Introduction causes pathophysiology sign and symptoms diagnosis management nursing management of birth asphyxia

1. Prepared by
Bidya Thapa

2. Definition of Birth Asphyxia/
Asphyxia Neonatorum
Birth asphyxia is the medical condition
resulting from deprivation of oxygen to a
newborn infant that lasts long enough during the
birth process to cause physical harm, usually to
the brain.
In another word birth asphyxia is simply
defined as the failure to initiate and sustain
breathing at birth.
It’s literal meaning is:- Stopping of the
pulse.

3. According to the World Health
Organization birth asphyxia is defined as
“failure to initiate and sustain breathing at
birth”.

4. Classification of birth Asphyxia
Mild Birth
Asphyxia
Moderate Birth
Asphyxia
Severe Birth
Asphyxia
•Jittery or hyper alert
•Poor feeding
•Normal or fast
breathing
•Symptoms last for 24
to 48 hours and
resolving
spontaneously
• May be lethargic
•Feeding difficulty
•Occasional episode of
apnea and convulsions
• Baby may be floppy
or unconscious
•Not feed
•Frequent episodes of
apnea and convulsion
•Need urgent
treatment

5. Incidence of Birth Asphyxia
In Nigeria, study was done in the year 2012
total of 864 out of 26,000 neonates seen within
this period had birth asphyxia. 525(28/1000 live
births) had mild asphyxia while 32% were
severely asphyxiated. 61.5% of the asphyxiated
were born at maternities, churches or delivered
by traditional birth attendants or at home.
(Source:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
4776985/ )

6. • In Nepal (Dhulikhel Hospital) among the 3784
live births there were 102 babies with birth
asphyxia
(Source: Clinical Profile of Birth Asphyxia in
Dhulikhel Hospital: A Retrospective Study:
2009)

7. Etiology of birth asphyxia
Maternal factors:
A) Hypoxia
B) Anemia
C) Diabetes
D) Hypertension
E) Smoking
F) Nephritis
G) Heart diseases
H) Too young or too old

8. Placenta/umbilical cord:
A) Abruption of placenta
B) Placenta previa
C) Prolapsed cord
D) Premature rupture
of membrane
E) Fetomaternal
hemorrhage
F) Umbilical cord compression
G) Infection/ Inflammation

9. Fetal factors:
A) Multiple births
B) Congenital of malformed fetus
C) Severe cardio pulmonary disease

10. Pathophysiology of Birth Asphyxia
Source: nzrc.org.nz/assests/guidelines/other-
information/Guidelines-Physiology-of-Birth-
Asphyxiz.pdf

11. Heart rate is decreased as myocardium reverts to anaerobic metabolism
Causes fetus into Primary Apnea
Lack of oxygen leads to decline or stop function of neurons
Hypoxia leads to loss conciousness
Severe hypoxia in uterus
Causes/ Triggers

12. If no timely intervantion than death occurs
Ventilation, Oxygenation and compression is required
Causes cardiac function to impaired
Respiration is reversed; if not than baby will fall into Secondary Apnea
Lactic acid is released

13. Signs and symptoms of birth asphyxia
• Skin color that is bluish, gray, or pale
• Weak breathing / respiratory distress (or
failure to breathe)
• A slow heart rate or weak pulse
• Weak reflexes
• Poor muscle tone
• Acidosis (a dangerously high level of acid in
the blood)
• Seizures

14. Diagnosis of birth asphyxia
a) History taking:
- maternal anamnesis- perinatal risk factors;
- clinical factors of asphyxia, with primary
and secondary apnea, neurological cardiac
and renal perturbances, apgar score at 5 and
10 minutes.

