3. Definition
WHO: Asphyxia is incapacity of newborn
to begin or to support of spontaneous
respiration after delivery due to breaching
of oxygenation during labor and delivery
India: Asphyxia is absent or ineffective
respiration of newborn of 1 minute old with
Apgar score less than 4
4. Definition
Great Britain: Asphyxia is critical
insufficiency of oxygen in fetus during
delivery so severe that leads to
development of metabolic acidosis and
depression of spontaneous respiration
5. Definition
Canada: Asphyxia is breach of gas
exchange when hypoxia and hypercapnia,
and considerable metabolic acidosis occur
6. Definition
Australia: Asphyxia is a state with
mother has complications in perinatal
period that decrease provision with oxygen
and leads to acidosis
functional violation minimum 2 organs due
to acts of acute hypoxia
7. Definition
Ukraine: Asphyxia of newborn as a
nosological form is conditioned by causes
when fetus out and find (connect) with
severe maternal-placental and (or)
umbilical flow leads to increasing of
oxygen approach to fetus tissue and
hypoxia development
9. Asphyxia
Asphyxia: means to be pulse less, but more
useful is a definition of impaired or interrupted
gas exchange.
These situations can take place:
a. Intrauterine: the gas exchange depends on
the function of placenta, and the blood-flow in
the umbilical vessels.
b. Intrapartum
c. Postnatal: after delivery the gas exchange
takes place in the pulmonary vesicles or alveoli
and depends on the function of the heart, lungs
and brain.
10. Causes of Asphyxia
Fetal hypoxia:
Mother: hypoventilation during anesthesia, cyanotic heart disease,
respiratory failure or carbon monoxide poisoning.
Low maternal blood pressure as a result of the hypotension that may
compression of the vena cava & aorta by the gravid uterus
Inadequate relaxation of the uterus to permit placental filling as a
result of uterine tetany caused by excessive administration of
oxytocin
Premature separation of the placenta; placenta previa
Impedance to the circulation of blood through the umbilical cord as a
result of compression or knotting of the cord
Uterine vessel vasoconstriction by cocaine, smoking
Placental insufficiency from numerous causes, including gestosis,
eclampcia, toxemia, postmaturity
Extremes in maternal age (< 20 years or >35 years)
Preterm or postterm gestation.
11. Causes of Asphyxia
Intrapartus asphyxia:
More frequently inadequate obstetric aid
Using focerps, vacuum extraction, cresteller,
cesaring cection
Trauma: narrow pelvis, presentation
Extremely rapid or prolonged labor
Multiple gestation
Drags depression of CNS: anaesthesia, sedatics
& analgetics
Meconium –stained amniotic fluid
12. Causes of Asphyxia
Postnatal hypoxia:
Anemia severe enough to lower the oxygen content of
the blood to a critical level due to severe hemorrhage or
hemolytic disease
Shock severe enough to interfere with the transport of
oxygen to vital cells from adrenal hemorrhage,
intraventricular hemorrhage severe enough to age,
overwhelming infection or massive blood loss
A deficit in arterial oxygen saturation resulting from
failure to breathe adequately postnatally due to a
cerebral defect, narcosis, or injury
Failure of oxygenation of an adequate amount of blood
resulting from of cyanotic congenital heart disease of
deficient pulmonary function
22. Apgar Score of the Newborn
SIGNSCORE 0 1 2
Heart rate Absent <100 beats/min >100
Respiratory
effort Absent Weak,irregular Strong cry
Muscle tone Flaccid Some flexion Well
Reflex irritability (response to catheter in nostril)
No Grimace Cough or sneeze
Skin colour Blue, pale extremities blue pink
23. CRITERIAS OF SEVERE
ASPHYXIA:
°Severe metabolic or mix acidosis pH ≤
7.00 in arterial blood of umbilical vessels
°Assessment by Apgar is 0-3 during more
than 5 minutes
° Neurological symptoms such as general
hypotonic, lethargy, coma, seizures
°Damage of vital organs (lungs, heart and
other) in fetus or newborn
31. DIAGNOSIS
Clinical symptoms
Metabolic derangement
Renal and/or cardiac failure
Assessment of the brain:
a.. EEG EEG is useful particulary in the asphyxiated term
newborn.
Serial recordings are almost necessary.
Low voltage. Burst-suppression patterns or electrical inactivity are
associated with bad prognosis.
Rapid resolution of EEG abnormalities and/or normal interictal EEG
are associated with a good prognosis.
b. Ultras onography: Ultrasound can be useful in premature
newboms
but is of more limited value in the term newborn.
c. Computed tomography: CT is of major value both acutely
during the
neonatal period and later in childhood. The optimal timing of CT
scanning is
between 2 and 4 days.
