neonatal resuscitation

1. Birth asphyxia

2. Specific learning
objectives
Definition
Causes
Classification
Complications
Diagnosis
Areas of growth
Timeline
Summary
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3. Definition
WHO: Asphyxia is incapacity of newborn to begin or to support
spontaneous respiration after delivery due to breaching of oxygenation
during labor and delivery Asphyxia is absense or ineffective respiration of
newborn of 1 minute old with Apgar score less than 4
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5. Apgar score
•Scores of 0-3 are considered critical, especially in babies born at or near
term
•Scores of 4-6 are considered below normal and indicate that the
medical intervention is likely required
•Scores of 7+ are considered normal
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8. Causes

9. Fetal hypoxia
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• 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 cause compression
of the vena cava & aorta by the gravid uterus
• 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.

10. Intrapartum asphyxia
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• More frequently inadequate obstetric aid
• Using forceps, vacuum extraction, caesarean section (immediate)
• Trauma: narrow pelvis, malpresentation
• Extremely rapid or prolonged labor
• Multiple gestation
• Drugs depression of CNS: anesthesia, sedatives & analgesics
• Meconium-stained amniotic fluid.

11. Postnatal hypoxia
• Anemia due to severe hemorrhage or hemolytic disease
• Shock from adrenal hemorrhage, intraventricular hemorrhage, overwhelming infection,
massive blood loss
• Failure to breathe due to a cerebral defect, narcosis or injury
• Failure of oxygenation resulting from of cyanotic congenital heart disease or deficient
pulmonary function
• Multiple gestation;
• Placental abruption; • Placenta previa; • Preeclampsia; • Meconium-stained amniotic
fluid; • Fetal bradycardia;
• Prolonged rupture of fetal membranes;
• Maternal diabetes;
• Maternal use of illicit drugs;
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12. Classification
• Mild
• Moderate
• severe
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13. MILD ASPHYXIA
• The infant who experiences mild asphyxia initially will be
depressed. This is followed by a period of hyperalertness,
which resolves within 1 or 2 days.
• Clinical symptoms: hyperalertness (jitteriness), increased
irritability and tendon reflexes, exaggerated Moro response;
There are no local signs
• The prognosis is excellent for normal (good) outcome.
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14. MODERATE ASPHYXIA
• The infant who experiences moderate asphyxia will be very
depressed. This is followed by a prolonged period of
hyperalertness and hyperreflexia.
• Clinical symptoms: • lethargy, hypotonia • suppressed
reflexes with or without seizures • Generalised seizures
often occur 12 to 24 hours after episode of asphyxia, but
are controlled easily, resolving in a few days regarding of
therapy.
• The prognosis is variable (20-40% with abnormal outcome).
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15. 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 hypotonia, lethargy, coma,
seizures, brainstem, autonomous dysfunction;
• Evidence of multiorgan system dysfunction in the immediate neonatal
period - damage of vital organs (lungs, heart and others) in fetus or
newborn;
• Severe asphyxia is associated with coma, intractable seizures activity,
cerebral oedema, intracranial haemorrhage.
• The infant often became progressively more depressed over the first 1
to 3 days, as a cerebral oedema develops, and death may occur during
this period.
• Survival is usually associated with poor long-term outcome (100% with
abnormal outcome);
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16. Acute complications
• Hypoxic-ischemic encephalopathy (HIE)
• Hypotension
• Seizures
• Persistent pulmonary hypertension
• Hypoxic cardiomyopathy
• Necrotizing enterocolitis
• Acute tubular necrosis
• Adrenal hemorrhage and necrosis
• Hypoglycemia, polycythemia
• Disseminated intravascular coagulation
Sarnat criteria • Pupils • Respirations • Heart rate • Bronchial & salivary
secretions • Gastrointestinal motility • Seizures • EEG • Duration of symptoms
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17. Hypoxic-ischemic cerebral injury –
HIE (encephalopathy
• Is caused by a combination of hypoxemia, ischemia, that
results in a decreased supply of oxygen to cerebral tissue
• During perinatal asphyxia, birth trauma, hypercapnia and
acidosis may contribute further to the cerebral insult.
• Level of consciousness • Neuromuscular control • Muscle