15. b) Physical examination:
APGAR SCORE: The APGAR score is a simple
method of quickly assessing the health and vital
signs of a new born baby after delivery.
The scoring is done in a newborn baby at 1
minute and 5 minutes. The Apgar score is related to
the status of oxygenation of the fetus immediately
after birth.
Apgar score is tabulated as follows:

17. Total score: 10
a) No asphyxia: 7-10
b) Mild asphyxia: 4-6
c) Severe asphyxia: 0-3

19. Management of a Neonate with Birth
Asphyxia
In Mild case:
1. Allow the baby to begin breast feeding.
2. If the baby is receiving oxygen or otherwise
cannot be breastfeed, expressed breast milk
can be given.
3. Provide ongoing care

20. In Moderate to Severe case:
1. Treat breathing difficulty if present: Immediately
resuscitate the baby using a bag and mask if the
baby:
i. If not breathing at all, even when stimulated or
ii. Is gasping or
iii. Has a respiratory rate less than 20 breath per
minutes
2. Establish an IV line and give only IV fluid for the
first 12 hours and monitor the urine output

21. 3. Restrict the fluid volume to 60 ml per kg
body weight for the first day.
4. If convulsion present, treat for convulsion to
prevent worsening of the baby’s conditions
5. Allow the baby to breast feed, if the baby
become responsive. If not able to suck give
expressed breast milk.
6. Provide ongoing care to the baby:
i. Assess the baby every two hourly:
• If the baby’s temperature is less than 36.5
degree centigrade or more than 37.5 degree
centigrade, treat immediately.

22. • Treat for convulsion or breathing difficulty as
required
ii. Encourage the mother to hold and cuddle
the baby.
iii. If the baby is unconcious, lethargic or floppy,
handles and loves the baby gently to prevent
injury when the baby’s muscle tone is low.
Support the baby’s entire body specially the
head.
iv. If the baby’s condition is not improving after
three days, assess again for the signs of
sepsis

23. v. If the baby has not had convulsions for three
days after discontinuing Phenobarbital, the
mother is able to feed the baby, and there
are no other problems requiring
hospitalizations, discharge the baby.
vi. Follow up in 1 week, or earlier if the mother
notes serious problems like feeding
difficulties, convulsions.
vii. Help the mother find the best method of
feeding if the baby is feeding slowly, have the
mother feed frequently.

24. vii. Discuss that the baby’s may have breathing
problems in home and how to deal with this
at home.

25. Newborn Resuscitation
About 10% of newborns need some
assistance to initiate breathing at birth. Of
which, less than 1% require extensive
resuscitation measures to keep newborn alive.
The National Resuscitation Programme was
developed by American Academy of Pediatrics
(AAP) in conjunction with American Heart
Association(AHA) following the neonates
resusicatation can generally be identified by a
rapid assessment of following three
characteristics:

26. a) Term Gestation (yes/no)
b) Crying or breathing (yes/no)
c) Good muscle tone (yes/no)
If answer to all these questions is “yes”,
the baby does not need resuscitation. The
baby should be dried and placed in skin to
skin contact with the mother. APGAR scoring
should be done simultaneously. But if the
answer is “no”, the infant needs
resuscitation.

27. TABC of Resuscitation
• T- Maintainence of temperature through dry
the baby quickly, remove wet linen and place
the baby under radiant warmer
• A- Establish an open airway by position the
infant, suction mouth and nose (in few cases
trachea) and ET intuabtion, if needed to
ensure open airway.
• B- Initiate breathing through tactile
stimulation and positive pressure ventialtion
when necessary, using either bag and mask or
bag and ET tube

28. • C- Circulation by chest compression and
medications if needed
1. Preparation for newborn resuscitation
• Preparation of area or place for
resuscitation: the area should be near by
labour room, free from draft and fan, should
be warmed.
• Preparing of clean surface for resuscitation:
the surface should be flat, clean and dry and
covered with warm cloths

29. • Preparation of equipments: the following
equipments should be ready for resuscitation
of newborn
i. Suction equipment:
- Mucous extarctor or gauze
- Electrical or manual suction
- Suction catheter(10 fr or 12 fr)
- Feeding tube 6 fr and 20ml syringe

