Background: The objective of our study was to evaluate the association between perinatal asphyxia and hypoxicischemic encephalopathy (HIE) with the presence of ante and intrapartum risk factors and/or abnormal fetal heart rate (FHR) findings, in order to improve maternal and neonatal management. Methods: We did a prospective observational cohort study from a network of four hospitals (one Hub center with neonatal intensive care unit and three level I Spoke centers) between 2014 and 2016. Neonates of gestational age ≥ 35 weeks, birthweight ≥1800 g, without lethal malformations were included if diagnosed with perinatal asphyxia, defined as pH ≤7.0 or Base Excess (BE) ≤ − 12 mMol/L in Umbical Artery (UA) or within 1 h, 10 min Apgar < 5, or need for resuscitation > 10 min. FHR monitoring was classified in three categories according to the American College of Obstetricians and Gynecologists (ACOG). Pregnancies were divided into four classes: 1) low risk; 2) antepartum risk; 3) intrapartum risk; 4) and both ante and intrapartum risk. In the first six hours of life asphyxiated neonates were evaluated using the Thomson score (TS): if TS ≥ 5 neonates were transferred to Hub for further assessment; if TS ≥ 7 hypothermia was indicated. Results: Perinatal asphyxia occurred in 21.5‰ cases (321/14,896) and HIE in 1.1‰ (16/14,896). The total study population was composed of 281 asphyxiated neonates: 68/5152 (1.3%) born at Hub and 213/9744 (2.2%) at Spokes (p < 0.001, OR 0.59, 95% CI 0.45-0.79). 32/213 (15%) neonates were transferred from Spokes to Hub. Overall, 12/281 were treated with hypothermia. HIE occurred in 16/281 (5.7%) neonates: four grade I, eight grade II and four grade III. Incidence of HIE was not different between Hub and Spokes. Pregnancies resulting in asphyxiated neonates were classified as class 1) 1.1%, 2) 52.3%, 3) 3.2%, and 4) 43.4%. Sentinel events occurred in 23.5% of the cases and FHR was category II or III in 50.5% of the cases. 40.2% cases of asphyxia and 18.8% cases of HIE were not preceded by sentinel events or abnormal FHR. Conclusions: We identified at least one risk factor associated with all cases of HIE and with most cases of perinatal asphyxia. In absence of risk factors, the probability of developing perinatal asphyxia resulted extremely low. FHR monitoring alone is not a reliable tool for detecting the probability of eventual asphyxia.

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INTRODUCTION: Rules for optimal placement and use of vacuum have not been tested in a clinical setting. We evaluated the effect of the adherence to the recommended checklist for vacuum delivery (VD) on maternal and perinatal outcomes. METHODS: Retrospective cohort study including all VD over 4 years. Kiwi Omni Cup was used in all cases and the operators were encouraged to follow 3 rules: recording of fetal head station and position, performing no more than 4 tractions, and no more than 3 cup applications. A checklist to record the procedure was also introduced. RESULTS: The overall rates of VD and cesarean delivery (CD) were respectively 4.4% and 17.9%. Cases in which the 3 rules were respected had lower incidence of III–IV degree perineal lacerations after controlling for episiotomy, nulliparity, and indication for the procedure (P=.025), but similar rates of failure of vacuum extraction (2.1% versus 2.2%, P=1) and adverse neonatal composite outcome (10.8% versus 11.7%, P=.71). Introduction of the checklist for VD resulted in an increase in the compliance to the rules (83.8% versus 62.8%, P=.000). Neither failure of vacuum nor adverse maternal or neonatal outcomes was related to occiput posterior position or high station of the head in cases respecting rules. CONCLUSION: Compliance with the recommended rules in VD results in a lower rate of severe perineal lacerations but it does not affect success of OVD or neonatal outcome. A continuous training program is a main factor to reach a successful procedure and reduce adverse outcome, even in cases of occiput posterior delivery.