HIE After Birth: A Guide for Parents, From the Cooling Cot to the Answers

Birth injury to babies · 18 min read · Published 28 October 2026 · Reviewed 28 October 2026 · Next review April 2027

By Dr Rosemary Listing, PhD (Law) · Medical negligence lawyer since 2013 · Of Counsel, Peter Evans & Associates

If that is where you are now, in a ward bed or a NICU chair or awake at home at 3 a.m., I am so sorry. I wrote this guide for that moment, and for all the moments after it. It starts with what HIE is, then follows the order parents actually live it: the first week, the results, coming home, the long wait, and, for some families, the questions about what went wrong.

You don't need to read it all. Find your question below and go straight there.

What HIE is

Sometimes HIE follows a sudden emergency: the uterus tearing (uterine rupture), the placenta coming away early (placental abruption), the cord slipping down ahead of the baby (cord prolapse), or a baby's shoulders getting stuck at birth (shoulder dystocia). Sometimes it builds more slowly, over hours of labour in which the baby's oxygen reserves run down. Sometimes no clear cause is ever found. And in a small number of babies who are first thought to have HIE, a different cause turns up later: a 2026 study from one tertiary NICU found about 1 in 10 cooled babies had another explanation, such as a metabolic or genetic condition.

HIE is not rare, and you are not the only family going through this. The NSW Agency for Clinical Innovation guide reports that 358 babies born after 34 weeks in the Australian and New Zealand neonatal network were cooled in 2020.

Stage 1 · The first week

If your baby is 35 weeks or more and has moderate or severe encephalopathy in the first six hours, the team will usually offer cooling, also called therapeutic hypothermia. Your baby's core temperature is lowered to 33 to 34°C and held there for about 72 hours, then brought back up slowly. The NSW guide expects at-risk babies to be checked every hour for those first six hours, and the newborn retrieval service (NETS in NSW, PIPER in Victoria) to be called early, because cooling works best when it starts early.

The evidence for cooling is strong. A Cochrane review led by Melbourne neonatologist Susan Jacobs pooled the major trials and found that cooling reduces death and major disability in babies with moderate or severe HIE. Queensland's HIE guideline, reissued in July 2026, sets out the same core approach as NSW and Victoria.

The first week is often the hardest. Babies may be on a breathing machine, have seizures that need medicine, and be covered in wires for brain monitoring. Mothers are often recovering in a different hospital. Many parents can't hold their baby until after rewarming. My guide to cooling, rewarming and the first week in NICU goes through it hour by hour, with the questions to ask and the things you can still do for your baby. If your baby wasn't cooled, or cooling started late, my guide to babies who weren't cooled explains how the criteria work and when that deserves a closer look.

Stage 2 · The results

Most cooled babies have an MRI in the first week or two, after rewarming, and an EEG (a recording of brain activity) during and after cooling. The MRI report is the moment many parents dread. It may describe injury to particular parts of the brain, such as the basal ganglia and thalamus (deep structures involved in movement) or the watershed areas (the outer zones between the brain's main blood supplies). The pattern can say something about how and when the injury happened, which matters later if you want to know what went wrong.

It is common for the grade to change, and for the MRI not to match how your baby seems. Parents tell me, again and again, that two babies with similar scans went on to do very differently. My guides to what your baby's HIE grade means and reading the MRI and EEG reports explain the words in plain language, and the questions to ask the neonatologist or neurologist when they go through the results with you.

Stage 3 · Coming home

For many families, feeding is what keeps them in hospital. Babies after HIE may struggle to suck and swallow safely, and some go home with a nasogastric (NG) tube, or later a gastrostomy (G-tube). My guide to feeding after HIE covers what parents in this stage ask most.

Before you leave, you should be told about follow-up: usually a high-risk infant follow-up clinic, with regular developmental checks for at least the first two years. If your baby has, or may have, developmental delay, the NDIS early childhood approach supports children younger than 9 and their families. My guide to early intervention after HIE explains how to get physio, occupational therapy and speech therapy started, and who pays.

