Encephalopathy In Term Infants Research Articles

Insights from serial magnetic resonance imaging in neonatal encephalopathy in term infants.

Limited serial neuroimaging studies use magnetic resonance imaging (MRI) to define the evolution of hypoxic-ischemic insults to the brain of term infants and encompass both the primary injury and its secondary impact on cerebral development. The optimal timing of MRI to fully evaluate the impact of hypoxic-ischemic encephalopathy on brain development and associated neurodevelopmental sequelae remains unknown. Goals: (a) review literature related to serial neuroimaging in term infants with HIE; (b) describe pilot data in two infants with HIE treated with therapeutic hypothermia who had a brain injury at day 3-5 and underwent four additional MRIs over the next 12 weeks of life and developmental evaluation at 24 months of age. Early MRI defines primary injury on diffusion-weighted imaging, yet the full impact may not be fully apparent until after 1 month of life. The full impact of an ischemic injury on the neonatal brain may not be fully visible until several weeks after the initial insult. This suggests the benefit of obtaining later time points for MRI to fully define the extent of injury and its neurodevelopmental impact. Few studies inform the nature of the evolution of brain injury with hypothermia in HIE, limiting understanding of potential neuroprotection. MRI is the standard of care for prognosis in infants with HIE, however timing for optimal prognostic prediction remains unclear. Insights from MRI after the first week of life may assist in defining the full extent of brain injury and prognostic significance. A pilot study using five MRI timepoints up to 3 months of age, is presented. More data is required with a systematic evaluation of the impact of early brain injury on brain development in term infants with HIE following TH.

A Comprehensive Clinical Approach to Hypoxic Ischaemic Encephalopathy in Term Infants: A Review

A Comprehensive Clinical Approach to Hypoxic Ischaemic Encephalopathy in Term Infants: A Review

A Comprehensive Clinical Approach to Hypoxic Ischaemic Encephalopathy in Term Infants: A Review

A Comprehensive Clinical Approach to Hypoxic Ischaemic Encephalopathy in Term Infants: A Review

Association of Hypoxic Ischemic Encephalopathy With Hyponatremia In Term Infants Within First 24 Hours of Life

Background: Electrolytes disturbances observed in hypoxic ischemic encephalopathy can further complicate the already asphyxiated babies Serum sodium is one of the most important electrolytes associated with neuronal activity, routinely serum sodium is added after 24 hour of life in maintenance fluid of neonates but we will monitor the changes in our suspected cases earlier so that early intervention should be done to reduce the perinatal mortality and its fatal outcomes. Aim: To determine the association of hyponatremia with hypoxic ischemic encephalopathy in term infants during first 24 hours of life. Methods: Case control study was carried out at Department of Pediatrics, Aziz Bhatti Shaheed Teaching Hospital Gujrat from12th Feb 2018 to 12th Feb 2019. 134 cases and 134 controls were included in the study. Full term babies (>37 weeks) of either gender was included for both cases and controls. Cases were hypoxic ischemic encephalopathy infants who has history of delayed cry at birth of >5 minutes, respiratory distress and moaning. Hyponatremia was labelled if serum sodium levels are below 130 mmol/lit. Matched controls i.e. healthy neonates from same setting were selected for the study. The serum sodium levels were compared between cases and controls. Results: Serum sodium was unequally distributed among cases & controls (Median±IQR 136±5, 139±8, P value using Mann Whitney U test= 0.01). Hyponatremia was also unequally distributed among cases & controls (3.4% vs 0.4%, P value using Fischer exact test = 0.01). Logistic regression analysis using STEP wise analysis proved that the association found regarding hyponatremia/ serum sodium with hypoxic ischemic encephalopathy is not significant after adjusting for weight and gender of the infant. The distribution of birth weight and gender among cases and controls was similar (P value > 0.05). Conclusion: It is concluded that hyponatremia is not associated with hypoxic ischemic encephalopathy in term infants during first 24 hours of life. Keywords: Hypoxic ischemic encephalopathy, Hyponatremia, Serum sodium, Perinatal asphyxia

Impact of sedative agents on cerebral blood flow and outcomes of hypoxic-ischemic encephalopathy in term infants