30. ii. Ventilation euipments:
- Newborn size self inflating bag with
reservoir(bag volume 250-400ml)
- Facemask; normal weight size 1 and small
newborn size 0
- oxygen with flow meter and tube
iii. Intubation Set:
- Laryngoscope with straight blades: No.
0(preterm) and 1(Term)
- Extra bulb and batteries for laryngoscope
- ET tube(2.5mm,3mm and 3.5mm)
- Stylet
- Scissors

31. iv. Medications:
-Epinephrine
- Naloxone
- Sodium Bicarbonate
- NS
- Sterile water
v. Miscellaneous:
- Watch, linen, shoulder roll, sthethoscope,
adesive tape, syringe(1,2 ,3, 5,10cc), gauze,
three way stopcocks and gloves

32. • Preparation of human resources: All births are
anticipated high risk so at least 2 persons with
skills of resuscitation should be ready at every
delivery.
2. Deciding if the newborn need resuscitation
• Thoroughly dry and stimulate the baby, rub
all over the body specially up and down the
back with warm and dry cloths. Flicking the
sole may be useful.
• Discard the wet cloth and wrap the baby
quickly with new warm dry cloths

33. • Look for breathing and crying.
• Decide if the baby need resuscitation or not.
3. Doing newborn resuscitation
If the baby is not breathing/ breathing less
than 30 breaths per minute or is gasping:
• Quickly clamp the cord, tie and cut the cord
leaving a stump 10 cm long
• Cover baby’s head with cloth or cap
• Maintain temperature: quickly dry and place
baby under radiant warmer
• Establish an open airway

34. Start resuscitation
Step of Resuscitation
1. Position the baby:
The baby should be positioned on back
with neck slightly extended with the rolled
cloth under the shoulder. Make sure
resuscitation is warm and well lit with
covering head and lower body.

35. picture

36. 2. Clear the airway:
• Wipe the baby’s mouth and nose with a clean
gauze or cloth or suction mouth then nose.
Suction only while pulling suction tube out.
Introduce suction tube upto 3cm in each
nostril. Do suction for less than 20 secs. If
thick meconium is present in amniotic fluid
than the mouth, oropharynx and hypopharynx
should be suctioned as soon as the head is
delivered.

37. • Quickly reassess the baby after positioning
the baby and airway clearance. If the baby is
breathing without difficulty, no further
resuscitation is needed. But if the baby has
difficulty in breathing or not breathing like:
- Gasping
- Breathing less than 30 breaths per minute
with or without or in- drawing of chest,
grunting, shallow irregular breathing.
• Give oxygen. If the baby has no spontaneous
breathing or still cyanosed, start ventilation
the baby by AMBU bag or other available bag
and mask.

38. 3. Ventilation with bag and mask
For bag and mask ventilation, use the baby
size mask to cover the baby’s mouth and nose.
To ventilate, hold the mask with one hand to
ensure an airtight seal using one or two
fingers of the same hand to hold the chin and
keep the head slightly extended . Squeeze the
bag with other hand using finger to only
control volume. Ventilate once or twice, watch
for chest rises. If the chest does not rise, check
the baby’s position, repositions the baby, the
mask and dry again until you get chest rise
with each breaths. If necessary, repeat
suctioning.

40. • Start by giving 100% Oxygen by connecting
oxygen cylinder to face mask
• Ventilate at a rate of 40 to 60 per minute,
leaving as much time for breathing out as for
breathing in.
• Allow the baby to breathe out. Check to see if
the chest and abdomen is moving with
ventilation and whether you can hear proper
breath sounds.
• Continue ventilation until the baby
spontaneously cries or breaths or heart rate
60-100.

41. • When the baby’s breathing is normal, stop
ventilation and continue to monitor the baby
closely.
• If spontaneous respiration with heart rate
more than 100/m, discontinue ventilation
gradually. Provide tactile stimulation and
monitor heart rate, respiration and colour.
• If heart rate is between 60-100, continue
ventilation.
• If heart rate is less than 60 per minute
ventilation and begin chest compressions
• If there is no breathing or gasping after 20
minutes stop ventilation the baby has died.