32. DIAGNOSIS
I. Intrauterine assessment
A. Ultrasound and Doppler technique:
Ultrasound: to measure the growth of the fetus. For this reason it is important have
a reliable gestational age. Early during pregnancy an ultrasound will be done to
date the fetus. This method safer than common clinical methods. The growth
retarded fetus is in a great risk of developing asphyxia.
Doppler techniques: to measure the blood flow in the umbilical vessels or aorta. A
low flow or decreasing flow indicates a fetus in risk of asphyxia.
B.Electrofysiological:
Severe pathological fetus heart rate will lead to cessation of the delivery with
Caesarean section.
Fetal heart rate: Episodes of bradycardia can be dangerous and lead to brain
damage. The problem is to do this type of measurement during long periods and on
every pregnant woman.
II. Extrauterine assessment
C. Biochemical
- C blood sample drawn from the umbilical artery is an ideal way to evaluate
whether an intrapartum asphyxia exist or not. Low pH (< 7, 00) indicates the
intrapartum asphyxia.
PC02 and P02 will also be deranged as you have a diminished gas exchange. The
low pH is the result of an increased level of H+ and lactate.
35. ABC resuscitation
A- Airways (maintenance of passable ness
of airway)
B- breathing (stimulation of breathing)
C- circulation (to support of circulation)
D-drug
36. ABC resuscitation
Step A- immediately after delivery the
infant’s head should be placed in a neutral
or slightly extended position
Rolled towel under the shoulders
37. Step A- immediately after delivery the infant’s head
should be placed in a neutral or slightly extended
position
39. If meconium is present in amniotic fluid, after sucking of
mouth and nose we must suck a pharynx by tube after
laryngoscopes
40. If it is inadequate we must use step B.
At first the tactile stimulation should be given to newborn, for
example- gentle flicking of the feet or heel
42. If these measures are inadequate, mechanical ventilation
should be initiated, using mask and bag ventilation
43. If ventilation is adequate supplemental oxygen may be
given to improve heart rate or skin colour
44. If mechanical ventilation does not improve the respiration, heart
rate or colour skin, the following step is “C”-circulation. At first the
assessment of heart rate is necessary
45. If heart rate is less than 60 beats/minute, or between 60 and 80
beats and is not improving, cardiac compression is a lower on/third
of sternum
Chest compressions with two fingers
46. ABC resuscitation
Your big fingers must be lie on the sternum, other finder
should lie under the back of newborn
47. ABC resuscitation
If heart rate is less then 80 beats per minute the cardiac
compression should be continued. If heart rate is 80 beats per
minute or more the cardiac compression should be stop .
48. Brain death
The clinical diagnosis of brain death is made on the basis
of
- coma manifested by lack of response to pain, light, or
auditory stimulation;
- apnea confirmed by documentation of failure to breathe
when pCO2 is greater then 60 mm Hg tested by 3
minutes;
- absent bulbar movements and brainstem reflexes
(including midposition or fully dilated pupils with no
response to light or pain and with absent oculocephalic,
caloric, corneal, gag, cough, rooting and sucking
reflexes, flaccid tone and absence of spontaneous or
induced movements (excluding activity mediated at the
spinal cord level)
50. PROGNOSIS.
Prognosis is difficult because of the inability to
establish the precise extent and duration of
cerebral insult and injury. At the time of delivery
low delayed Apgar scores between 0 and 3 at
10, 15 and 20 minutes' of age are associated
with significantly increased mortality and
morbidity, e.g. cerebral palsy. The single most
useful prognostic factor is the severity of the
neonatal neurological syndrome.
51. HI brain injure is the most impotent consequence of
perinatan Asphyxia
Leads to increase lactate, fall in pH, ↓ATP, ↑
glucose utilization, loss of cerebrovascular
autoregulation
Impairs ion pumps with accumulation Na,Cl,H2O,
Ca intracellularly
↑ amino acid neurotransmitters (glutamate,
aspartate)
Generation of free radicals & leukotriens wich
they overwhelm endogeneous scavenger
mechanism
Damage nucleic acids, lipids & proteins
58. Birth trauma
The term “Birth trauma” is used to denote
mechanical and anoxic trauma incurred by
the infant during labor and delivery.
59. Birth trauma
The incidence of B.T. has been estimated
at 2 – 7 per 1000 live births. Overall 5 - 8
per 100000 infants die of B.T. and 25 per
100000 die of anoxic injuries.
Some injuries may be latent initially but
later result in severe illness or squealed
61. Birth trauma
When fetal size, presentation, or
neurological immaturity complicate
this event, such intrapartum forces
may lead to tissue damage, edema,
hemorrhage or fracture in the
neonate.
62. Birth trauma
The use of obstetrical instruments may
further amplify the effect of such forces or
may induce injury by itself.