Мета роботи . Порівняти вплив морфіну та інших седативних засобів на стан мозкового кровотоку та результати лікування гіпоксично-ішемічної енцефалопатії у доношених новонароджених. Матеріали і методи . Досліджено 205 доношених новонароджених з гіпоксично-ішемічною енцефалопатією за Sarnat II-III ст. в терміні d”72 годин після пологів. Немовлята були стратифіковані за фармакологічним препаратом для медикаментозної седації під час проведення штучної вентиляції легень на групи із застосуванням морфіну (n=71) та групу порівняння (n=134), в яку увійшли оксибутират натрію, діазепам та дексмедетомідин в стандартних рекомендованих дозах. Проведений порівняльний аналіз впливу морфіну та інших лікарських засобів на стан церебральної перфузії та на результати лікування гіпоксично-ішемічної енцефалопатії. Результати і обговорення . Отримана достовірна відмінність поміж групами допплерівського індексу мозкового кровотоку RI у першу добу (0,64 [0,55-0,74] в групі морфіну та 0,68 [0,61-0,75] в групі контролю, р=0,037), і на третю добу лікування (відповідно 0,64 [0,55-0,70] проти 0,67 [0,61-0,75] при р=0,040), більш низькі показники САТ (51 [43-60] мм рт.ст. проти 56 [49-60] мм рт.ст. при р=0,017), більша у 2,2 рази частота судом (р=0,038) та вища майже у 2 рази концентрація протеїну S-100 на третю добу (р=0,029) у групі морфіну. Частота розвитку небажаного результату у вигляді церебральної лейкомаляції також була у 2 рази вище в групі морфіну (18,4%) ніж у контрольній групі (8,9%), хоча різниця виявилась недостовірною (р=0,051), але з очевидною тенденцією. Висновки . В гострому періоді гіпоксично-ішемічної енцефалопатії у доношених новонароджених застосування морфіну у якості препарату седативної дії у порівнянні з іншими фармакологічними препаратами призводить до низки негативних ефектів стосовно впливу на церебральну перфузію та на кінцеві результати лікування.

Impact of inotropes on cerebral blood flow in acute period of severe hypoxic-ischemic encephalopathy in term infants

OBJECTIVE. To determine impact of dopamine and dobutamine administration on cerebral blood flow in acute period of severe hypoxic-ischemic encephalopathy in neonates.MATERIALS AND METHODS. Data of 205 term infants with Apgar score at birth of 7 or less and Sarnat stage II-III collected during 72 hours of life. The relationships between mean blood pressure, RI and PI using dopamine and dobutamine during the first three days of the acute period of severe hypoxic-ischemic encephalopathy were analyzed.RESULTS AND DISCUSSION. During first three days of treatment no significant difference was found in mean blood pressure and cerebral blood flow administering dobutamine or combination of dobutamine and dopamine as inotropic support.In the acute period of HIE comparing to dobutamine if dopamine administered Resistant Index of cerebral arteries (RI) changed negatively, namely: dopamine administration on Day 1 of treatment led to decrease in RI during the first day of treatment (p = 0.021). The use of dopamine in 2nd day led to decrease in RI on 2nd day (p = 0.033) as well as on the 3rd day of the study (p = 0.016). The using of dopamine during the 3rd day was associated with decrease in the Pulsatile Index (PI) in the 3rd day of the study (p = 0.023).CONCLUSIONS. The administration of single dopamine or in combination with dobutamine leads to deterioration of cerebral perfusion, namely, a significant decrease in the resistance of the cerebral vessels, which is an unwanted prognostic sign for the short-term outcomes and complications of HIE.

Diagnostic and predictable values for doppler indices of cerebral blood flow in acute period of severe hypoxic-ischemic encephalopathy in term infants

OBJECTIVE. To determine diagnostic and predictable values for Doppler indices of cerebral blood flow in acute period of severe hypoxic-ischemic encephalopathy in neonates.MATERIALS AND METHODS. Data of 205 term infants with Apgar score at birth of 7 or less and Sarnat stage II-III was collected during d”72 hours of life. The correlation between RI and PI indices and Glasgow Coma Scale, serum protein S-100, seizures, confirmed by the aEEG, was analyzed, as well as prognostic model for unwanted development of neurological complications such as cerebral leukomalacia.RESULTS AND DISCUSSION. In the acute period of HIE Resistive Index (RI) and Pulsatile Index (RI), measured in the anterior cerebral artery on Day 3 after the end of the therapeutic hypothermia and brain reperfusion, reliably correlate with the serum concentration of brain damage marker protein S-100 (r=-0.2; p=0.037 and r=-0.2; p=0.039 respectively) as well as risk of cerebral leukomalacia (p=-0.13; p=0.016). The prognostic model based on the values of RI, PI, S-100 and GCS with sensitivity of 33% and 100% specificity predicts potential risk of leukomalacia after severe HIE in 32.7% – 42.1%.CONCLUSION. The evaluation of Doppler indices of cerebral blood flow RI and PI in the acute period of hypoxic ischemic encephalopathy in the term newborns has a significant diagnostic and predictable value and correlates with the severity and short-term clinical follow-up of HIE.

