Optimization of Routine Obstetric and Neonatal Care in the Management of Severe Perinatal Asphyxia in Term or Near-term Newborns: Analysis of Sub-optimal Care

Perinatal asphyxia at term is a severe pathology that can lead to peripartum death or a birth in vital distress with neurological damage known as anoxic-ischemic encephalopathy (AIE), representing 1.6 per thousand births. In this unexpected and urgent situation, obstetric and neonatal management will have a decisive impact on the neonatal and neurological prognosis of the newborn. Despite a significant improvement in prognosis in recent years, it remains severe, with an estimated risk of death of 15-20% and moderate to severe disability in survivors of 30%.

The management of severe perinatal asphyxia combines a large number of risks that have been identified as providing suboptimal care in a patient deemed to be vulnerable. Batlle showed in an obstetrical clinical audit, in the form of a peer review in France in 2010, that half the cases of per-partum asphyxia audited were considered "possibly or certainly avoidable". Similar results were found in studies in Denmark and Sweden. Chevallier et al in France showed that around 35% of newborns requiring hypothermia did not receive it in accordance with French recommendations. The aim of analyzing this sub-optimal care is to identify the systematic factors that led to the error, and to suggest solutions to avoid similar cases in the future.

Corrective action has been taken on the basis of these studies: "Every case of asphyxia could be used as an example for learning" is the title of an article proposing recommendations for obstetric clinical practice based on audits of perinatal asphyxia cases. In Queensland, the implementation of a national education program on fetal heart rate reading has led to a significant reduction in the incidence of AIS from 250 to 160 events/100,000 live births. In the UK, a pragmatic approach has been initiated to improve prognosis in the context of perinatal asphyxia. "Each Baby Count" https://www.rcog.org.uk/eachbabycounts, is a national platform recording every case of perinatal asphyxia and AIE, and collecting data on sub-optimal care. This work will help to improve the quality of care both locally and nationally.

These experiences suggest that the identification of sub-optimal obstetric and neonatal care through a voluntary approach by the centers can lead to improved prevention and management. In France, serious adverse events are analyzed during morbidity and mortality reviews, which remain internal to the facilities and have limited impact at national level. The aim of this study is to describe cases of death or HIE, to analyze the risk factors and to assess the optimality of care in both obstetrics and pediatrics.

Inclusion criteria

• Newborn at or near term (≥ 36 weeks of amenorrhea), considered to be alive at the onset of labor and presenting severe perinatal asphyxia

Severe perinatal asphyxia is considered if

• Severity in its impact on the newborn:

• a neonatal death during the initial hospitalization, since birth and before a possible return home, before D28 ".

OR

• moderate to severe anoxic-ischemic encephalopathy OR
• a newborn hospitalized in the first week of life for hypoxic-ischemic encephalopathy or convulsions related to a perpartum event.

AND

• Biological perinatal asphyxia:

• a pH (arterial or, failing that, venous) ≤ 7.10 or base deficit ≥ 16mmol/L or lactates ≥ 11mmol/L during the first three hours of life OR
• In the absence of biological documentation of metabolic acidosis, an Apgar ≤ 5 to 5 minutes of life or the need for neonatal resuscitation (ventilatory support at birth and Apgar score ≤ 7 to 10 minutes of life).
• If none of the biological elements are available in the file, keep the clinical inclusion criteria below (In the absence of biological and clinical Apgar data (home delivery type), inclusion may be based on neonatal outcome (death - hypoxic ischemic encephalopathy - neonatal convulsions).

Exclusion criteria

• Fetal death in utero prior to hospital admission
• Medical termination of pregnancy
• Severe malformations with potential impact on child survival and development.
• Neonatal encephalopathy not due to perinatal asphyxia