Although breech presentation carries
the greatest risk of injury, delivery by
cesarean section does not guaranteed an
injury – free infant.
63. The risk of birth injury
Primiparity
Small maternal stature
Maternal pelvic anomalies
Extremely rapid
Prolonged labor
Deep transverse arrest of descent of presenting
part of fetus
Oligohydramnions
Abnormal presentation (i.e. breech)
64. The risk of birth injury
Use of mid-forceps or vacuum extraction
Cesarean section
Versions and extraction
Very low birth weight infant or extreme
premature
Postmature infant (> 42 week of gestation)
Fetal macrosomia
Large fetal head
Fetal anomalies (see teratoma)
66. Classification of birth injuries
I. Soft-tissue injuries
- caput succedaneum
- subcutaneous and retinal hemorrhage,
petechia
- ecchymoses and subcutaneous fat
necrosis
67. Classification of birth injuries
II. Cranial injuries
cephalohematoma
fractures of the skull
68. Classification of birth injuries
III. Intracranial hemorrhage
subdural hemorrhage
subarachnoid hemorrhage
intra- and peryventricular
hemorrhage
parenchyma hemorrhage
69. Classification of birth injuries
IV. Spine and spinal cord
fractures of vertebra
Erb-Duchenne paralysis
Klumpke paralyses
Phrenic nerve paralyses
Facial nerves palsy
70. Classification of birth injuries
V. Peripheral nerve injuries
VI. Viscera (rupture of liver, spleen
and adrenal hemorrhage)
VII. Fractures of bones.
72. Birth trauma
Petechiae and ecchymosis are common
manifestation of birth trauma in the newborn. If
the etiology is uncertain, studies to rule out
coagulation disorders or infections etiology are
indicated. This lesions resolve spontaneously
within 1 week. Petechiae of the skin of the heard
and neck are common. All are probably
secondary to a sudden increase in intrathoracic
pressure during passage of the chest through
the birth canal. Parents should be assured that
they are temporary and result of normal hazards
of delivery.
73. Birth trauma
Subcutaneous fat necrosis. Although
not detectable et birth this irregularly
shaped, hard no pitting, subcutaneous
plagues with overlying dusky, red – purple
discoloration may by caused by pressure
during delivery. They appear during the
first 2 weeks of life usually in large babies
on the cheeks, arms, back, buttocks end
thinks.
74. Birth trauma
Caput succedaneum is a subcutaneous
extraperiosteal fluid collection with poorly
defined margins it may extend across the
midline over suture lines end is usually
associated with heat molding the soft
tissue edema will usually resolve over the
few days post partum.
75. Birth trauma
Cephalohematoma is a subperiosteal collection of
blood secondary to rupture of the blood vessels between
the scull and pereostium, its extent will be delineated by
suture lines over days. The extent of hemorrhage may
be severe enough to present as anemia and hypotension
with secondary hyperbilirubinemia. It may be a focus of
infection leading to meningitis, particularly when there is
a concominant skull fracture. Skull X-rays should be
obtained if there are CNS symptoms, if the hematoma is
very large or if the delivery was very difficult. Resolution
occurs over 1 to 2 month, occasionally with residual
calcification as a thrombus.
76. Birth trauma
INTRACRANIAL HEMORRHAGE occur in 20% to more
than 40% of infants with birth weight under 1500 gm but
is less common among more mature infants.
Intracranial hemorrhage may occur in the subdural,
subarachnoid, intraventricular or intracerebral regions.
Subdural and subarachnoid hemorrhage follow head
trauma e.g., in breech, difficult and prolonged labor and
after forceps delivery. Other forms of intracranial
bleeding are associated with immaturity and hypoxia.
With better obstetric care intracranial bleeding has
become rare.
