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Neonatal Asphyxia

Dr. Herman Bermawi, SpA(K)


Dr. Julniar M Tasli, SpA(K)

Know the definition, risk factor, diagnosis and


management of asphyxia neonatorum

1.
2.
3.

Define perinatal asphyxia


Know the criteria to diagnose asphyxia
Define risk conditions that predispose the
fetus and neonate to asphyxia

Prinatal asphyxia is an insult to the fetus


or newborn, due to :

Lack of oxygen (hypoxia) and / or


Lack of perfusion (ischemia) to various organ, and maybe
associated with
Lack of ventilation (hypercapnea)

AAP & ACOG ( 2004 ) :


1. Apgar score < 5 at age 5 min
2. Cord pH < 7.0
3. Neurological disorders & multiorgan syst. Dysf.

1 % - 1,5 % of total live birth:


< 36 week : 9 %
> 36 week : 0,5 %

20 % o perinatal death

A. Antepartum condition
1. Matenal Factors:

DM

Toxemia

Hypertension

Cardiac disease

Collagen vascular disease

Infections

Insoimmunization

Drug addiction
2. Obstetric Factor:

Placenta Previa

Cord prolaps

PROM

Polyhidramnion

Placenta insuffeciency

Chorioamnionitis

B. Inpartum Conditions
1.
2.
3.
4.
5.

Abnormal plasentation
Pricipitate or prolonged delivery
Difficult delivery
Post term delivery
Forceps or vacum delivery

C. Fetal or neonatal conditions


1.
2.
3.
4.
5.

Prematurity
Respiratry distress syndrome
Meconium aspiration syndrome
Sepsis, pneumonia, hemolitic disease
Cardiac or pulmonary anomalies

1.Suction Equipment
Bulb Syringe/ mechanical suction and tubing, suction catheter 5F
or 6 F, 10 F or 12 F
8 F feeding tube and 20 ml syringe meconium aspirator
2. Bag and mask equipment
3. Intubation equipment
4. Medications :

Epinephrine 1/10.000

Isotonic crystaloid

Naloxone hydrocloride

Dextrose 40 %

Normal saline

Umbilical Vessel catetherization supplies


5. Miscellaneous
Gloves, radiant warmer, linens, stethoscope, oropharyngeal
airway

Balon Mengembang
Sendiri (BMS)

Balon Tidak
Mengembang Sendiri
(BTMS)
T-piece resuscitator

All O2 difuse across the palcental membrane


from the mothers blood to the baby blood
Only a small fraction of the fetal blodood
passed through the fetal lungs
Alveoli is filled with fluid
The blood vessels in the fetal lungs are
markedly constricted
Most of the blood flow through the ductus
arteriosus into the aorta

After Birth:
+ Noconnection to the placenta
+ A baby get oxygen from the lung
1. The fluid in the alveoli is absorbed into the lungs
tissue and replace by air
2. The umbilical arteri and vein clamped increases
systemic blood presure
3. O2 in the alveoli relaxation of blood vessel in the
lungs
4. The ductus arteriosus begin to constrict more
blood flow trough the lungs O2 to tissues

1.
2.
3.
4.
5.

Cardiac output is maintenaned early, but


changes radically
Selective vasocontrictor to gut, kidneys,
muscles, skin
Pulmonary blood flow by hypoxia and
asidosis
Respiration center is depressed
Severe stage of asphyxia O2 to the heart
& brain - myocardial function
O2 to the vital organ
- brain injury

Score

Sign

Heart Rate

Absent

< 100/ m

100/ m

Respiratons

Slow, irregular

Good, crying

Muscle tone

Limp

Some flexion

Active motion

Reflex irritability No response

Grimace

Colour

Pink body, blue


extremitas

Cough,
sneeze,cry
Completely pink

Blue or pale

Assigned at 1 and 5 minute after birth, If < 7


every 5 minute 20 minute

Newborn Resuscitation Algorithm.

2010 by American Academy of Pediatrics

Provide warm therapy


Position, clear airway (as necessary)
Dry, stimulate, reposition
Give oxygen (as necessary) :
Free-flow O2 & Tactile stimulation

Vigourus baby if :
- strong respiratory efforts
- good muscle tone
- heart rate > 100 / minute

Insert a laryngoscope and use a 12 F or 14 F


catheher to clear the mouth & posterior
pharynx

Attack the endotracheal tube to a suction


source

Apply suction as tube is slowly with drawn

Repeat as necessary until clear

Indication:

1. Apnea or gasping breath

2. Heart rate < 100 bpm


3. Persistant central cyanosis despite FI O2 100%
Use : 1. Flow inflating bag volume 240 750 mL
2. Self inflating bag
Rate : 40 60 breath per minute
Pressure : 30 40 am H2O and then
Mask : - Face Mask : - Full term
- Pre term
- Round
- Anatomical shape
- With cushioned rim

