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Birth asphyxia
 Specific learning

A
objectives
Definition

Causes

Classification

Complications

Diagnosis

Areas of growth

Timeline

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Summary 2
 Definition
WHO: Asphyxia is incapacity of newborn to begin or to support
spontaneous respiration after delivery due to breaching of
oxygenation during labor and delivery Asphyxia is absense or
ineffective respiration of newborn of 1 minute old with Apgar
score less than 4

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 Apgar score
•Scores of 0-3 are considered critical, especially in babies born at or near
term
•Scores of 4-6 are considered below normal and indicate that the medical
intervention is likely required
•Scores of 7+ are considered normal

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Causes
 Fetal hypoxia

• Mother: hypoventilation during anesthesia, cyanotic heart disease,

respiratory failure or carbon monoxide poisoning.
• Low maternal blood pressure as a result of the hypotension that may cause
compression of the vena cava & aorta by the gravid uterus
• Premature separation of the placenta; placenta previa
• Impedance to the circulation of blood through the umbilical cord as a result
of compression or knotting of the cord
• Uterine vessel vasoconstriction by cocaine, smoking
• Placental insufficiency from numerous causes, including gestosis, eclampcia,
toxemia, postmaturity
• Extremes in maternal age (< 20 years or >35 years)
• Preterm or postterm gestation.
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 Intrapartum asphyxia
• More frequently inadequate obstetric aid
• Using forceps, vacuum extraction, caesarean section
(immediate)
• Trauma: narrow pelvis, malpresentation
• Extremely rapid or prolonged labor
• Multiple gestation
• Drugs depression of CNS: anesthesia, sedatives & analgesics
• Meconium-stained amniotic fluid.

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 Postnatal hypoxia
• Anemia due to severe hemorrhage or hemolytic disease
• Shock from adrenal hemorrhage, intraventricular hemorrhage, overwhelming
infection, massive blood loss
• Failure to breathe due to a cerebral defect, narcosis or injury
• Failure of oxygenation resulting from of cyanotic congenital heart disease or
deficient pulmonary function
• Multiple gestation;
• Placental abruption; • Placenta previa; • Preeclampsia; • Meconium-stained
amniotic fluid; • Fetal bradycardia;
• Prolonged rupture of fetal membranes;
• Maternal diabetes;
• Maternal use of illicit drugs;
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 Classification
• Mild
• Moderate
• severe

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 MILD ASPHYXIA
• The infant who experiences mild asphyxia initially will be
depressed. This is followed by a period of hyperalertness, which
resolves within 1 or 2 days.
• Clinical symptoms: hyperalertness (jitteriness), increased
irritability and tendon reflexes, exaggerated Moro response;
There are no local signs
• The prognosis is excellent for normal (good) outcome.

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 MODERATE ASPHYXIA
• The infant who experiences moderate asphyxia will be very
depressed. This is followed by a prolonged period of
hyperalertness and hyperreflexia.
• Clinical symptoms: • lethargy, hypotonia • suppressed reflexes
with or without seizures • Generalised seizures often occur 12
to 24 hours after episode of asphyxia, but are controlled easily,
resolving in a few days regarding of therapy.
• The prognosis is variable (20-40% with abnormal outcome).

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 SEVERE ASPHYXIA
• Severe metabolic or mix acidosis pH ≤ 7.00 in arterial blood of umbilical
vessels;
• Assessment by Apgar is 0-3 during more than 5 minutes;
• Neurological symptoms such as general hypotonia, lethargy, coma, seizures,
brainstem, autonomous dysfunction;
• Evidence of multiorgan system dysfunction in the immediate neonatal period
- damage of vital organs (lungs, heart and others) in fetus or newborn;
• Severe asphyxia is associated with coma, intractable seizures activity,
cerebral oedema, intracranial haemorrhage.
• The infant often became progressively more depressed over the first 1 to 3
days, as a cerebral oedema develops, and death may occur during this period.
• Survival is usually associated with poor long-term outcome (100% with
abnormal outcome);
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 Acute complications
• Hypoxic-ischemic encephalopathy (HIE)
• Hypotension
• Seizures
• Persistent pulmonary hypertension
• Hypoxic cardiomyopathy
• Necrotizing enterocolitis
• Acute tubular necrosis
• Adrenal hemorrhage and necrosis
• Hypoglycemia, polycythemia
• Disseminated intravascular coagulation
Sarnat criteria • Pupils • Respirations • Heart rate • Bronchial & salivary secretions •
Gastrointestinal motility • Seizures • EEG • Duration of symptoms
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 Hypoxic-ischemic cerebral injury – HI
E (encephalopathy
• Is caused by a combination of hypoxemia, ischemia, that results
in a decreased supply of oxygen to cerebral tissue
• During perinatal asphyxia, birth trauma, hypercapnia and
acidosis may contribute further to the cerebral insult.
• Level of consciousness • Neuromuscular control • Muscle tone •
Posture • Stretch reflexes • Segmental myoclonus • Complex
reflexes: Suck, Moro, oculovestibular tonic neck • Autonomic
function

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 Diagnosis
• Clinical symptoms and metabolic derangement – blood sample
from the umbilical artery - low pH (< 7, 00) - indicates the
intrapartum asphyxia.
• Renal and/or cardiac failure
• Assessment of the brain: EEG Serial recordings are almost
necessary. Low voltage. Burst-suppression patterns or electrical
inactivity are associated with bad prognosis. Rapid resolutionof
EEG abnormalities and/or normal interictal EEG are associated
with a good prognosis.

