Asphyxia Neonatorum

Dr Theresa L Mendonca

Introduction

Asphyxia neonatorum, also called birth Asphyxia or newborn asphyxia, is defined as a failure
to start regular respiration within a minute of birth.

Asphyxia neonatorum is a neonatal emergency as it may lead to hypoxia (lowering of oxygen

supply to the brain and tissues) and possible brain damage or death if not correctly managed.

Newborn infants normally start to breathe without assistance and usually cry after delivery. By
one minute after birth most infants are breathing well. If an infant fails to establish sustained
respiration after birth, the infant is diagnosed with asphyxia neonatorum.

Normal infants have good muscle tone at birth and move their arms and legs actively, while
asphyxia neonatorum infants are completely limp and do not move at all. If not correctly
managed, asphyxia neonatorum will lead to hypoxia and possible brain damage or death.

Definition
1. Defined as impaired respiratory gas exchange accompanied by the development of acidosis

2. Asphyxia neonatorum is respiratory failure in the new-born, a condition caused by the

inadequate intake of oxygen before, during, or just after birth.

3. Birth asphyxia is defined as a reduction of oxygen delivery and an accumulation of carbon

dioxide owing to cessation of blood supply to the fetus around the time of birth.

4. WHO Defined A failure to initiate and sustain breathing at birth.

5. NNF (National Neonatology Forum ):

Moderate asphyxia is Slow gasping breathing or an apgar score of 4-6 at 1 minute of age
Severe asphyxia is No breathing or an apgar score of 0-3 at 1 minute of age
Neonatal evaluation

APGAR scoring

Aerican Academy of Pediatrics (AAP) and the American College of Obstetrics and
Gynecology (ACOG), all of the following must be present for the designation of asphyxia
(1992):

• Profound metabolic or mixed acidemia (pH <7.00) in an umbilical artery blood sample, if
obtained

• Persistence of an Apgar score of 0-3 for longer than 5 minutes

• Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)

• Multiple organ involvement (eg, of the kidney, lungs, liver, heart, intestines)
Moderate birth asphyxia – adequate breathing wasn’t established during the first minute after
birth, but heart rate is 100 per minute and more; there is decreased muscle tone and poor reflex
irritability. Apgar score is 4-6 at the first minute. “Blue asphyxia”.

Severe birth asphyxia - Heart rate is less than 100 per minute, breathing is absent or labored
(gasping breathing), skin is pale, muscle atony. Apgar score is 0-3 at the first minute. “White
asphyxia”.

How Does Asphyxia Occur?

 Interruption of umbilical cord blood flow, eg: cord compression during labour.
 Failure of exchange across the placenta, eg: abruption
 Inadequate perfusion of maternal side of placenta, eg: maternal hypotension
Compromised fetus who cannot tolerate transient intermittent hypoxia of normal labour
 Failure to inflate lungs

Predisposing Factors

Maternal Causes

Maternal -- Pulmonary hypertension

 Chronic HPT

Antenatal conditions eg Abnormal uterine contraction

Antepartum haemorrhage

Prolapsed cord

Malpositions etc

Fetal Causes

Multiple pregnancies

Big baby with CPD

 Fetal anomalies
- Congenital abnormalities of the lung

Pathogenesis

Hypoxic cellular damages:

a. Reversible damage(early stage):

Hypoxia may decrease the production of ATP, and result in the cellular functions . But these change can
be reversible if hypoxia is reversed in short time.

b. Irreversible damage: If hypoxia exist in long time enough, the cellular damage will become irreversible
that means even if hypoxia disappear but the cellular damages are not recovers. In other words, the
complications will happen.
Asphyxia development:

a. Primary apnea : breathing stops but normal muscular tone or hypertonia, tachycardia (quick
heart rate), and hypertension
Happens early and shortly, self-defended mechanism No damage to organ functions if
corrected quickly

b. Secondary apnea Features of severe asphyxia or unsuccessful resuscitation, usually result in damage
of organs function.

Fetal response to asphyxia

Respiratory Metabolic acidosis

EEG changes

Loss of faster rhythm iso-electric rhythms Prolonged voltage suppression with burst
of spike waves indicating risk of significant brain damage

Pathology of Brain Damage

Acidosis alteration in cell membrane permeability fluid shift cerebral

edema,

Anoxia chromatolytic changes in neuron neuron necrosis and neuroglia reactions

Neuron necrosis may be focal, multifocal or diffusely over the cerebral cortex, brainstem,

Clinical features

Apnoea,

bradycardia

Altered respiratory pattern - grunting, gasping Cyanosis Pallor-shock

Hypotonia

Unresponsiveness
Organs Involved In Asphyxia

(1) Asphyxia results in alteration in blood flow to various organs, hence multiple organ injury

Kidney abnormalities occur in 50% of asphyxiated infants

CNS abnormalities in 30% & CVS & pulmonary abnormalities in 25%

• Renal abnormalities - Oliguria, elevated β2 , microglobulin,

• azotaemina, elevated serum creatinine, acute tubular necrosis

(2) CNS abnormalities – HIE(Hypoxic ischemic encephalopathy , -IVH

3. CVS abnormalities - Ventricular failure (R > L) Tricuspid regurgitation Hypotension Pulmonary
abnormalities - PFC, pulmonary haemorrhage

4. GIT abnormalities - bleeding GIT, NEC (Necrotising Enterocolitis )

5. Bone marrow abnormalities - Thrombocytopenia etc

Specific Management Prevent Further Brain Damage

• Maintain temperature, perfusion, oxygenation & ventilation

• Correct & maintain normal metabolic & acid base milieu

• Prompt management of complication

Management of a neonate with perinatal asphyxia

1. • Delivery room care

 Obtain arterial cord blood for analysis

• Transfer the infant to NICU if ▫ Apgar score 0-3 at 1 minute ▫

 Cardiopulmonary Rescuscitation

2. NICU care
a. Maintain normal temperature ▫
 b. Maintain normal oxygenation and ventilation ▫
Maintain saturations between 90% and 95% and avoid any hypoxia or hyperoxia ▫
Avoid hypocarbia, as this would reduce the cerebral perfusion ▫
Avoid hypercarbia, which can increase intracranial pressure and predispose the baby to
intracranial bleed.
c. . Maintain normal tissue perfusion ▫

Start intravenous fluid ▫

Administer dobutamine (preferred) or dopamine to maintain adequate cardiac output, as required.

Do not restrict fluid as this practice may predispose the babies to hypo perfusion.

Restrict fluid only if there is hyponatremia (Sodium

Preventing asphyxia

• Perinatal assessment –

Regular antenatal check ups –

High risk approach –

Anticipation of complications during labour –

Timely intervention ( eg. LSCS)

• Perinatal management –

Timely referral –

Management of maternal complications Prevention,