Increase of heart rate


Improved in color
Spontaneous breathing

Provided by :

- The thumb technique


- The two finger technique

Place : on the externum above xyphoid


Rate : 90 per minute
Ratio chest compreton to ventilator
3:1
Depth : 1/3 the depth of the chest

Indications :
1. to suction meconium
2. to improve ventilation in bag and mask ventilation
in effective
3. To coordinate ventilation and chest compression
4. To administration medication such as ephinephrine
5. When prolonged ventilation is needed
6. Administer surfactant
7. When congenital diaphagmatic hernia is suspected.

1. Endotracheal tube :
- uniform type
- size : 2,5 3,5 mm
2. Laryngoscope
- small handle
- blade handle no : - 1 = full term
- 0 = preterm
- 00 = extremelly
preterm

1. Epinephrine
Indications : HR < 60 bpm after 30 sec of PPV and
mother 30 sec of PPV + chest
compressions
How : - ET
- Umbilical vein
Doze : 0.1 0.3 mL / kg of a 1 : 10.000 sol ( UV )
0.3 1.0 mL / kg of a 1 : 10.000 sol ( ET )
Repeat every 3 5 minutes
2. IV normal saline / ringer lactate 10 mL/ kgBB

3. Naloxone hydrocloride
Indication : respiratory depressons caused by
maternal narcotics ( morphine, micpheridium,
butorphanol tartrate ) : in 4 hours before
delivery
Dose 0,1 mg/kg via ET / IT

I. Early sequallae :
1. Metabolic
a. Metabolic acidosis
b. Inapropiate anti diuretic hormone
secretion
2. Rerpiratory
a. RDS : increase severity of RDS
b. Transient tachypnoe of the new born
c. Respiration of meconium antenatally may
lead to MAS

Cardiac
a. myocardial ischemia
b. Persistent pulmonary hypertention of the new
born
c. PDA
4. CNS : hypoxic ischemia encephalopathy (HIE)
5. Renal Inpairment : ATN
6. Hemathological : DIC
7. Gastrointestinal : NEC
3.

II. Late Sequalance

Depend on the severity of asphyxia. Clinical


severity of HIE is a better predictor of long
outcome

DISCONTINUATION OF RESUCITATION
Discontinuation of resucitation of despite all
step resuscitation heart beat remain absent
after 10 minute stop resuscitation

- Hypoxia
- Ischemia
- Clinical neurological syndrome
Sarnat and Sarnat Classified HIE into 3
gradies
1. Grade I (mild)
2. Grade II (moderate)
3. Grade III (severe)

Grade I HIE
-

Alternating period of lethargy, irritability, Hyperalertness, jitteriness


Poor feeding
Increased muscle tone, exaggerated deep tendon reflex.
Increase heart rate
Pupils : dilated
No seizures
Symtomps resolver in 24 hour

Grade II HIE
-

Lethargy
Poor feeding, depressed gag reflex
Hypotonia
Low heart rate and pupillary constriction indicating parasympathetic
stimulation
50 70 % neonates display seizures usually in the first 24 hour after
birth

Grade III HIE :


Neurological abnormality progressing :
- Coma
- Flacidity
- Absent reflexes
- Pupil : fixed, slight reactive
- Apnea, bradycardia, hypotension
- Seizzure are uncomon but if present they are
intractable

Acute tubular necrosis : oliguria,


hematuria, polyuria

Cardiomyopathy : hypotension

Persistent pulmonary hypertension :


tachypnea, hypoxemia

Hepatic necrosis : ammonia, jaundice,

AST/ ALT

NEC : distention, bloody stools

Adrenal insufficiency : glucose, Na,


BP

Inappropiate secretion of ADH : oliguria,


Na

1.
2.

Prevention in the best management


Timing is very crucial and a few minute of
delay can lead to death or life long suffering
from handicap

3.

Maintain oxygenation and acid base balance

4.

Start mechanical ventilation if necessary

5.

Monitor and maintain body temperature

6.

Correct and maintain caloric, fluid, electrolyte


and glucose levels ( D 10 % at 60 cc/kg/day )

7. Correct hypovolemia (whole blood)


8. Avoid fluid overload, hypertension, hyperviscocity
9. Administer phenobarbital for treatment of
seizzurnes
- Administer phenobabital 20 mg/kg iv over 5 minute
- can be increased in dose 5 mg/kg every 5 minute
until seizurnes are controlled or until maximum
dose 40 mg/kb is reached
10. No other therapeutic interventions have been
proven helpful ie. Corticosteroids, prophylactic
phenobarbital, furosemite, manitol, etc