguity regarding whether Dr. Kuykendall declined NICU attendance prior to the procedure, which raises questions about adherence to the standard of obstetric care. Dr. Harlass's reference to NICU protocols for high-risk, unscheduled C-section deliveries supports his opinions that the alleged failures align with deviations from established care standards. Dr. Kuykendall and nursing staff had a shared responsibility to ensure the appropriate NICU team was present at the delivery, particularly for high-risk unscheduled C-Sections. Criticisms from Dr. Harlass, based on his familiarity with the national standard of care for board-certified OB/GYNs, indicated that a qualified individual capable of intubating the newborn should have been present. Harlass acknowledged he was unaware of any national standard requiring a neonatologist specifically at such a procedure, nor was he familiar with the neonatology standard for resuscitating a meconium-covered newborn. However, this lack of knowledge did not affect his assertion that Dr. Kuykendall deviated from the standard of care by failing to ensure the necessary NICU personnel were available for the delivery. It was also noted that evidence of a violation of internal hospital policy alone does not establish a breach of the standard of care without qualified expert testimony. Ultimately, it was concluded that Dr. Kuykendall breached the national standard of obstetric care by not ensuring the presence of a qualified NICU team member during the delivery. Dr. Harlass emphasized during his deposition that the prolonged oxygen deprivation experienced by newborn E.C. was due to the absence and delayed arrival of a qualified NICU team member, specifically a neonatologist or respiratory therapist, at the time of extraction and subsequent intubation. Despite an attending non-NICU nurse anesthetist successfully intubating E.C., this does not negate Dr. Harlass’s assertion that Dr. Kuykendall failed to meet the standard of obstetric care by not ensuring the presence of a qualified NICU team member for resuscitating a non-responsive newborn. On appeal, Dr. Kuykendall argues that Kipfinger improperly altered her factual theory by referencing parts of Dr. Harlass’s deposition not previously considered by the district court, which criticized her original limited arguments against his summary judgment motion. Dr. Kuykendall urges that these new arguments should be disregarded or only deemed relevant for context due to the deficiencies noted in Kipfinger’s initial briefing. He cites the case of Pilgeram v. GreenPoint Mort. Funding, Inc., to support the principle that new legal theories or arguments should generally not be introduced on appeal unless extenuating circumstances justify the failure to present them in the lower court. The court determined that the new agency theory could not be considered on appeal in Pilgeram due to several reasons: (1) the moving party failed to raise the new theory in prior pleadings or motions, (2) the existing factual record did not meet the necessary elements for the new theory, (3) reviewing the new theory on appeal would prejudice the non-moving party's ability to present contrary evidence, and (4) a genuine issue of material fact persisted even if the existing record could prima facie support the new theory. Summary judgment is appropriate only when the record shows no genuine issue of material fact and the moving party is entitled to judgment as a matter of law. In contrast, Dr. Kuykendall, the moving party in this case, bears the burden of proving no genuine issue of material fact exists. Dr. Kuykendall's motion for summary judgment focused on a specific allegation of malpractice regarding the lack of a resuscitation team during a C-section. She argued that the need for an intubation team was not evident until after the delivery and that a capable provider was present at all times. However, Kipfinger's malpractice claim included a broader array of factual averments and expert testimony, which Dr. Kuykendall did not contest regarding the district court's treatment of these additional allegations as amendments to the complaint. Unlike Pilgeram, Kipfinger's limited arguments against the summary judgment motion were not a strategic choice but rather a response to Dr. Kuykendall's narrowly defined initial arguments. Dr. Kuykendall contends that only the 8-page excerpt of Dr. Harlass’s deposition, included in Kipfinger’s opposition brief, should be considered for contextual understanding of the District Court's reasoning for granting summary judgment. Dr. Kuykendall refrains from expressing an opinion on whether the District Court should have independently examined the rest of the Harlass deposition transcript. However, the District Court explicitly indicated that it reviewed the full range of expert depositions and disclosures, contradicting Dr. Kuykendall’s argument and demonstrating that it considered the entire Harlass deposition when making its summary judgment decision. Furthermore, the