Neonatal Encephalopathy and HIE - Bedside Clinical Proforma

1. Patient Demographics & Intrapartum History

Mother's Name: Mother's Name | Baby's Name: Baby of ...
Sex: Male / Female | Age: Hours / Days of Life | Gestation: Completed Weeks (≥35w for cooling)
Birth Weight: Grams (≥1800g for cooling) | Delivery Mode: Normal / Forceps / Vacuum / Emergency LSCS
Indication for Operative Delivery: Fetal bradycardia / Obstructed labor / Cord prolapse / Abruptio placentae
Amniotic Fluid: Clear / Meconium Stained (Thin / Thick pea-soup)

Cord arterial blood gas: pH ... (≤7.00?) | Base Deficit: ... mmol/L (≥16 mmol/L?)
Apgar Scores: 1 min: ... | 5 min: ... (≤5?) | 10 min: ...
Duration of resuscitation required: Positive pressure ventilation ... mins | Chest compressions: ... mins
Time to first spontaneous cry / breath: ... minutes

Category 1: Level of Consciousness: Hyperalert (Stage I) / Lethargic, Obtunded (Stage II) / Stupor, Coma (Stage III)
Category 2: Spontaneous Motor Activity: Normal, irritable / Decreased / Completely absent
Category 3: Muscle Tone: Normal, slightly increased / Generalized hypotonia / Flaccid
Category 4: Autonomic Function:
- Pupils: Dilated, reactive (Sympathetic - Stage I) / Constricted, miosis (Parasympathetic - Stage II) / Fixed, dilated, skew (Stage III)
- Heart rate: Tachycardia / Bradycardia / Variable
- Respiration: Regular / Periodic, hypoventilation / Apnea requiring mechanical support
Category 5: Primitive Reflexes:
- Sucking & Rooting: Exaggerated / Weak, sluggish / Completely absent
- Moro reflex: Exaggerated / Incomplete, weak / Completely absent
Category 6: Neonatal Seizures:
- Clinical Seizures: Absent (Stage I) / Present (Stage II) / Refractory or Decerebrate posturing (Stage III)
- Seizure Semiology: Subtle (cycling, lip smacking, paroxysmal blinking) / Focal clonic / Multifocal / Tonic
Final Classification: Stage I (Mild) / Stage II (Moderate) / Stage III (Severe)

Eligibility confirmed: Gestation ≥35w, Weight ≥1800g, Severe acidosis + Moderate/Severe Encephalopathy
Time of cooling initiation: ... hours of life (MANDATORY strictly within 6 hours!)
Cooling method: Servo-controlled total body cooling blanket / Phase changing material (PCM)
Target rectal core temperature: 33.5°C ± 0.5°C (Maintained strictly for 72 continuous hours)
Rewarming protocol: Started at 72 hours | Rate: 0.5°C every 2 hours over 10-12 hours
Complications of cooling monitored: Bradycardia, hypotension, thrombocytopenia, coagulopathy, subcutaneous fat necrosis

Amplitude-Integrated EEG (aEEG) Background: Continuous normal / Discontinuous / Burst-suppression / Low voltage / Flat
First-Line Anticonvulsant: Inj. Phenobarbital 20 mg/kg IV infused over 20 mins | Additional bolus: 10-20 mg/kg
Second-Line (if refractory): Levetiracetam (40-60 mg/kg) / Fosphenytoin (20 mg PE/kg) / Midazolam infusion
Pyridoxine trial (100 mg IV): Performed / Not indicated

Central Nervous System: Fontanelle tension / Cerebral edema / Cranial USG (RI of anterior cerebral artery: ...)
Renal System: Urine output: ... mL/kg/hour (Oliguria <1 mL/kg/h?) | Serum Creatinine: ... mg/dL | BUN: ... mg/dL
Cardiovascular System: BP: ... mmHg | Capillary refill: ... s | Serum Troponin-I: ... | Echo: Myocardial strain / PPHN
Hepatic System: Serum AST: ... IU/L | Serum ALT: ... IU/L | PT / INR: ...
Metabolic: Blood glucose (hypoglycemia?): ... mg/dL | Serum Calcium: ... mg/dL | Serum Sodium (SIADH?): ... mEq/L

Brain MRI timing: Optimal window Days 4 to 7 of life post-rewarming
MRI Sequences: DWI / ADC (acute cytotoxic edema) | T1/T2 (Loss of posterior limb of internal capsule - PLIC sign)
Hearing evaluation: Diagnostic BERA at 3 months
High-Risk Clinic follow-up: Amiel-Tison / DASII at 1, 3, 6, 9, 12, 18, 24 months