tone • Posture • Stretch reflexes • Segmental myoclonus •
Complex reflexes: Suck, Moro, oculovestibular tonic neck •
Autonomic function
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19. Diagnosis
• Clinical symptoms and metabolic derangement – blood sample from the umbilical
artery - low pH (< 7, 00) - indicates the intrapartum asphyxia.
• Renal and/or cardiac failure
• Assessment of the brain: EEG Serial recordings are almost necessary. Low
voltage. Burst-suppression patterns or electrical inactivity are associated with bad
prognosis. Rapid resolutionof EEG abnormalities and/or normal interictal EEG are
associated with a good prognosis.
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20. • Ultrasound: to measure the growth of the fetus. The growth retarded fetus is in a
great risk of developing asphyxia. Ultrasound can be useful in premature
newborns.
• 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.
• 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.
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21. ABC resuscitation
• A- Airways (maintenance of passableness of airway)
• B- breathing (stimulation of breathing)
• C- circulation (support of circulation)
Step A- immediately after delivery the infant’s head should be
placed in a neutral or slightly extended position • Roller towel
under the shoulders
And airway established by clearing the mouth, then the
nose by rubber bag.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 or rubbing of the
back
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23. • If these measures are inadequate, mechanical ventilation should
be initiated, using mask and bag ventilation
• If ventilation is adequate supplemental oxygen may be given to
improve heart rate or skin colour
• If mechanical ventilation does not improve the respiration, heart
rate or colour skin, the following step is “C”-circulation. At first
rate is necessary
• If heart rate is less than 60 beats/minute, or between 60 and 80
beats and is not improving, cardiac compression must be
lie on the sternum, other fingers should lie under the back of
• If heart rate is less then 80 beats per minute the cardiac
continued. • If heart rate is 80 beats per minute or more the
be stopped .
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24. Birth trauma
• The term “Birth trauma” is used to denote mechanical and
by the infant during labor and delivery. • The process of birth
compressions, contractions, and tractions.
• When fetal size, presentation or neurological immaturity
such intrapartum forces may lead to • tissue damage, •
fracture in the neonate.
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25. • The risk of birth injury
• Small maternal stature
• Maternal pelvic anomalies
• Extremely rapid • Prolonged labor •
Using forceps, vacuum extraction • Versions and extraction •
descent of presenting part of fetus
• Oligohydramnions
• Abnormal presentation (i.e. breech)
• Very low birth weight infant or extreme premature • Postmature
gestation)
• Cesarean section • Fetal macrosomia • Large fetal head • Fetal
teratoma)
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26. Classification of birth injuries
I. Soft-tissue injuries • - caput succedaneum • - subcutaneous
and retinal hemorrhage, petechia • - ecchymoses and
subcutaneous fat necrosis
II. Cranial injuries • cephalohematoma • fractures of the skull
III. Intracranial hemorrhage • subdural hemorrhage •
subarachnoid hemorrhage • intra- and periventricular hemorrhage
• parenchyma hemorrhage
IV. Spine and spinal cord • fractures of vertebra • Erb-Duchenne
paralysis • Klumpke paralyses • Phrenic nerve paralyses • Facial
nerves palsy
V. Peripheral nerve injuries • VI. Viscera (rupture of liver, spleen
and adrenal hemorrhage) • VII. Fractures of bones.
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27. • Petechiae and ecchymosis are common manifestation of birth trauma in the
newborn. Petechiae of the skin of the head and neck are common. These lesions
resolve spontaneously within 1 week.
• They are caused by a sudden increase in intrathoracic pressure during labor
when the fetus passes through the birth canal.
• They are temporary and are the result of normal course of delivery.
• If the etiology is uncertain, studies to rule out coagulation disorders or infections
etiology are indicated.
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28. • Caput succedaneum is a subcutaneous extraperiosteal fluid collection in the
presenting part of fetus
• It is caused by infiltration of subcutaneous soft tissue in the presenting part
resulting from pressure in birth canal • with poorly defined margins
