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Definition

Perinatal asphyxia is an insult to the

fetus/newborn, due to:
 Lack of oxygen (hypoxia) and/or
 Lack of perfusion (ischemia) to various
organ, and may be associated with
 Lack of ventilation (hypercapnia).

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 Definition
Essential characteristics: American Academy of
Pediatrics (AAP) and the American College Of
Obstetricians and Gynecologists (ACOG):
1. Profound metabolic or mixed acidemia (pH < 7)
2. Apgar score of 0-3 for >5 min
3. Neurologic manifestations: seizures, hypotonia, coma, or
hypoxic ischemic encephalopathy (HIE)
4. Evidence of multiorgan system dysfunction in the
immediate neonatal periode.
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 Incidence

 1.0-1.5% of total live birth :

 <36 wk : 9%

 >36 wk : 0.5%

 ~20% of perinatal death

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 Apgar score (1952)
 A scoring system to help assessing a
neonate’s transition after birth
 Conceived to report on the state of the
newborn and effectiveness of resuscitation.
 Poor tool for assessing asphyxia

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 APGAR SCORING
Sign 0 1 2
Appearance Blue or pale Pink body with Completely
(color) blue extr pink
Pulse Absent Slow >100 bpm
(heart rate) (<100 bpm)
Grimace No response Grimace Cough or
(reflex irritability) sneeze
Activity Limp Some flexion Active
(muscle tone) movement
Respirations Absent Slow, irregular Good, crying

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Organ effects of asphyxia
 CNS
 Lung

 Cardiovascular system

 Renal system

 Gastrointestinal tract

 Blood

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Consequences of Asphyxia CNS
 Cerebral hemorrhage
 Cerebral edema
 Hypoxic-ischemic
encephalopathy
 Seizures

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 Intrauterine asphyxia
↓
Pathogenesis
Fetal ↓pO2, ↑pCO2, ↓pH, ↓BP Intrauterine asphyxia
↓ ↓
Intracellular edema Fetal ↓pO2, ↑pCO2, ↓pH, ↓BP
↓
↑ Cerebral tissue pressure
↓ Loss of vascular autoregulation
Focal ↓ Cerebral blood flow ↓
↓ ↓Cerebral blood flow
Generalized brain swelling
↓
↑ Intracranial pressure Brain Necrosis
↓
Generalized ↓ cerebral blood flow
↓
Brain necrosis Brain swelling 10
Consequences of Asphyxia
Lung

 Delayed onset of respiration

 Respiratory distress syndrome from
surfactant deficiency or dysfunction
 Pulmonary hemorrhage
 Persistent pulmonary hypertention

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Consequences of Asphyxia
Cardiovascular system

 Shock
 Hypotention
 Myocardial necrosis
 Congestive heart failure
 Ventricular dysfunction

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Consequences of Asphyxia
Renal system

 Oliguria-anuria
 Acute tubular or cortical necrosis
 Renal failure

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Consequences of Asphyxia
Gastrointestinal system

 Paralytic ileus or delayed (5-7 days)

necrotizing enterocolitis.

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 Consequences of Asphyxia
Blood

 Disseminated intravascular coagulation

 Thrombocytopenia can result from shortened
platelet survival
 Bone Marrow recovers over time

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 Consequences of Asphyxia
Metabolic
 Acidosis
 Hypoglicemia (hyperinsulinism)
 Hypocalcemia
 Hyponatremia/ Syndrome of inappropriate
antidiuretic hormone secretion (SIADH)

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 Management
 Optimal management is prevention: identify the fetus being subjected
 Immediate resuscitation: maintenance of adequate ventilation,
oxygenation, perfusion.
 Correct metabolic acidosis:
Volume expander: to sustain tissue perfusion
 NS or Ringers Lactate

 O neg if (+) evidence of blood loss

 Albumin: not recommended

Na Bicarbonate
 Only with adequate ventilation and circulation

 Only when CPR is prolonged and the infant remains

unresponsiveness
 1-2 mEq/kg of a 0.5 mEq/L slow IV

 Temperature: Avoid perinatal hyperthermia

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 Management
 Maintain a normal serum glucosa level (75-100
mg/dL) to provide adequate substrate for brain
metabolism. Avoid hyperglycemia to prevent
hyperosmolality and a possible increase in brain
lactate levels
 Controle of seizures: phenobarbital is the drug of
choice.
 Prevention of cerebral edema: fluid restriction (eg.
60 ml/kg)

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Neonatal Resuscitation

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 Primary versus Secondary Apnea

Primary Apnea Secondary Apnea

• no respiration • no respiration
• decreasing heart rate • heart rate very low
• BP maintained • BP low
• responds to stimulus • No response to stimulation

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Signs of a Compromised Newborn

 Cyanosis

 Bradycardia

 Low blood pressure

 Depressed
respiratory effort
 Poor muscle tone

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© 2000 AAP/AHA
Preparation for Resuscitation Personnel
and Equipment

 Trained person to initiate

resuscitation at every delivery
 Recruit additional personnel,
for more complex delivery
 Prepare necessary equipment
– Turn on radiant warmer
– Check resuscitation equipment
 Team concept

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© 2000 AAP/AHA
 Evaluating the Newborn
Immediately after birth, the following
questions must be asked:

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© 2000 AAP/AHA
 Evaluation

Action Decision

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© 2000 AAP/AHA
Initial Steps

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© 2000 AAP/AHA
 Provide Warmth

Prevent heat loss by

 Placing newborn under
radiant warmer
 Drying thoroughly
 Removing wet towel

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© 2000 AAP/AHA
Preventing Heat Loss

Premature newborns
 Special problems
– Thin skin
– Decreased subcutaneous tissue
– Large surface area

 Additional steps
– Raise environment temperature
– Cover with clear plastic sheeting
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© 2000 AAP/AHA
Opening the
Airway

Open the airway by

 Positioning on back or side
 Slightly extending neck
 “Sniffing” position
 Aligning posterior pharynx, larynx and trachea

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© 2000 AAP/AHA
Clear Airway: No Meconium Present

Suction mouth first,

then nose

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© 2000 AAP/AHA
If meconium present and
newborn is vigorous
If:
 respiratory effort is strong

 muscle tone is good

 Heart rate > 100/ min

Then:
 Use bulb syringe or large bore catheter

to clear mouth and nose

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Meconium present
and newborn
NOT vigorous
Tracheal suction
 Administer oxygen
 Insert laryngoscope, use 12F or 14F suction
catheter to clear mouth
 Insert endotracheal tube
 Attach endotracheal tube to suction source
 Apply suction as tube is withdrawn
 Repeat as necessary
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© 2000 AAP/AHA
Management of Meconium

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© 2000 AAP/AHA
Dry, Stimulate to Breathe, Reposition

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© 2000 AAP/AHA
Tactile Stimulation

Potentially Hazardous Stimulation

 shaking
 slapping the back
 squeezing the rib cage
 hot and cold compresses
 dilating anal sphincter

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© 2000 AAP/AHA
Resuscitation Flow Diagram

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© 2000 AAP/AHA
Post - Resuscitation Care

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© 2000 AAP/AHA
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