Prognostic values of serum neuronal biomarkers NSE and protein S-100 in acute period of severe hypoxic-ischemic encephalopathy in term infants

It remains unclear if the serum concentrations of neuron-specific enolase (NSE) and protein S-100 correlate with severity and possible complications of hypoxic ischemic encephalopathy (HIE) as well as monitoring parameters of cerebral perfusion and central hemodynamics in term newborns.The aim of research. To determine diagnostic and predictable values of NSE and protein S-100 in acute period of severe hypoxic-ischemic encephalopathy in neonates.Materials and methods. Data of 89 term infants with Apgar score at birth of seven or less and Sarnat stage II-III was collected during ≤72 hours of life. The correlation between NSE, S-100 and Glasgow Coma Scale, seizures, confirmed by the aEEG, the unwanted development of neurological complications such as cerebral leukomalacia, and the short-term clinical results were analyzed.Result. In acute period of HIE the concentration of serum neuronal biomarkers S-100 and NSE proteins substantially exceeds the reference values for the first hours after labor and exceeds the normal range until the 5th day of life. The dynamics of these data significantly changes during this period. Mostly diagnostically and prognostically significant the measurement of biomarkers was on the 3rd day of treatment, immediately after the end of the therapeutic hypothermia, at the beginning of rewarming and brain reperfusion, when both indicators were most closely correlated with the assessment of the GCS: NSE (r=-0.3; p=0.002 ) and S-100 (r=-0.3; p=0.003). The value of S-100 on day 1 correlating with the following unwanted development of leukomalacia is above 1.8 μg/L (p=0.002), which is more than 3 times higher from the reference level of 0.51 μg/L given by Simon-Pimmel J. (2017) for term newborns.Conclusion. The evaluation of the serum concentrations of protein S-100 and neuron-specific enolase in the acute period of hypoxic ischemic encephalopathy in the term newborns has a significant diagnostic and predictable value and correlates with the severity and short-term clinical results of HIE

Mri patterns of hypoxic ischemic encephalopathy in term infants and correlation with neurosonographic appearance & clinical outcome

Mri patterns of hypoxic ischemic encephalopathy in term infants and correlation with neurosonographic appearance & clinical outcome

Neonatal cerebral function monitoring – understanding the amplitude integrated EEG

Amplitude integrated electroencephalography (aEEG) is produced by cerebral function monitors (CFM), and is increasingly used in neonates following research into hypothermia for hypoxic ischaemic encephalopathy in term infants. Formal training packages in aEEG in term infants are limited. aEEG is used less often in clinical practice in preterm infants, and requires an understanding of the normal changes seen with increasing gestational age. A number of classifications for aEEG interpretation exist; some purely for term neonates born, and others encompassing both preterm and term neonates. This article reviews the basics of aEEG, its indications and limitations. We also discuss its role in prognostication in term and preterm infants.

Pharmacotherapy for Neonatal Seizures: Current Knowledge and Future Perspectives.

Seizures are the most common neurological emergencies in the neonatal period and are associated with poor neurodevelopmental outcomes. Seizures affect up to five per 1000 term births and population-based studies suggest that they occur even more frequently in premature infants. Seizures are a sign of an underlying cerebral pathology, the most common of which is hypoxic-ischaemic encephalopathy in term infants. Due to a growing body of evidence that seizures exacerbate cerebral injury, effective diagnosis and treatment of neonatal seizures is of paramount importance to reduce long-term adverse outcomes. Electroencephalography is essential for the diagnosis of seizures in neonates due to their subtle clinical expression, non-specific neurological presentation and a high frequency of electro-clinical uncoupling in the neonatal period. Hypoxic-ischaemic encephalopathy may require neuroprotective therapeutic hypothermia, accompanying sedation with opioids, anticonvulsant drugs or a combination of all of these. The efficacy, safety, tolerability and pharmacokinetics of seven anticonvulsant drugs (phenobarbital, phenytoin, levetiracetam, lidocaine, midazolam, topiramate and bumetanide) are reviewed. This review is focused only on studies reporting electrographically confirmed seizures and highlights the knowledge gaps that exist in optimal treatment regimens for neonatal seizures. Randomised controlled trials are needed to establish a safe and effective treatment protocol for neonatal seizures.

