Severe Birth Asphyxia: Acute and Long-Term Care

In this chapter, we review neonatal hypoxic-ischemic encephalopathy (HIE), including its natural history, diagnosis, management, and prevention strategies, and the bioethical and medico-legal challenges surrounding this condition. Amongst term infants, neonatal HIE remains a common cause of mortality, however HIE attributable to intrapartum hypoxia is rare. Therapeutic hypothermia has shown promise in reducing the long term neurologic sequelae, which include cerebral palsy, developmental delay, and visual and auditory impairment. Infants with severe sequelae require considerable medical, financial, and familial resources throughout their life. Strategies to prevent intrapartum HIE have been widely adopted, though with mixed results. Meanwhile the fear of litigation has had significant negative effects on obstetric management and willingness to practice. Medical associations have established guidelines to aid in the identification of those infants with HIE due to an intrapartum event. Prognostic uncertainty, especially in the first weeks of life, remains a major challenge in management of these infants. Withdrawal of life sustaining treatment (LST) may be ethically appropriate in selected cases; however the time period wherein the infant is most dependent on LST to survive overlaps the period of prognostic uncertainty, making such decisions difficult. These decisions are best made in conjunction with the family and in an ethically rigorous and systematic fashion.

Keywords: Birth asphyxia, Hypoxic-ischemic encephalopathy, Cerebral palsy, Life sustaining treatment, Neurologic disability, Defensive medicine, Litigation, Resource allocation, Prognostic uncertainty, Parental rights, AAP, ACOG.