Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia

Area of Science:

• Obstetrics and Gynecology
• Neonatal Medicine
• Healthcare Quality Improvement

Background:

• Neonatal encephalopathy (NE) requires root cause analysis for improved care and systems.
• A New Zealand study reviewed all moderate to severe NE cases from 2010.
• This is the first national clinical review of such NE cases in New Zealand.

Purpose of the Study:

• To conduct a multidisciplinary review of NE cases post-labor without acute peripartum events.
• To determine the frequency of contributing factors and potentially avoidable morbidity/mortality.
• To identify themes for quality improvement in NE management.

Main Methods:

• Reviewed all moderate/severe NE cases in New Zealand (2010-2011) after labor onset, excluding acute peripartum events and normal early indicators.
• Included cases with abnormal cord gases (pH ≤ 7.2, base excess ≤ -10, lactate ≥ 6) or low Apgar scores if no cord gases were available.
• Multidisciplinary team used a structured tool to assess contributory factors, avoidability, and quality improvement themes.

Main Results:

• Eighty-three infants met criteria; 25% died before discharge. Abnormal cord gases were frequent (84% with results).
• Contributing factors were found in 84% of cases, predominantly personnel factors (76%).
• 55% of cases with morbidity/mortality were potentially avoidable, often due to personnel factors; cardiotocography interpretation was a key theme.

Conclusions:

• Multidisciplinary review of NE post-uncomplicated labor reveals significant avoidable morbidity and mortality.
• Identified issues, like staff training in fetal surveillance, are amenable to quality improvement.
• Focusing on personnel factors and cardiotocography interpretation can enhance NE care.