42. • In hospital setting, resuscitation bag should be
attached with the oxygen source(5-6litre) and
reservoir so as to deliver 90-100% oxygen.
• After the 30 secs of ventilation with 100%
oxygen, evaluate the heart rate and take a
follow up action.
• If the heart rate is less than 60 per minute,
continue ventilation and begin chest
compression.
• If there is no breathing or gasping after 20
minutes stop ventilation the baby has died.

43. 4. Chest compression
Chest compression are provided by using
either thumb technique or two figure technique.
• Thumb technique : put the thumbs on the
lower third of the sternum (above the xiphoid
and below an imagery line between the
nipples). Encircle your finger around the baby
to its back.
• Finger technique: put your 2nd and middle
fingers on the lower third of the sternum
(same as above).

45. I. During chest compression, pressure is
applied to lower third of sternum, depressing
it ½ to ¾ inch.
II. Ventilate for the baby after 3 chest
compression.
III. Do not do chest compression and ventilation
at the same time.
IV. About 90 compression should be given in 1
minute. 1 ventilation should be given after 3
chest compression (1:3).

46. V. In 1 minutes 30 ventilation and 90
compression are given.
VI. Re check respiration and heart rate: if heart
rate <60 /m. Again repeat the cycle of
ventilation and respiration and compression .
VII.Recheck: if the heart rate >60, stop
compression continue ventilation.

47. VIII.If heart rate >100 /m and baby is breathing
on his own, stop ventilation, support the
baby with warmth, oxygen and stimulation
until pink and active.
IX. Stop ventilation and chest compression after
20 minutes if no response.
Note:-After ventilation and chest
compression, if heart rate is <60 b/m,
administer the medicines.

48. Care after Resuscitation
Care and support after resuscitation include:
1. Successful resuscitation situation
• Counsel / advice mother and family: teach
mother to check breathing, warmth and
contact health personnel’s if any.
• Encourage for breast feeding as soon as
possible to help give newborn more energy.

49. • Explain mother and family about danger signs
and seek help if needed.
• Check newborn hourly for at least 6 hours for.
 Breathing problems (<30 or 60), chest in-drawing
 Temperature, color , grunting, gasping
• Give normal care to baby
• Maintain record about resuscitation such as
steps, APGAR score, care after resuscitation.
• Do follow up: ask the mother to bring baby for
a follow up visit on day 2 or 3rd .

50. 2. Need referral situation
I. Counsel/ advice
 Mother, family about the resuscitation and
baby’s condition
 About care needed by baby
 Refer baby to higher and well facilitated hospital
 Encourage for breast feeding is baby can suck
 Keep baby warm during referral time and
throughout the way
 Maintain baby’s temperature by KMC is possible

51. II. Give care:
 Keep resuscitation continue/ stimulate the baby
 Continue to monitor breathing and color
 Keep baby warm
 Continue oxygen during transport if possible
 Arrange for referral
 Prepare record for referral as per hospital’s
protocol
 Follow up visit

52. 3. Condition of unsuccessful resuscitation
situation
If the baby is not breathing after 20 minutes of
active resuscitation , stop resuscitation and
declared the baby’s medical condition i.e. Baby
has died. The mother and family need support
and care which includes:

53. I. Counsel/ Advice
 Mother and family about resuscitation
 Care of dead body
 Answer queries they have in a clear manner
 Find what they wish to do with the baby’s body
 Talk family about needs and care of mothers

54. II. Ask the mother to return for postpartum visit
within 3 weeks.
III. Do all the necessary recording and notification
for a baby’s birth, death and other medical
record .
IV. Cleaning equipment and supplies and replace
in an appropriate place.

