not-yet-known not-yet-known not-yet-known unknown Objective To assess the prevalence of adverse perinatal outcomes - and evaluate the association between intrapartum-related neonatal encephalopathy (IP-NE) and i) emergency referrals and ii) emergency cesarean sections (CS) by obstetric risk factors. Design Cross-sectional with a nested case-control study. Setting Two hospitals in rural Eastern Uganda. Population Women giving birth to a live or stillborn baby weighing >2000 grams between June and December 2022. Methods We used prospectively collected perinatal e-registry data to assess the prevalence of adverse perinatal outcomes. Logistic regression with interaction was used to assess the association between IP-NE and emergency referral and emergency CS across risk groups of hypertensive disorders, antepartum hemorrhage, prolonged/ obstructed labor, and birth weight. Main outcome measures Adverse perinatal outcomes were stillbirths, 24-hour neonatal deaths, and IP-NE (defined as Apgar score <7 at 5 minutes, cord blood lactate ≥5.5 mmol/L, and Thompson score ≥5). Results Of 6,550 births, 10.2% had an adverse perinatal outcome: 3.8% stillbirths, 0.6% neonatal deaths, and 5.7% IP-NE. Adverse outcomes were high among neonates whose mothers had antepartum hemorrhage (31.3%) and prolonged or obstructed labor (27.2%). Emergency referral and CS did not change the association between IP-NE and obstetric risks, except in prolonged or obstructed labor. Without emergency CS, the predicted probability of IP-NE was 0.73 (95% CI: 0.51–0.95); with CS, it decreased to 0.45 (95% CI: 0.39–0.50). Conclusions Neonates born to mothers with obstetric emergencies had low healthy survival rates. Emergency referral and CS showed limited benefits in reducing IP-NE, indicating challenges in accessing appropriate care.