The impact of a register on the management of neonatal cooling in Switzerland

BackgroundTherapeutic hypothermia following hypoxic ischaemic encephalopathy in term infants was introduced into Switzerland in 2005. Initial documentation of perinatal and resuscitation details was poor and neuromonitoring insufficient. In 2011, a National Asphyxia and Cooling Register was introduced. AimsTo compare management of cooled infants before and after introduction of the register concerning documentation, neuromonitoring, cooling methods and evaluation of temperature variability between cooling methods. Study designData of cooled infants before the register was in place (first time period: 2005–2010) and afterwards (second time period: 2011–2012) was collected with a case report form. Results150 infants were cooled during the first time period and 97 during the second time period. Most infants were cooled passively or passively with gel packs during both time periods (82% in 2005–2010 vs 70% in 2011–2012), however more infants were cooled actively during the second time period (18% versus 30%). Overall there was a significant reduction in temperature variability (p<0.001) comparing the two time periods. A significantly higher proportion of temperature measurements within target temperature range (72% versus 77%, p<0.001), fewer temperature measurements above (24% versus 7%, p<0.001) and more temperatures below target range (4% versus 16%, p<0.001) were recorded during the second time period. Neuromonitoring improved after introduction of the cooling register. ConclusionManagement of infants with HIE improved since introducing the register. Temperature variability was reduced, more temperature measurements in the target range and fewer temperature measurements above target range were observed. Neuromonitoring has improved, however imaging should be performed more often.

Neuro protection for infants

Infants receive a variety of brain injuries—intraventricular hemorrhage in preterm infants, hypoxic ischemic encephalopathy in term infants, and often poorly defined events resulting in cerebral palsy and other neurodevelopmental abnormalities. Recently, specific neuroprotective therapies have been tested to improve, including antenatal magnesium treatment for preterm deliveries and therapeutic hypothermia for hypoxic ischemic encephalopathy. Numerous other neuroprotective treatments, including stem cell treatments and erythropoietin treatments, are being tested in animal models and erythropoietin treatments. In this issue of The Journal, Benders et al report that the treatment of term infants with perinatal arterial ischemic strokes with erythropoietin is safe and feasible. This pilot study should result in formal therapeutic trials. Such interventions are gaining traction as a number of neonatologists are teaming up with pediatric neurologists to develop neurologic neonatal intensive care units to better diagnose and develop treatments for infants at high-risk of brain injury. The use of newer imaging and monitoring tools makes these efforts very likely to succeed. Article page 481▶ Feasibility and Safety of Erythropoietin for Neuroprotection after Perinatal Arterial Ischemic StrokeThe Journal of PediatricsVol. 164Issue 3PreviewTo perform a feasibility and safety study with recombinant human erythropoietin (rhEPO) in neonates with perinatal arterial ischemic stroke. Full-Text PDF

Therapeutic hypothermia in term infants after perinatal encephalopathy: The last 5 years in Switzerland

BackgroundTherapeutic hypothermia (TH) following perinatal asphyxial encephalopathy in term infants improves mortality and neurodevelopmental outcome. In Europe, most neonatal units perform active cooling whereas in Switzerland passive cooling is predominantly used. Aims(i) To determine how many infants were cooled within the last 5years in Switzerland, (ii) to assess the cooling methods, (iii) to evaluate the variation of temperature of different cooling methods, and (iv) to evaluate the use of neuromonitoring. Study designRetrospective cohort study. PatientsNotes of all cooled term infants between March 2005 and December 2010 in 9 perinatal and two paediatric intensive care centres were retrospectively reviewed. Active cooling was compared to passive cooling alone and to passive cooling in combination with gel packs. Results150 infants were cooled. Twenty-seven (18.2%) were cooled actively, 34 (23%) passively and 87 (58.8%) passively in combination with gel packs. Variation of temperature was significantly different between the three methods. Passive cooling had a significant higher variation of temperature (SD of 0.89) than both passive cooling in combination with gel packs (SD of 0.79) and active cooling (SD of 0.76). aEEG before TH was obtained in 35.8% of the infants and 86.5% had full EEG. One cUS was performed in 95.3% and MRI in 62.2% of the infants. ConclusionTarget temperature can be achieved with all three cooling methods. Passive cooling has the highest variation of temperature. Neuromonitoring should be improved in Swiss neonatal and paediatric intensive care units. Our results stress the importance of national registries.

