Birth asphyxia/ asphyxia neonatorum :

Asphyxia neonatorm means non establishment of satisfactory pulmonary respiration at

birth.Asphyxia neonatornum is respiratory failure in the new born. A condition caused by the
inadequate intake of oxygen before, during, or just after birth. Birth asphyxia is defined as a
reduction of oxygen delivery and an accumulation of carbondiooxide owing to cessation of
Definition: failure to initiate and sustain breathing (WHO),
American academy of paediatrics and America college of obstetrics and gynecology presence
of all of following of all of following criteria :
 Profound metabolic or mixed academia (pH<7.00) in ubilical cord blood.
 Persistensce of low Apgar scores less than 3 for more than 5 minutes
 Signs of neonatatal neurologic dysfunction ( eg., seizures, encephalopathy, tone
abnormalities).
 Evidence of multiple organ involvement ( such as that of kidney , lungs, liver, heart
and intestine).
Scoring system
Signs scores
0 1 2
Appearance Blue or pale Blue limbs and pink All pink
body
Pulse/ heart rate Absent <100/min >100/min
Grimace (reflex) None Slight good
Activity limp Some movement active
Respiratory effort none Weak or slow Good cry

Intervention as scoring system

Score activities
0-3, severe birth asphyxia Immediate resuscitative procedure
4-6, moderate birth asphyxia Immediate resuscitative procedure
>7, minimal or no asphyxia No action required

 Etiology
 Maternal factors:
 Hypoxia
 Anemia
 Diabetes
 Hypertension
 Smoking
 Nephritis
 Heart diseases
 Too young or too old

 Placenta/umbilical cord:
 Abruption of placenta
  Placenta previa
 Prolapsed cord
 Premature rupture 
 of membrane
 Fetomaternal 
 Hemorrhage
 Umbilical cord compression
 Infection/ Inflammation

 Fetal factors:
 Multiple births
 Congenital of malformed fetus
 Severe cardio pulmonary disease

 Signs and symptoms auses/ Triggers

  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

 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.
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:
Total score: 10
a) No asphyxia: 7-10
b) Mild asphyxia: 4-6
c) Severe asphyxia: 0-3
• Management of a Neonate with Birth Asphyxia
In Mild case:
 Allow the baby to begin breast feeding.
 If the baby is receiving oxygen or otherwise cannot be breastfeed, expressed breast milk
can be given.
 Provide ongoing care
In Moderate to Severe case:

 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
a) Restrict the fluid volume to 60 ml per kg body weight for the first day.
b) If convulsion present, treat for convulsion to prevent worsening of the baby’s
conditions
c) Allow the baby to breast feed, if the baby become responsive. If not able to suck give
expressed breast milk.
d) Provide ongoing care to the baby:
e) Assess the baby every two hourly:
f) If the baby’s temperature is less than 36.5 degree centigrade or more than 37.5 degree
centigrade, treat immediately.

g) Treat for convulsion or breathing difficulty as required

h) Encourage the mother to hold and cuddle the baby.
i) 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.
j) If the baby’s condition is not improving after three days, assess again for the signs of
sepsis
k) 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.
l) Follow up in 1 week, or earlier if the mother notes serious problems like feeding
difficulties, convulsions.
m) Help the mother find the best method of feeding if the baby is feeding slowly, have
the mother feed frequently.

n) vii. Discuss that the baby’s may have breathing problems in home and how to deal
with this at home.
 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:
 Term Gestation (yes/no)
 Crying or breathing (yes/no)
 Good muscle tone (yes/no)
 o 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.

 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
 C- Circulation by chest compression and medications if needed

 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
 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

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

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
 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

 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
 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.

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.
 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.
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,
 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.
 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.
 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
repeat suctioning.
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).

 During chest compression, pressure is applied to lower third of sternum, depressing it

½ to ¾ inch.
 Ventilate for the baby after 3 chest compression.
 Do not do chest compression and ventilation at the same time.
 About 90 compression should be given in 1 minute. 1 ventilation should be given
after 3 chest compression (1:3).

 In 1 minutes 30 ventilation and 90 compression are given.

 Re check respiration and heart rate: if heart rate <60 /m. Again repeat the cycle of
ventilation and respiration and compression .
 Recheck: if the heart rate >60, stop compression continue ventilation.
 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.
 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.

 Care after Resuscitation

 Care and support after resuscitation include:
 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.

 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 .

 Need referral situation

 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
 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
 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:
 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
  Ask the mother to return for postpartum visit within 3 weeks.
 Do all the necessary recording and notification for a baby’s birth, death and other
medical record .
 Cleaning equipment and supplies and replace in an appropriate place.
 Nursing Management
Assessment for Birth Asphyxia
Physical Examination

o Respiratory System
 Low APGAR scores
 Breathing shallow, irregular, tachypnea
 Snoring, breathing nostrils, retracted suplasternal / substernal, cyanosis
 Baby does not breathe / breath over 30

o Cardiovascular System
 Optimal pulse, rapid or irregular may be within the normal range (120-160 x / min)
 Heart rate more than 100

o Integument System
 Presence of cyanosis / pallor - indication of gravity hypoxia
 Pitting edema of the hands and feet

o Digestive System
 Weak reflexes
 Lethargy
 Small stomach capacity

o Musculoskeletal System
 Decreased muscle tone
 Edema, weak reflexes, there are no lines on the soles of the feet most / all of the palm.

 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

 Nursing Interventions
 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.

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.

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.

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.

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.

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.

 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
 Delayed Compliance
 Retarded mental and physical growth
 Epilepsy up to 30% of severe asphyxia
 Minimal brain dysfunction

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

Severe hypoxia in u
Heart rate is decreased as myocardium reverts to anaerobic metabolism