OBJECTIVE: To characterize clinical management of deliveries resulting in neonatal hypoxic ischemic encephalopathy. DESIGN: Retrospective case series SETTING: Three academic referral medical centers in the United States POPULATION: All neonates ≥35 weeks’ gestation with HIE based on cord blood pH<7.0, base deficit of ≥12.0mmol/L, along with relevant radiological, laboratory, and clinical findings. METHODS: Clinical management was characterized based on whether (i)delivery occurred within 120 minutes of presentation, (ii)delivery occurred due to a sentinel event such as cord prolapse or uterine rupture, and (iii)the fetal heart rate tracing(FHR) demonstrated variability, accelerations, or both upon presentation and in the half hour before delivery. MAIN OUTCOME MEASURES: Relationship of mode of delivery to FHR tracing characteristics at delivery. Obstetric outcomes, labour course and management were analysed. RESULTS: Of 144,904 deliveries, 102 maternal-newborn dyads met criteria. Of these, 19 delivered within 120 of minutes of presentation and four further women experienced a sentinel event. Of the remaining 79, 66(84%) had a FHR tracing on presentation that demonstrated variability, accelerations or both. Of these 66 cases, 27 had a fetal heart tracing that demonstrated variability, accelerations or both in the 30 minutes preceding delivery. CONCLUSION: Approximately two-thirds of cases of HIE occurred in cases where the FHR tracing initially demonstrated variability, accelerations, or both, without a sentinel event and without a condition requiring delivery within 120 minutes of presentation. Of these >40% had variability, accelerations, or both in the half hour before delivery. This suggests additional insights are required to prevent some cases of HIE.

Objective. This study examined the predictive ability of established Maternal Early Warning systems (MEWS) for different types of maternal morbidity, in order to discern an optimal early warning system. Design. Retrospective cohort study. Setting. Four-hospital urban academic system. Population. All patients admitted to the obstetric services of this hospital system in 2018. Methods. All patient vital signs were collected and three sets of published MEWS criteria were evaluated in relation to maternal morbidity. The test characteristics of each MEWS, as well as for heart rate, blood pressure, and oxygen saturation individually and in different combinations were compared. Main Outcome Measures. Maternal morbidity, defined as a composite of hemorrhage, infection, acute cardiac disease, and acute respiratory disease, ascertained from informatics and administrative data. Results. Of 14,597 obstetric admissions, 2,451 patients experienced composite morbidity (16.8%). The sensitivities (15.3% - 64.8%), specificities (56.8% - 96.1%), and positive predictive values (22.3% - 44.5%) of the three MEWS criteria ranged. Of patients with any morbidity, 28% met criteria for the most liberal vital sign combination, while only 2% met criteria for the most restrictive parameters, compared to 14% and 1% of patients without morbidity, respectively. Sensitivity of all vital sign combinations was low (maximum 28.2%), while specificity ranged from 86.1 – 99.3%. Conclusions. Though all MEWS criteria demonstrated poor sensitivity for maternal morbidity, permutations of the most abnormal vital signs have high specificity, suggesting that MEWS may be better implemented as a trigger tool to target more sensitive screening techniques for maternal morbidity.