Epidemiologic survey on hospitalized neonates in China.

To carry out a nationwide epidemiologic survey on the neonates in urban hospitals with an attempt to understand the disease spectrum and treatment outcomes of hospitalized neonates in China. The clinical data of 43,289 hospitalized neonates from 86 hospitals in 47 Chinese cities (22 provinces) between January 1, 2005 and December 31, 2005 were retrospectively analyzed. The male:female ratio was 1.73:1. Premature infants accounted for 26.2% of the hospitalized neonates, which was higher than that reported in 2002 (19.7%). The top three diseases during the neonatal period were jaundice, pneumonia, and hypoxic-ischemic encephalopathy. The incidences of pneumonia, meconium aspiration syndrome, and bilirubin encephalopathy in term infants were higher than those in premature infants, while the incidences of asphyxia, respiratory distress syndrome, and pulmonary hemorrhage in term infants were lower than those in premature infants. The incidences of asphyxia, small for gestational age infant, and wet lung were higher in neonates whose mother had pregnancy induced hypertension. The outcomes of these hospitalized neonates included: recovered, 63.9%; improved, 27.3%; discharged due to the family's own decisions, 7.6%, and died, 1.2%. Nearly half (46.4%) of the neonatal death occurred within 24 hrs after admission. The incidence of premature birth shows an increasing trend among hospitalized neonates. Since the neonatal deaths mainly occur within 24 hrs after admission, monitoring during this period should be enhanced.

Symptomatic Parieto-Occipital Epilepsy as Sequela of Perinatal Asphyxia

Perinatal hypoxic-ischemic encephalopathy in term infants has been well-documented as a cause of selective brain damage over the parasagittal brain regions in cases of partial asphyxia. We describe 10 patients (7 boys, 3 girls) who developed normally after perinatal asphyxia, and who later experienced parieto-occipital epilepsy. We retrospectively reviewed medical records, electroencephalograms, and neuroimaging findings. All patients had a history of perinatal asphyxia requiring intensive care. Subsequent developmental milestones were apparently normal. Seizures started at ages ranging from 10 to 168 months (mean, 72 months). The seizures comprised complex partial seizures with visual symptomatology in 5 cases, complex partial seizures without visual symptomatology in 4 cases, and focal motor seizures with secondary generalization in the remaining case. Brain magnetic resonance imaging demonstrated localized parieto-occipital lesions in 9 cases, and normal findings in the remaining one. Electroencephalograms revealed predominantly occipital foci in 8. In all patients, the epileptogenic foci involved either unilateral or bilateral parieto-occipital regions. Intelligence quotients and visuospatial cognitive functions were impaired in 7 patients. Seizures were finally controlled in only 4 patients. Symptomatic parieto-occipital epilepsy caused by mild perinatal hypoxic-ischemic encephalopathy is sometimes pharmaco-resistant and accompanied by mild cognitive and visuospatial impairments.

Intrapartum fever and chorioamnionitis as risks for encephalopathy in term newborns: a case–control study

In this study we examined the relationship between diagnoses of isolated intrapartum fever or chorioamnionitis and the risk of encephalopathy in term newborns. We conducted a population-based, case-control study in Washington State using 1994 to 2002 linked data from the Washington State Birth Registry and the Comprehensive Hospital Abstract Reporting System (CHARS). We identified 1060 singleton, term newborns (602 males, 458 females) with International Classification of Diseases (ICD-9) diagnoses consistent with encephalopathy, and 5330 unaffected control newborns (2756 males, 2574 females). Intrapartum fever was defined by a diagnosis of intrapartum temperature of >38 degrees C in the birth registry or CHARS databases. Chorioamnionitis was defined using ICD-9 diagnoses recorded in CHARS. We identified 2.2 cases of encephalopathy per 1000 births. Isolated intrapartum fever was associated with a 3.1-fold (95% confidence interval [CI] 2.3-4.2) increased risk of newborn encephalopathy. Chorioamnionitis was associated with a 5.4-fold (95% CI 3.6-7.8) increased risk of encephalopathy. We found that isolated intrapartum fever and chorioamnionitis were independently associated with an increased risk of encephalopathy in term infants. Our data also indicate that there is a spectrum of risk for encephalopathy in term infants exposed to intrapartum fever. Infants born to women with signs of chorioamnionitis other than isolated intrapartum fever may be at higher risk of encephalopathy than those exposed only to isolated intrapartum fever.

