What medical records are reviewed in an HIE birth injury case?

The purpose is to reconstruct the timeline around the birth, establish when oxygen deprivation occurred, and evaluate whether the medical team's decisions at each point measured up to the accepted standard of care.

Both ACOG and the American Academy of Pediatrics note that causation in HIE cases depends on reviewing clinical findings, fetal monitoring, acid-base status, imaging, and other evidence together rather than individually.

The fetal heart rate monitoring record tends to be one of the most carefully examined pieces of evidence in an HIE case, as it shows whether fetal compromise appeared during labor and what the response was. Experts also look at:

• Labor progress notes and nursing records documenting the sequence of events
• Medication records, including oxytocin administration
• Operative reports and cesarean section records, including timing of delivery
• Documentation of complications like placental abruption, cord prolapse, or uterine rupture
• Umbilical cord blood gas results, providing objective data on the baby's acid-base status near the time of delivery

The timeline running from the first sign of an abnormal fetal tracing through the decision to deliver is often where the legal analysis is focused.

What newborn and NICU records are reviewed?

The severity of the newborn in the immediate postdelivery period is determined by Apgar scores, records of neonatal resuscitation, and duration of assisted ventilation. NICU records covering blood gas results, seizure documentation, EEG findings, and therapeutic hypothermia are then reviewed to determine whether HIE was recognized and treated within the six-hour window the AAP identifies for cooling therapy.

What imaging and neurological records matter?

Brain MRI is the most informative imaging study in an HIE case and can identify the pattern, location, and extent of oxygen-related brain injury. The AAP recommends MRI before discharge for neonates who received therapeutic hypothermia. Later records, including pediatric neurology evaluations, developmental assessments, and therapy records, document the long-term consequences of the injury and form the basis for calculating future damages.

How Sean M. Cleary Can Help in an HIE Case

Knowing which records to request, how to read them, and how to connect them to a legal theory of negligence requires medical and legal expertise working together. Attorney Sean M. Cleary works with obstetric and neonatal experts who can analyze the full record and identify where the standard of care was not met. If your child was diagnosed with HIE and you want to know whether the medical record supports a malpractice claim, contact The Law Offices of Sean M. Cleary today for a free case evaluation.