Neonatal Asphyxia

Herman Bermawi
Know the definition, risk
factor, diagnosis and
management of asphyxia
neonatorum
1. Define perinatal asphyxia
2. Know the criteria to
diagnose asphyxia
3. Define risk conditions that
predispose the fetus and
neonate to asphyxia
Prinatal asphyxia is an insult to the fetus or
nwborn, due to :
1. Lack of oxygen (hypoxia) and / or
2. Lack of perfusion (ischemia) to various organ,
and maybe
associated with
3. Lack of ventilation (hypercapnea)

AAP & ACOG ( 2004 ) :

1. Apgar score < 3 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 % of 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. Abnormal plasentation
2. Pricipitate or prolonged delivery
3. Difficult delivery
4. Post term delivery
5. Forceps or vacum delivery

C. Fetal or neonatal
conditions
Prematurity
1.
2. Respiratry distress syndrome
3. Meconium aspiration syndrome
4. Sepsis, pneumonia, hemolitic disease
5. Cardiac or pulmonary anomalies
How does a baby receive O2
before birth ?
1. All O2 difuse across the palcental
membrane from the mothers blood to
the baby blood
2. Only a small fraction of the fetal
blood passed through the fetal lungs
3. Alveoli is filled with fluid
4. The blood vessels in the fetal lungs
are markedly constricted
5. 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
Pathophysiology of Antepatum Asphyxia
1. Cardiac output is maintenaned early, but changes
radically
2. Selective vasocontrictor to gut, kidneys, muscles, skin
3. Pulmonary blood flow by hypoxia and asidosis
4. Respiration center is depressed
5. Severe stage of asphyxia O2 to the heart & brain
- myocardial function O2 to the vital organ

- brain injury
 Score
Sign 0 1 2
Heart Rate Absent < 100/ m 100/ m
Respiratons - Slow, irregular Good, crying
Muscle tone Limp Some flexion Active motion
Reflex irritability No response Grimace Cough,
sneeze,cry
Colour Blue or pale Pink body, blue Completely pink
extremitas

Assigned at 1 and 5 minute after birth, If <

7
every 5 minute 20 minute
 Newborn Resuscitation Algorithm.

2010 by American Academy of Pediatrics

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)

14
 Balon Tidak Mengembang Sendiri
(BTMS)

15
T-piece resuscitator

16
 Oksigen (liter/menit

21
 Initial Assessment
Was he born at term ?
Is he breathing or crying ?
Does he good tones ?
 Provide warmth
Position the head and clear airway
(as necessary)
Dry the skin, stimulate the baby
( tactile stimulation )to breath and
reposition the head
Evaluation
 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 compression to
ventilation = 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
 Sequelae of birth
asphyxia

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
3.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
II. Late Sequalance
Depend on the severity of asphyxia. Clinical
severity of HIE is a better predictor of long
outcome. Cerebral palsy, epilepsy, mental
retardation, deafness, blindness, microcephally
or hydrocephaly.
 Discontinuation of
resuscitation
Discontinuation of resucitation of despite all
step resuscitation heart beat remain absent
after 10 minute stop resuscitation
Hypoxic ischemic encephalopathy
(HIE)

- 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. Prevention in the best management
2. 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
Resusitasi Upayakan Bayi
TERIMAKASIH