Prevention and treatment of postasphyxial, i.e. hypoxic-ischemic, brain damage can be considered at various levels or stages of the process. The first approach is based on epidemiological studies, which typically allow the delineation of risk factors for cerebral damage. By trying to eliminate or reduce such factors, one may influence the incidence of the disorder. At the second stage, the actual pathogenetic mechanisms, e.g. hypoxia or hypotension, leading to brain damage may be preventable or treatable. Finally, limiting the extent of the lesion immediately after the event may be possible.

The first consideration must be an agreed-upon definition of asphyxia. We cannot determine outcome of a condition if some observers are referring to apples and others to pears. Asphyxia is a pathophysiological event comprising both hypoperfusion and hypoxia, and these events result in compromise at a cellular level with the production of metabolic acids. This can be due to a wide number of insults, but a complication of the birth process is the most important cause. Asphyxia is not like intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), as these are conditions that can be diagnosed with a reasonable degree of precision with imaging techniques.

In this review I shall discuss the prognostic value of the clinical neurological examination, the EEG (and the various methods of recording it), evoked responses, and Doppler ultrasound measurements of cerebral blood velocity. Imaging modalities (ultrasound, CT, MRI) will be dealt with elsewhere under discussion of their diagnostic value.

Infants who require intensive care are at considerable risk of death or long-term neurodevelopmental disability. Therefore, noninvasive methods have been sought for assessing the structure and function of the brain in the immediate newborn period. The major aims are to investigate the prevalence and mechanisms of brain-damaging lesions, to test preventive strategies and treatment, and to assign the prognosis of the infants. Several methods have proved their worth, e.g., ultrasound imaging, electroencephalography, including the testing of evoked potentials, and Doppler ultrasonography for measuring flow velocity in intracerebral vessels.

Neurodevelopmental follow-up has an important role in perinatal management and research. The value of individual studies depends on the quality of the planning, the data collected, and the interpretation of the findings. Interpretation, in particular, has caused many problems; these have usually arisen because of a failure to understand the nature of the data and what they mean. Follow-up studies are labor intensive and, therefore, very expensive. If they are to continue, there must be a full understanding of their strengths and weaknesses by those who plan them, carry them out, and — above all, by those who analyze and interpret them.

Modern neonatal medicine raises a series of fundamental ethical questions. In the confrontation with these and in attempting to solve them, basic concepts concerning human life and death should be discussed. On what values do we base our practice? Terms such as human, right to life, sanctity of life, equality, and justice should all be considered with reference to the sick newborn baby. Leading Anglo-American contemporary philosophers who deal with such concepts have a tendency to link them to the autonomy of the individual. Is this a fruitful approach when dealing with ethical questions in neonatal medicine? In the following, I will exemplify this to elucidate the problem.