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 • Ultrasound: to measure the growth of the fetus. The growth
retarded fetus is in a great risk of developing asphyxia.
Ultrasound can be useful in premature newborns.
• Doppler techniques: to measure the blood flow in the umbilical
vessels or aorta. A low flow or decreasing flow indicates a fetus in
risk of asphyxia.
• Computed tomography: CT is of major value both acutely
during the neonatal period and later in childhood. The optimal
timing of CT scanning is between 2 and 4 days.

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 ABC resuscitation
• A- Airways (maintenance of passableness of airway)
• B- breathing (stimulation of breathing)
• C- circulation (support of circulation)
Step A- immediately after delivery the infant’s head should be
placed in a neutral or slightly extended position • Roller towel
under the shoulders
And airway established by clearing the mouth, then the nose
by rubber bag.If it is inadequate we must use step B.
At first the tactile stimulation should be given to newborn, for
example - gentle flicking of the feet or heel or rubbing of the back
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 • If these measures are inadequate, mechanical ventilation should be
initiated, using mask and bag ventilation
• If ventilation is adequate supplemental oxygen may be given to improve
heart rate or skin colour
• If mechanical ventilation does not improve the respiration, heart rate or
colour skin, the following step is “C”-circulation. At first the assessment of heart
rate is necessary
• If heart rate is less than 60 beats/minute, or between 60 and 80 beats and is
not improving, cardiac compression must be performed. Big fingers must lie on
the sternum, other fingers should lie under the back of newborn
• If heart rate is less then 80 beats per minute the cardiac compression should be
continued. • If heart rate is 80 beats per minute or more the cardiac
compression should be stopped .
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 Birth trauma
• The term “Birth trauma” is used to denote mechanical and
anoxic trauma incurred by the infant during labor and delivery. •
The process of birth is associated with compressions,
contractions, and tractions.
• When fetal size, presentation or neurological immaturity
complicate this event, such intrapartum forces may lead to •
tissue damage, • edema, • hemorrhage • or fracture in the
neonate.

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 • The risk of birth injury
• Small maternal stature
• Maternal pelvic anomalies
• Extremely rapid • Prolonged labor •
Using forceps, vacuum extraction • Versions and extraction • Deep transverse
arrest of descent of presenting part of fetus
• Oligohydramnions
• Abnormal presentation (i.e. breech)
• Very low birth weight infant or extreme premature • Postmature infant(> 42
week of gestation)
• Cesarean section • Fetal macrosomia • Large fetal head • Fetal anomalies (see
teratoma)
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 Classification of birth injuries
I. Soft-tissue injuries • - caput succedaneum • - subcutaneous and
retinal hemorrhage, petechia • - ecchymoses and subcutaneous fat
necrosis
II. Cranial injuries • cephalohematoma • fractures of the skull
III. Intracranial hemorrhage • subdural hemorrhage • subarachnoid
hemorrhage • intra- and periventricular hemorrhage • parenchyma
hemorrhage
IV. Spine and spinal cord • fractures of vertebra • Erb-Duchenne
paralysis • Klumpke paralyses • Phrenic nerve paralyses • Facial nerves
palsy
V. Peripheral nerve injuries • VI. Viscera (rupture of liver, spleen and
adrenal hemorrhage) • VII. Fractures of bones.
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 • Petechiae and ecchymosis are common manifestation of birth
trauma in the newborn. Petechiae of the skin of the head and
neck are common. These lesions resolve spontaneously within
1 week.
• They are caused by a sudden increase in intrathoracic pressure
during labor when the fetus passes through the birth canal.
• They are temporary and are the result of normal course of
delivery.
• If the etiology is uncertain, studies to rule out coagulation
disorders or infections etiology are indicated.

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 • Caput succedaneum is a subcutaneous extraperiosteal fluid
collection in the presenting part of fetus
• It is caused by infiltration of subcutaneous soft tissue in the
presenting part resulting from pressure in birth canal • with
poorly defined margins
• It may extend across the midline over suture lines
• This swelling is resolved rather quickly within several days post
partum.

