Recognising risk of neonatal encephalopathy with advancing gestation in nulliparous women is crucial for case review

In neonatal encephalopathy (NE), establishing the history includes scrutiny of the perinatal events contributing to the infant’s condition. For births initially considered ‘low risk’ but resulting in peripartum hypoxia, it is crucial to perform interdisciplinary case review. The neonatal perspective (although retrospective) is valuable, but the denominator of healthy babies is not reviewed, only the injured, so hindsight bias should be recognised. Nevertheless, we must consider potential opportunities to act differently and mitigate, particularly if clear risk factors were underappreciated at the time. In Aotearoa New Zealand, the Perinatal and Maternal Mortality Review Committee (PMMRC) collects national data on NE.1 Annual reports include clinical and demographic factors, which facilitate case review to document contributing factors and potential preventability.2 The PMMRC report1 documents …