District Court granted summary judgment to Dr. Kuykendall regarding the standard of care and breach elements of Kipfinger’s malpractice claim based on reasoning not initially raised by Dr. Kuykendall in her motion or initial brief. In her brief, Dr. Kuykendall only claimed entitlement to summary judgment based on concessions in Kipfinger’s complaint, without addressing the Harlass deposition. It wasn't until her reply brief that she introduced numerous evidentiary arguments and citations, which were not available for Kipfinger to respond to before summary judgment was granted. The District Court, responding to Kipfinger's broad opposition and Dr. Kuykendall's new claims, independently requested and reviewed the entire six-plus hour Harlass deposition testimony after the case had been submitted for decision. Procedural unfairness arises from preventing the non-moving party from presenting evidentiary arguments on appeal based on the complete Rule 56 record that was initially referenced in Dr. Kuykendall’s reply brief. The District Court granted summary judgment without allowing the non-moving party an opportunity to address new grounds raised in the reply, which is contrary to precedents like Tags Realty, LLC v. Runkle and WLW Realty Partners, LLC v. Cont’l Partners VIII, LLC. The court emphasized that summary judgments should not rely on arguments introduced for the first time in reply briefs, as fairness necessitates consideration of the entire factual record. Despite the complexities of the case and the challenges posed by the parties' selective briefings, the court highlighted the need for thorough review to avoid substantial injustice. The District Court acknowledged the fundamental right to a jury trial and access to the courts, asserting that it is unjust to dismiss a claim without adequate briefing. Ultimately, genuine issues of material fact were found to exist, preventing the grant of summary judgment to Dr. Kuykendall regarding the standard of care and breach elements of Kipfinger’s medical malpractice claim, supported by expert testimony and relevant materials. Kipfinger's ability to prove the causation element of her medical malpractice claim against Dr. Kuykendall is to be determined by the trier of fact at trial. Dr. Kuykendall's motion for summary judgment argued that Kipfinger effectively conceded the inability to establish causation through her amended complaint, which mentioned the unavailability of a NICU resuscitation team during her C-section and the eventual intubation of her child, E.C., by a non-NICU CRNA. Additionally, Dr. Kuykendall pointed to testimony from Kipfinger’s own expert, Dr. Steven A. Ringer, indicating that Dr. Kuykendall's alleged negligence did not lead to E.C.’s hypoxic-ischemic injury (HIE), either during or after birth. Furthermore, Dr. Harlass was deemed unqualified to opine on the causation of HIE due to his specialty focus and lack of assertions on this issue in his reports. The District Court did not rule on Dr. Kuykendall's causation motion, reasoning that Kipfinger had not established the standard of care. However, the court mistakenly concluded that Dr. Kuykendall was entitled to summary judgment regarding the standard of care and breach. Under de novo review standards, the appellate court has the discretion to address Dr. Kuykendall's unaddressed motion for summary judgment on causation, as the case allows for a determination based on the existing record to promote judicial economy. The court conducted a discretionary Rule 56 review concerning an unresolved summary judgment issue likely to re-emerge following a reversal related to asbestos injury claims. It emphasized that when a case is dismissed via a pretrial motion without credibility concerns, the court has broad review authority, allowing for an independent examination of the entire case. In the case involving Dr. Kuykendall, it was established that E.C. was diagnosed with hypoxic-ischemic encephalopathy (HIE) shortly after birth. The court determined that Dr. Kuykendall mischaracterized Kipfinger’s amended complaint; the alleged “concessions” could not reasonably be interpreted as admissions against Kipfinger’s medical malpractice claim. Kipfinger’s causation theory comprises two main assertions: first, that Dr. Kuykendall's negligence prior to the C-Section—specifically, failures in monitoring and timely intervention—caused undue stress on E.C., leading to oxygen deprivation and severe acidosis during delivery. Second, Kipfinger contends that the absence of qualified NICU personnel during the C-Section delayed necessary post-extraction resuscitation, exacerbating oxygen deprivation and resulting in HIE. This two-fold theory of causation is further supported by deposition testimony from Dr. Harlass. E.C. exhibited ACOG Category III fetal heart tracing patterns by 3:20 p.m., which were unresponsive to intrauterine resuscitation. At birth, E.C. displayed mild acidosis that later intensified. Although there were no immediate signs