77. Predisposing factors of IVH
premature
respiratory distress syndrome
hypoxic ischemic or hypotensive injuries
reperfusion of damaged vessels
increased venous pressure
pneumothorax
hypervolemia, hypertensia
78. The etiologic factors with IVH in low-
birth-weight infants (Intravascular inflow
factors)
impaired autoregulation
seizers
manipulation with infant
infusion of hyperosmotic solutions
rapid colloid infusion
apnea
presents of patent ductus arteriosus
hypertension and use of ECMO
79. The etiologic factors with IVH in low-
birth-weight infants (Intravascular
outflow factors)
respiratory distress
pneumothorax
congestive heart failure
continuous positive airway pressure
labor/delivery
acute angle of the internal cerebral vein
80. The etiologic factors with IVH in low-birth-
weight infants (Vascular and extra vascular
structural factors)
normal regression of germinal matrix
relatively large blood flow to deep cerebral
structures
hypoxic-ischemic injury to germinal matrix or its
vessels
present of fibrinolitic enzymes
poor structural support of germinal matrix
vessels
abrupt termination of media in arteries proximal
to germinal matrix
81. Clinical manifestation IVH
Absent Moro reflex
Poor muscle tone
Lethargy
excessive somnolence
Pallor or cyanosis
Respiratory distress
DIC
Jaundice
83. Laboratory correlates of blood loss
Metabolic acidosis
Low hematocrit
Hypoxemia, hypercarbia
Respiratory acidosis
Thrombocytopenia and prolongation of
protrombin time (PT) and partial
thromboplastin time (PTT)
85. Outcomes and prognosis
Patients with massive bleeding have a
poor prognosis. About 10-15% infants may
develop post hemorrhagic hydrocephalus
and chronic neurological pathology
86. Spinal cord
Strong traction exerted when the spine is
hyper extended or when the direction of
pull is lateral, or forceful longitudinal
traction on the trunk while the head is still
firmly, engaged in the pelvic, especially
when combined with flections and torsion
of vertical axis, may produce fracture and
separation of the vertebra. Tran section of
the cord may occurs with or without
vertebral fractures
87. Clinical data
Areflexia
Loss of sensation
Complete paralysis of voluntary motion
below the level of injury
Epidural hemorrhage
Apnea
88. Delivery room
If cord injury is suspected, effort in the
delivery room should immediately focus on
resuscitation and prevention of further
insult.
The head should be made immobile
relative to the spine and secured on a flat,
firm surface with padding of pressure
points.
89. Duchenne-Erb paralysis
Injury to the 5th and 6th cervical nerves
Affected arm is adducted, internally
rotated
Forearm is in pronation
Wrist is flexed
Arm falls limply to the side of the body
when passively adducted
Moro, biceps and radial reflexes absent
91. Klumpke’s paralysis
injury to the 7th and 8th cervical and 1st thoracic
spinal nerves
Horner syndrom (ipsilateral ptosis and miosis) if
the thoraxic spinal nerve is involved
Absent of movements of the wrist
92. Phrenic nerve palsy
Injury to the C3,C4 or C5
Brachial plexur injury
RDS
Paradox (upward) movement during
inspiration
94. Long bone injures
Loss of spontaneous arm or leg movement
is usually the first sing of humeral or
femoral injury, following by swelling and
pain on passive motion
97. HIE
Selective necrosis of the neurons of the
deeper cerebral cortical layers is the
hallmark of hypoxic injury to the perinatal
brain in full-term babies, parasagittal
cerebral injury occurs as a result of the
generalized reduction in the cerebral blood
flow. In preterm babies, the areas of
infarction involve the deeper
periventricular white matter. Neuronal
necrosis may also entail basal ganglia.
98. HIE
Some of the ischemic infants with
encephalopathy gradually improve while
others deteriorate. If not treated promptly,
20 to 30 percent of infants with severe
ischemia die.
107. Sarnat
Outcome
Mild: About 100% normal
Moderate: 80% normal; abnormal if
symptoms more than 5 to 7 days
Severe: About 50% die; remainder with
severe sequel
109. Diagnosis.
A thorough neurological examination
combined with a careful history is helpful
for the diagnosis. Ultrasound examination
of the brain, EEG, intracranial pressure
measurement and computed scanning arc
is valuable.
112. Treatment.
Prevention of asphyxia remains the most important mode of
treatment. Careful monitoring of the fetus during labor and prompt
appropriate intervention at the earliest signs of fetal compromise is
important in preventing perinatal asphyxia.
The rapid responders from anoxia need observation in the nursery
for only 12 to 24 hours. These babies become active, and start
accepting feeds within a few hours. The slow responders need more
aggressive management. Both: hypoxemia and hyperoxemia as well
as hypercapnia should be circumvented, since they affect cerebral
blood flow. These babies should be kept in ward, with a minimal
noise level or in the nursery. Intravenous fluids should be restricted
to two-third of the maintenance requirements and blood glucose
levels must be maintained at 75-100 mg/dL. Acidosis,
hypocalcaemia and hypoglycemia need correction. Seizures should
be controlled with phenobarbitone but not in preterm babies who are
severely disturbed and in those with decerebration.
113. Treatment
curative and protective regimen in newborn
Children with severe A or BT should be undergo
strict regimen because the rest more frequently
associated with emergency position if baby
The infant must lie on the hard surface with
fixated neck by collar
The baby is observed in bed or incubator, is not
washed and sometimes is turned side to side.
The transport of this infant prohibitive.
Oxygen (ingalation or mask or apparatus )
Feeding throught catheter 40-50% daily calories
114. Treatment
curative and protective regimen in newborn
Baby with subcompensation of all function
must be undergo spareing regimen.
May be washed (in bad)
Feeding through catheter and spoon. If he
can suck he may be apply to mother brest
Common (general) regimen is
administrated for healthy child or
reconvalescents