Stage 4 · The long wait

"Wait and see" is the phrase parents hate most, and the one they hear most. It is honest, because many effects of HIE only show as a baby grows. But it can make it very hard to simply be with your baby.

Here is something Sam didn't know, and many parents don't. Waiting no longer has to mean waiting until two. Research led by Australian cerebral palsy researcher Iona Novak, published in JAMA Pediatrics in 2017, found that cerebral palsy, or a high risk of it, can be accurately predicted before six months' corrected age using an MRI, a video assessment of a baby's movements (the General Movements Assessment) and a structured neurological examination (the HINE). An early diagnosis means earlier therapy. Cerebral Palsy Alliance runs a free early diagnosis clinic for babies up to 12 months' corrected age.

My guides to living with "wait and see" and early signs, milestones and a cerebral palsy diagnosis cover what to watch for, what is normal variation, and how to ask for an assessment rather than wait.

And because so many of you are searching for this: many babies who are cooled for HIE grow up with no lasting effects, or with effects that are mild. Some have serious, lifelong disability. Both are true, and nobody can honestly tell you in the first weeks which your baby will be.

Stage 5 · The answers

For some families, the questions about what happened start in the NICU. For others they come months or years later, often at 3 a.m., often as guilt. Should I have gone in earlier? Should I have said something when the heart rate dropped? My guide for parents who keep replaying the birth is about that, for mothers and for partners.

The decisions in labour and in those first hours were not yours to make. They belonged to the clinicians caring for you, measured against standards like these:

• RANZCOG, the college that trains and sets standards for Australian obstetricians, sets out how a baby's heart rate should be monitored, interpreted and acted on in its Intrapartum Fetal Surveillance guideline (5th edition, 2025).
• The NSW ACI guide sets out how at-risk babies should be recognised, checked hourly and referred for cooling.
• The NSW Incident Management policy requires serious incidents to be reported and reviewed, and the family to be offered the findings.

If you want to understand whether something went wrong, the first step is nearly always the records: the CTG (heart rate trace), the cord blood gases, the observation charts and the timing of each call. My guides to getting the records and finding out what happened and whether your baby's HIE could have been prevented explain what to ask for and what an independent expert would look at. You can also ask the hospital for a birth debrief, and under the Australian Open Disclosure Framework the hospital should talk to you honestly when a patient has been harmed. If you want an independent body to look at the care, the NSW Health Care Complaints Commission handles complaints about health services, and our guide to making a complaint after a traumatic birth includes a free template.

How the law looks at HIE

A medical negligence claim for HIE is usually brought on behalf of the child, and sometimes also by a parent for their own injury, such as psychological harm. In broad terms, it has to show two things.

That the care fell below the accepted standard. In NSW, section 5O of the Civil Liability Act 2002 says a professional is not negligent if they acted in a way widely accepted by peer professional opinion as competent practice, unless that opinion is irrational. In HIE cases, independent obstetric and midwifery experts usually comment on the labour, and a neonatologist on the care after birth.

That this caused, or made worse, the injury. This is often the hardest part. A paediatric neurologist or neuroradiologist usually looks at the MRI pattern, the cord gases and the timeline to say when the injury most likely happened, and whether earlier action would have made a difference.

Information is part of care too. In Rogers v Whitaker, the High Court made clear that patients are entitled to the information a reasonable person would want about material risks, and that includes decisions in labour.

A good outcome doesn't always mean there's nothing to look at. Some families are told there is "no case because he's fine", and later find that problems with speech, learning or attention appear at school age. My guide to claims when your baby is doing well explains why the answer depends on the injury and how it affects your child as they grow.

Time limits for children work differently from those for adults, and differ between states. They are generally more generous for a child's own claim, but evidence fades: CTG traces, staff memories and equipment logs don't keep forever. Our guide to NSW time limits sets out the general rules, and my guide to time limits and compensation for a baby's HIE claim explains how they apply to children and what compensation is meant to cover. It is always better to ask early than to wait.

In my practice

The parents I speak with after HIE almost never start by asking about a claim. They start with "nobody told us anything", or "I just want to know if it was my fault". Usually, by the time they call me, they have read every forum post there is, and they have been told by well-meaning people that it was "just one of those things".

