title: Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia.
abstract: The recently published monograph, Neonatal encephalopathy and neurologic outcome, from the American College of Obstetricians and Gynecologists calls for a root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. A national clinical review of these individual cases has not previously been undertaken.
  
  
  
  The objective of the study was to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality and to identify themes for quality improvement.
  
  
  
  National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at 1 minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011 was undertaken. Cases were included if they had abnormal gases as defined by any of pH of ≤ 7.2, base excess of ≤ -10, or lactate of ≥ 6 or if there were no cord gases, an Apgar score at 1 minute of ≤ 7. A clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality and to identify themes to guide quality improvement.
  
  
  
  Eighty-three babies fulfilled the inclusion criteria for the review, 56 moderate (67%) and 27 severe (33%), 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH of ≤ 7.0, base excess of ≤ -12, or lactate of ≥ 6; and 42% (8 of 19) without cord gases had 5 minute Apgar scores < 5. Excluding 5 babies who died within a day of birth, all but 1 baby were admitted to a neonatal unit within 1 day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor.
  
  
  
  A multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.
authors.affiliation: University of Auckland, Auckland, New Zealand. Electronic address: l.sadler@auckland.ac.nz.
authors.forename: Lynn C
authors.initials: LC
authors.lastname: Sadler
authors.affiliation: University of Auckland, Auckland, New Zealand.
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Farquhar
authors.affiliation: University of Auckland, Auckland, New Zealand.
authors.forename: Vicki L
authors.initials: VL
authors.lastname: Masson
authors.affiliation: Auckland District Health Board, Auckland, New Zealand.
authors.forename: Malcolm R
authors.initials: MR
authors.lastname: Battin
mesh_terms: D001238:Asphyxia Neonatorum / Q000453:epidemiology* / Q000517:prevention & control; D001927:Brain Diseases / Q000453:epidemiology*; D015148:Cardiotocography; D054869:Clinical Audit; D002983:Clinical Competence; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007745:Labor Onset; D019300:Medical Errors; D009520:New Zealand / Q000453:epidemiology; D062209:Patient Handoff; D011247:Pregnancy; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012151:Resuscitation; D012720:Severity of Illness Index; D061665:Time-to-Treatment
keywords: contributory factors; maternity; neonatal encephalopathy; perinatal asphyxia; potentially avoidable; review