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Observational Study
. 2019 Oct;59(5):699-705.
doi: 10.1111/ajo.12957. Epub 2019 Feb 12.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study

Lynn C Sadler  1   2 , Vicki L Masson  2 , Sue Belgrave  3 , Hillary F Bennett  4 , Jutta van den Boom  5 , Suzanne Miller  6 , Malcolm R Battin  7
Affiliations
Observational Study

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study

Lynn C Sadler et al. Aust N Z J Obstet Gynaecol. 2019 Oct.

Abstract

Background: In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee.

Aims: To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event.

Materials and methods: Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens.

Results: Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation.

Conclusions: There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Keywords: acute peripartum event; contributory factors; human factors; neonatal encephalopathy; potentially avoidable.

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Comment in

  • Shoulder dystocia; NAPLAN scores.
    Blanchette G. Blanchette G. Aust N Z J Obstet Gynaecol. 2020 Apr;60(2):E1. doi: 10.1111/ajo.13151. Aust N Z J Obstet Gynaecol. 2020. PMID: 32291757 No abstract available.
  • Sadler et al reply to Blanchette.
    Sadler L, Masson V, Belgrave S, Bennett H, van den Boom J, Miller S, Battin M. Sadler L, et al. Aust N Z J Obstet Gynaecol. 2020 Apr;60(2):E2. doi: 10.1111/ajo.13138. Aust N Z J Obstet Gynaecol. 2020. PMID: 32291763 No abstract available.

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