Sometimes it was. HIE does happen after excellent care, and when that is what the records show, I tell families so plainly, because that answer matters too. But my doctoral research, and many years of reading birth records, have shown me how often serious harm in health care comes from a chain of small things rather than one dramatic mistake: a trace noted as "suspicious" and not escalated, a registrar caught in theatre, a cord gas not taken, a call to the retrieval team made at hour five instead of hour two. Each link can look small on its own. Together, they can change a child's life. That is why the records from the first hours matter so much, and why it is worth getting them while everything is still fresh. Our guide to getting and reading your birth records explains how.

Both/and: HIE can follow excellent care, and some HIE is preventable

Both things are true. Some babies are injured by events nobody could have predicted or stopped in time, and the teams who resuscitate and cool them do extraordinary work. And some HIE follows warning signs that were missed, delays in getting a baby born, or delays in starting cooling. You can be deeply grateful to the people who saved your baby and still want to know whether it had to happen. Asking that question is not ingratitude. It is how the system learns.

The bigger picture

In 2024, the NSW Legislative Council's Birth Trauma inquiry found that much birth trauma stems from avoidable and preventable factors, and heard repeatedly from parents who felt shut out of information about their own births. NSW's HIE guidance itself grew out of a consensus statement by the Clinical Excellence Commission, written so that HIE would be recognised consistently in every hospital, not just the big ones. Our birth injury map shows how HIE connects to the injuries mothers suffer in the same births, such as haemorrhage, uterine rupture and complications of pre-eclampsia.

Support

• Miracle Babies Foundation: NurtureLine 1300 622 243, 24 hours, for families of sick and premature newborns, including in-hospital peer support.
• Life's Little Treasures Foundation: information, care packs and NICU Connections groups.
• Cerebral Palsy Alliance: the early diagnosis clinic and information for families, 1300 888 378.
• PANDA (Perinatal Anxiety & Depression Australia): 1300 726 306, or panda.org.au. For you and your partner.
• Birth Trauma Australia: birthtrauma.org.au.
• Our guide to finding support after birth trauma, much of it free.

Tess still has the screenshot of her mum's text: She's here! For months she couldn't look at it. Now it is her lock screen. "She was here," she told me. "She still is. Everything else, we're working out." Wherever you are in this, at the cooling cot or years down the track, you don't have to work it out on your own.

With care,
Rosemary

Frequently asked questions

References

• NSW Agency for Clinical Innovation. Hypoxic ischaemic encephalopathy in newborns: recognition, monitoring and early management. Clinical practice guide. Sydney: ACI; June 2024. aci.health.nsw.gov.au
• Queensland Clinical Guidelines. Hypoxic-ischaemic encephalopathy (HIE), July 2026. health.qld.gov.au
• Clinical Excellence Commission. NSW Consensus Statement: Newborn Hypoxic Ischaemic Encephalopathy. cec.health.nsw.gov.au
• Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database of Systematic Reviews 2013, CD003311. cochranelibrary.com
• Alternative diagnoses in neonates undergoing therapeutic hypothermia for presumed hypoxic–ischemic encephalopathy. PubMed Central
• Novak I, Morgan C, Adde L, et al. Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment. JAMA Pediatrics 2017;171(9):897–907. PubMed Central
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum Fetal Surveillance (C-Obs 1), 5th edn, September 2025. ranzcog.edu.au
• NSW Health. Policy Directive PD2020_047, Incident Management. health.nsw.gov.au
• Australian Commission on Safety and Quality in Health Care. Australian Open Disclosure Framework, June 2026. safetyandquality.gov.au
• Legislative Council Select Committee on Birth Trauma (NSW). Birth trauma. Report, 2024. parliament.nsw.gov.au
• National Disability Insurance Agency. What the early childhood approach is. ndis.gov.au
• Civil Liability Act 2002 (NSW), s 5O. legislation.nsw.gov.au
• Rogers v Whitaker (1992) 175 CLR 479; [1992] HCA 58. austlii.edu.au

Stories in this article are composites drawn from many families' experiences and have been changed so that no one can be identified. They do not describe any individual client.