of significant acidosis or hypoxic-ischemic encephalopathy (HIE), the risk of developing serious acidosis increased with delayed resuscitation post-delivery. Dr. Harry Wilson's Rule 26(b)(4) disclosure indicated that meconium passage occurred 4-12 hours prior to delivery, and E.C. faced acute placental compromise, increasing vulnerability to stress changes. The emergency C-section at 4:47 p.m. revealed placental cord gas results showing acute hypoxia yet maintained metabolic reserves. Following delivery, E.C. entered a non-supportive environment, leading to severe acidosis due to meconium aspiration and inadequate airway clearance, which resulted in significant brain injury. Initial suction attempts to clear meconium were unsuccessful, leading to chronic hypercapnia and severe acidosis. Dr. Wilson further clarified that E.C.'s metabolic reserves were adequate before placental severance but diminished significantly during delivery, affecting the newborn's ability to withstand the stress of labor. The excerpt outlines the assessment of a child's brain vulnerability and neurological injury related to inadequate medical attention during and after delivery. Initially, the child’s brain was intact at delivery with no severe acidosis; however, a deficient environment persisted post-delivery, exacerbating the situation. Dr. Steven A. Ringer, a neonatologist, testified that any delay in the NICU team’s arrival increased the child's risk of neurological injury, suggesting that a shorter delay would have likely resulted in a better outcome. Dr. Dale Bull, a pediatrician and neonatologist, reported that the child experienced brain damage due to oxygen deprivation following birth, with evidence indicating that the hypoxic-ischemic injury (HIE) began during labor and worsened post-delivery due to inadequate resuscitation. Blood gas analyses revealed only sub-critical hypoxia before birth, with severe injury evident shortly after. Dr. Sanjay P. Prabhu, a pediatric neuroradiologist, noted that imaging five days post-birth showed brain abnormalities consistent with severe hypoxia occurring within 24 hours before delivery and shortly thereafter, suggesting a second episode of partial hypoxia. His opinions are supported by peer-reviewed literature and expressed with medical certainty. Additionally, it is clarified that the lack of specific expertise in diagnosing HIE does not disqualify Dr. Harlass under relevant legal standards. E.C. was assessed for the risk of developing severe acidosis and hypoxic-ischemic encephalopathy (HIE), with Dr. Wilson's qualifications as a pediatric pathologist not disqualifying him from offering opinions on intrapartum and neonatal HIE causes. Similarly, Dr. Prabhu, despite not being a clinician or a board-certified subspecialist, is deemed qualified to provide expert opinions based on radiological analyses. The District Court noted that Kipfinger's opposition lacked extensive citations to expert opinions, yet all referenced materials were officially filed, including excerpts from supporting statements and discovery documents. Dr. Kuykendall did not contest the qualifications of the medical professionals in question regarding their expertise in the relevant fields. While Section 26-2-601(1, 2) MCA restricts certain medical malpractice expert opinions related to standards of care to those licensed in the same discipline as the alleged tortfeasor, it does not impose similar restrictions on qualified experts regarding medical causation opinions. Trial courts possess broad discretion under M. R. Evid. 702 to determine expert qualifications, with the level of an expert’s qualifications affecting the weight of their testimony rather than its admissibility. Dr. Kuykendall's claims that the opinions of Drs. Harlass, Wilson, Ringer, Bull, and Prabhu negated Kipfinger's ability to show a genuine issue of material fact on causation were deemed insufficient, as any gaps or inconsistencies in qualified expert testimony pertain to weight, not admissibility. Vigorous cross-examination, presentation of contrary evidence, and clear instructions on the burden of proof are established methods for challenging admissible evidence that may be questionable. Under Rule 702, the focus is on the reliability of the expert's field of expertise, the qualification of the witness, and the reliable application of that expertise to the facts. Cross-examination serves as a safeguard against unfounded expert opinions. The rejection of expert testimony is rare under Rule 702, and the requirement for "reliable methodology" does not necessitate that the expert be indisputably correct. Genuine issues of material fact exist regarding the causation element of Kipfinger's medical malpractice claim against Dr. Kuykendall, preventing summary judgment. Similarly, issues of material fact regarding the standard of care and breach also preclude summary judgment. The District Court's summary judgment in favor of Dr. Kuykendall is reversed and remanded for further proceedings.