Neonatal Asphyxia

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

Neonatal Asphyxia

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What are the criteria used to diagnose perinatal asphyxia?

What are the criteria used to diagnose perinatal asphyxia?

What are some risk factors that can predispose a fetus or neonate to asphyxia?

What are some risk factors that can predispose a fetus or neonate to asphyxia?

Neonatal Asphyxia

Dr. Herman Bermawi, SpA(K)

Know the definition, risk factor, diagnosis and

Define perinatal asphyxia

Prinatal asphyxia is an insult to the fetus

Lack of oxygen (hypoxia) and / or

AAP & ACOG ( 2004 ) :

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

Collagen vascular disease

C. Fetal or neonatal conditions

Umbilical Vessel catetherization supplies

All O2 difuse across the palcental membrane

Cardiac output is maintenaned early, but

Reflex irritability No response

Pink body, blue

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

Newborn Resuscitation Algorithm.

2010 by American Academy of Pediatrics

Provide warm therapy

Insert a laryngoscope and use a 12 F or 14 F

Attack the endotracheal tube to a suction

Apply suction as tube is slowly with drawn

Repeat as necessary until clear

1. Apnea or gasping breath

2. Heart rate < 100 bpm

Increase of heart rate

- The thumb technique

Place : on the externum above xyphoid

II. Late Sequalance

Depend on the severity of asphyxia. Clinical

Alternating period of lethargy, irritability, Hyperalertness, jitteriness

Grade III HIE :

Acute tubular necrosis : oliguria,

Persistent pulmonary hypertension :

Hepatic necrosis : ammonia, jaundice,

NEC : distention, bloody stools

Adrenal insufficiency : glucose, Na,

Inappropiate secretion of ADH : oliguria,

Prevention in the best management

Maintain oxygenation and acid base balance

Start mechanical ventilation if necessary

Monitor and maintain body temperature

Correct and maintain caloric, fluid, electrolyte

7. Correct hypovolemia (whole blood)

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