Whole body hypothermia for the treatment of hypoxic-ischaemic encephalopathy in term infants – a safety study in Hungary

Hypoxic-ischaemic encephalopathy is a major cause of long-term morbidity and mortality in term infants. Prolonged systemic hypothermia is a promising new approach for reducing brain damage in neonates. The aim of the open cohort-series clinical study was to collect data about the safety and technical feasibility of the hypothermia treatment in Hungary before joining to a randomised efficacy trial. The authors treated 28 asphyxiated term neonates with hypothermia between 2003 and 2005. Hypothermia (rectal temperature 33-34 degrees C) was maintained for 72 hours during continuous morphine analgesia. For historical control group 23 asphyxiated neonates were selected treated with standard therapy between 1996 and 2002. Entry criteria were the following: a 5-minute Apgar score 5 or less, the evidence of serious metabolic acidosis in the first hour of life (a BE of 15 mmol/l) and clinical sign of encephalopathy at the same time. Routine laboratory measurements of liver enzymes, renal functions, blood cell count, head ultrasound were performed daily. The anthropometric and clinical parameters (Apgar, pH, BE, neurological signs of encephalopathy) of the hypothermia and control infants were similar. There were no significant differences between the mortality of the hypothermia (10/28 36%) and the control (10/21 48%) groups. The clinical parameters (laboratory values, abnormality on the head ultrasound, incidence of serious hypotension, hypoglycaemia, bleeding, need for cardiovascular support, oliguria) and the neurological outcome after 1.5-2 year follow-up were also similar. This study demonstrated that prolonged whole body hypothermia of the asphyxiated neonate is safe and not associated with increased mortality and morbidity up to 18 month of age.

Chorioamnionitis and Neonatal Encephalopathy in Term Infants With Fetal Acidemia: Histopathologic Correlations

The aim of this study was to determine whether the presence or severity of histologic abnormalities of infection/inflammation such as chorioamnionitis, vasculitis, or funisitis confers an additional risk for neonatal encephalopathy in term infants delivered in the presence of severe fetal acidosis. The medical records as well as placental pathology of term infants (n = 51) born with a cord umbilical arterial pH <7.00 were reviewed. Abnormal outcome was predefined as Sarnat stage 2 or 3 neonatal encephalopathy in the first week of life or neonatal death as a consequence of severe brain injury. Consistent with prior data, the presence of severe fetal acidemia, a low 5-minute Apgar score, and need for cardiopulmonary resuscitation were significantly associated with neonatal encephalopathy. However, the presence of histologic chorioamnionitis had a poor predictive value and did not confer additional risk for the subsequent development of neonatal encephalopathy.

Antenatal antecedents of moderate or severe neonatal encephalopathy in term infants – a regional review

Regional audits of term infants with neonatal encephalopathy (NE) provide an opportunity to examine issues related to causation and quality of care. To document antenatal and intrapartum antecedents in a contemporary cohort of term infants with moderate or severe neonatal encephalopathy. Term infants admitted with moderate-severe neonatal encephalopathy over 4 years were identified. The clinical records were reviewed for information about the pregnancy and birth including interpretation of monitoring and subsequent management of the labour and delivery. Fifty-two maternal records were reviewed. No mothers were diabetic or had gestations > 42 weeks, but 17% of the babies were small for gestational age (SGA). The cohort had evidence of antenatal hypoxia in 15%, a sentinel event in 25% and suboptimal fetal monitoring practice in at least 42% of cases. Peripartum events were the major contributors to neurological damage in infants with neonatal encephalopathy. Suboptimal fetal monitoring practice and sentinel events remain the most common contributors. Ongoing education and training to address these issues should be available to all involved with intrapartum care in New Zealand.