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 • Cephalohematoma • is a subperiosteal collection of blood
resulting from rupture of the blood vessels between the skull
and periostium
• it does not extend over suture lines between adjacent bones. •
Its occurrence is commonly on one side of the head
• The extent of hemorrhage may be severe enough to present as
anemia and hypotension with secondary hyperbilirubinemia.

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 • It may be a focus of infection leading to meningitis,
particularly when there is a concomitant skull fracture. Skull X-
rays should be obtained if there are CNS symptoms, if the
hematoma is very large or if the delivery was very difficult. •
Resolution occurs over 1 to 2 month, occasionally with residual
calcification as a thrombus.

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 • INTRACRANIAL HEMORRHAGE • Occurs in 20% to more than
40% of infants with birth weight under 1500 gm, • is less
common among more mature infants. • Intracranial
hemorrhage may occur in the subdural, subarachnoid,
intraventricular or intracerebral regions. • Subdural and
subarachnoid hemorrhage follow head trauma (e.g. in breech,
difficult and prolonged labor and after forceps delivery). • Other
forms of intracranial bleeding are associated with immaturity
and hypoxia.

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 Predisposing factors of IVH • premature • respiratory distress
syndrome, apnea • pneumothorax • congestive heart failure •
presence of patent ductus arteriosus • hypoxic ischemic or
hypotensive injuries • increased venous pressure • hypervolemia,
hypertensia

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 • The structural and functional factors of IVH in low-birth-
weight infants • poor structural support of germinal matrix
vessels • relatively large blood flow to deep cerebral structure •
hypoxic-ischemic injury to germinal matrix or its vessels
• Clinical manifestation of IVH • Absent Moro reflex •
Weakness, seizures, muscular twitching • Poor muscle tone •
Hypotonia • Lethargy • excessive somnolence • Pallor or
cyanosis • Respiratory distress • Jaundice• Bulging anterior
fontanel • Temperature instability • Hypotonia • Brain stem
signs (apnea, lost extraocular movements, facial weakness,
abnormal eye signs)
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 55.Spinal cord Spinal cord injuriesare commonly caused by strong traction when • the spine
is hyper extended • forceful longitudinal traction on the trunk while the head is still firmly
engaged in the pelvic • shoulder dystocia
56.Clinical data • Areflexia • Loss of sensation • Complete paralysis of voluntary motion
below the level of injury • Epidural hemorrhage • Apnea
58.Brachial PalsyRisk Factors • Shoulder dystocia • Neonatal birthweight (macrosomia) •
Instrumental vaginal delivery • Breech presentation • Prior infant with brachial palsy
59.Erb Palsy –Upper trunk plexopathy • Injury to the 5th and 6thcervical nerves (C5-C6
root avulsion) • Arm falls limply to the side of the body when passively adducted •
Affected arm adduction & internal rotation • Elbow extended & forearm pronated • Wrist
is flexed • “Waiters tip” position • Moro, biceps and radial reflexes absent • +/- Horner
syndrome
60.Klumpke palsy • Lower trunk (C8, T1) injury • Poor grasp, proximal function preserved •
Absence of movements of the wrist • Horner syndrome (ipsilateral ptosis and miosis) if
the thoracic spinal nerve is involved • Flail arm • Injury to entire plexus
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 61.Phrenic nerve palsy • Injury to the C3,C4 or C5 • Brachial
plexus injury • RDS • Paradox (upward) movement during
inspiration
62.Clavicular fracture • Most common • Crepitus, palpable bony
irregularity • Sternoclaidomastoid muscle spasm • Cry during
movement of upper extremities
63.Intraabdominal injures – target organ • Liver • Spleen •
Adrenal gland (breech presentation)

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 52.Laboratory correlates of blood loss • Metabolic acidosis •
Low hematocrit • Hypoxemia, hypercarbia • Respiratory acidosis
• Thrombocytopenia and prolongation of prothrombin time (PT)
53.Diagnosis IVH • History • Clinical manifestation •
Transfontanel cranial ultrasonography • Computed tomography
• Glucose level • CBC - complete blood count • Lumbar puncture
54.Outcomes and prognosis • Patients with massive bleeding
have a poor prognosis. • About 10-15% infants may develop
post hemorrhagic hydrocephalus and chronic neurological
pathology

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 Intraabdominal injures
• Sudden presentation • Shock • Abdominal distension • Bluish
discoloration, jaundice, pallor • Poor feeding • Thachypnea,
tachycardia • history: difficult delivery
Diagnosis. • A thorough neurological examination • Ultrasound
examination of the brain • EEG • intracranial pressure
measurement • computed scanning • are valuable.
Treatment • The rapid responders from anoxia need
observation in the nursery for only 12 to 24 hours. • These
babies should be kept in ward, with a minimal noise level or in
the nursery. • Acidosis, hypocalcaemia and hypoglycemia need
correction. • Seizures should be controlled with phenobarbital
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 • Thankyou

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