55. Nursing Management
Assessment for Birth Asphyxia
1)Physical Examination
• Respiratory System
– Low APGAR scores
– Breathing shallow, irregular, tachypnea
– Snoring, breathing nostrils, retracted suplasternal
/ substernal, cyanosis
– Baby does not breathe / breath over 30

56. • Cardiovascular System
–Optimal pulse, rapid or irregular may be
within the normal range (120-160 x / min)
–Heart rate more than 100
• Integument System
–Presence of cyanosis / pallor - indication of
gravity hypoxia
–Pitting edema of the hands and feet

57. • Digestive System
–Weak reflexes
–Lethargy
–Small stomach capacity
• Musculoskeletal System
–Decreased muscle tone
–Edema, weak reflexes, there are no lines on
the soles of the feet most / all of the palm.

58. Nursing Diagnosis
1) Ineffective Breathing Pattern related to
immaturity of the respiratory organs
2) Risk of hypothermia related to systems that
have not been mature thermoregulation
3) Imbalanced Nutrition, Less Than
Body Requirements related to weak sucking
reflex

59. Nursing Interventions
1. Improving Gas Exchange by:
• Assessing the breathing pattern of Newton.
• Positioning the baby.
• Removing thick mucus play by soft and clean
gauze piece/suctioning.
• Observing conditions carefully for change in
respiration, color.
• Providing oxygen through head box with close
observation.

60. 2. Maintaining Body Temperature by:
• Maintaining room temperature.
• Wearing the clean cap and clothes
immediately after giving morning care.
• Keeping the baby on radiant warmer with
maintaining temperature.
• Keeping fan off and controlling air drafts.
• Removing all wet clothes immediately after
urination.

61. 3. Maintaining Nutrition by:
• Assessing the sign of hypoglycaemia.
• Initiating the breast-feeding as soon as
possible.
• Maintaining IV fluid in correct order.
• Guiding the mother about proper breast-
feeding.
• Burping technique must be taught.

62. 4. Preventing Aspiration by:
• Assessing the sucking pattern of the baby.
• Keeping the baby in lateral position after
feeding.
• Guiding the mother about proper feeding
technique.
• Giving the baby to the mother for sucking with
observation.

63. 5. Reducing Infection by:
• Assessing the general condition of the baby.
• Performing hand washing before and after
touching the baby.
• Providing all morning care as well as eye and
cord care.
• Controlling visitors.
• Minimizing invasive procedure.
• Monitoring signs of infection.
• Encouraging the mother for Exclusive Breast
Feeding.

64. 6. Reducing Anxiety by:
• Discussing about disease condition and its
causes.
• Informing about the cause of treatment.
• Encouraging to express her feelings.
• Assisting the mother to hold the baby
effectively.
• Giving the opportunity to parent to see the
baby more time.
• Explaining the detail about the procedure
before performing it.
• Encouraging the mother for breast-feeding
with taking more time.

65. Complication
a) Cardiovascular : Hypotension , cardiac failure
b) Renal: Acute cortical necrosis, renal failure
d) Liver function : Compromised
e) Gastrointestinal : Ulcer and necrotising
enterocolitis.
f) Lungs: Persistent pulmonary hypertension .
g) Brain : Cerebral edema , seizure

66. Delayed Compliance
• Retarded mental and physical growth
• Epilepsy up to 30% of severe asphyxia
• Minimal brain dysfunction

68. Reference
1. I.M. Balfour-lynn, H.B. Valman, Practical
Management of the Newborn, Fifth Edition,
Blackwell Scientific Publications
2. Diana Beck, frances ganges, Susan Goldman,
Phyllis Long, Saving Newborn Lives, Care of the
Newborn reference manual,published in
2004,KINETIK
3. Topic: Managing Birth Asphyxia:Helping Baby
Breathe: 2016
https://journals.lww.com/mcnjournal/Citation/2
016/01000/Managing_Birth_Asphyxia__Helping
_Babies_Breathe.13.aspx
4. Roshani Tuitui, Manual of Midwifery III, Edition,
Vidharthy Pustak Bhandar

69. 5. Kamala Uprety, Essential of Child Health
Nursing, First Edition(2018), Akshav
Publication