• It may extend across the midline over suture lines
• This swelling is resolved rather quickly within several days post partum.
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29. • Cephalohematoma • is a subperiosteal collection of blood
resulting from rupture of the blood vessels between the
• it does not extend over suture lines between adjacent
commonly on one side of the head
• The extent of hemorrhage may be severe enough to present
hypotension with secondary hyperbilirubinemia.
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30. • It may be a focus of infection leading to
meningitis, particularly when there is a concomitant skull
fracture. Skull X-rays should be obtained if there are CNS
hematoma is very large or if the delivery was very difficult. •
over 1 to 2 month, occasionally with residual calcification as
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31. • INTRACRANIAL HEMORRHAGE • Occurs in 20% to more than 40% of infants
with birth weight under 1500 gm, • 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.
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32. Predisposing factors of IVH • premature • respiratory distress
syndrome, apnea • pneumothorax • congestive heart failure
ductus arteriosus • hypoxic ischemic or hypotensive injuries
pressure • hypervolemia, hypertensia
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33. • The structural and functional factors of IVH in low-birth-
weight infants • poor structural support of germinal matrix
blood flow to deep cerebral structure • hypoxic-ischemic
or its vessels
• Clinical manifestation of IVH • Absent Moro reflex •
Weakness, seizures, muscular twitching • Poor muscle tone
Lethargy • excessive somnolence • Pallor or cyanosis •
Jaundice• Bulging anterior fontanel • Temperature
stem signs (apnea, lost extraocular movements, facial
signs)
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34. 55.Spinal cord Spinal cord injuriesare commonly caused by strong traction when • the
spine is hyper extended • forceful longitudinal traction on the trunk while the head
pelvic • shoulder dystocia
56.Clinical data • Areflexia • Loss of sensation • Complete paralysis of voluntary
motion below the level of injury • Epidural hemorrhage • Apnea
58.Brachial PalsyRisk Factors • Shoulder dystocia • Neonatal birthweight (macrosomia)
• Instrumental vaginal delivery • Breech presentation • Prior infant with brachial
59.Erb Palsy –Upper trunk plexopathy • Injury to the 5th and 6thcervical nerves (C5-
C6 root avulsion) • Arm falls limply to the side of the body when passively adducted
internal rotation • Elbow extended & forearm pronated • Wrist is flexed • “Waiters
radial reflexes absent • +/- Horner syndrome
60.Klumpke palsy • Lower trunk (C8, T1) injury • Poor grasp, proximal function
preserved • Absence of movements of the wrist • Horner syndrome (ipsilateral ptosis
spinal nerve is involved • Flail arm • Injury to entire plexus
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35. 61.Phrenic nerve palsy • Injury to the C3,C4 or C5 • Brachial
plexus injury • RDS • Paradox (upward) movement during
62.Clavicular fracture • Most common • Crepitus, palpable
bony irregularity • Sternoclaidomastoid muscle spasm • Cry
upper extremities
63.Intraabdominal injures – target organ • Liver • Spleen •
Adrenal gland (breech presentation)
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36. 52.Laboratory correlates of blood loss • Metabolic acidosis •
Low hematocrit • Hypoxemia, hypercarbia • Respiratory
Thrombocytopenia and prolongation of prothrombin time
53.Diagnosis IVH • History • Clinical manifestation •
Transfontanel cranial ultrasonography • Computed
CBC - complete blood count • Lumbar puncture
54.Outcomes and prognosis • Patients with massive bleeding
have a poor prognosis. • About 10-15% infants may develop
hydrocephalus and chronic neurological pathology
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37. Intraabdominal injures
• Sudden presentation • Shock • Abdominal distension •
Bluish discoloration, jaundice, pallor • Poor feeding •
Thachypnea, tachycardia • history: difficult delivery
Diagnosis. • A thorough neurological examination •
Ultrasound examination of the brain • EEG • intracranial
pressure measurement • computed scanning • are valuable.
Treatment • The rapid responders from anoxia need
observation in the nursery for only 12 to 24 hours. • These
babies should be kept in ward, with a minimal noise level or
in the nursery. • Acidosis, hypocalcaemia and hypoglycemia
need correction. • Seizures should be controlled with
phenobarbital
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38. • Thankyou
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