Division of Perinatology Department of Child Health Medical School University of Sumatera Utara

Division of Perinatology
Department of Child Health Medical School

University of Sumatera Utara
1
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).
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.
3
Incidence
1.0-1.5% of total live birth :
<36 wk : 9%
>36 wk : 0.5%
~20% of perinatal death
Apgar score (1952)
A scoring system to help assessing a

neonates transition after birth
Conceived to report on the state of the
newborn and effectiveness of resuscitation.
Poor tool for assessing asphyxia
APGAR SCORING
Sign
Appearance
(color)
Blue or pale
Pink body with Completely

blue extr
pink
Puls
(heart rate)
Absent
Slow
(<100 bpm)
>100 bpm
Grimace
(reflex irritability)
No response
Grimace
Cough or
sneeze
Activity
(muscle tone)
Limp
Some flexion
Active
movement
Respirations
Absent
Slow, irregular Good, crying
Organ effects of asphyxia

CNS
Lung
Cardiovascular system
Renal system
Gastrointestinal tract
Blood
Consequences of Asphyxia CNS
Cerebral hemorrhage
Cerebral edema
Hypoxic-ischemic
encephalopathy
Seizures
Intrauterine asphyxia
Fetal pO2, pCO2, pH, BP
Intracellular edema
Cerebral tissue pressure
Focal Cerebral blood flow
Generalized brain swelling
Intracranial pressure
Generalized cerebral blood flow
Brain necrosis
Pathogenesis
Intrauterine asphyxia
Fetal pO2, pCO2, pH, BP
Loss of vascular autoregulation
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
11
Cardiovascular system
Shock
Hypotention
Myocardial necrosis
Congestive heart failure
Ventricular dysfunction
12
Renal system
Oliguria-anuria
Acute tubular or cortical necrosis
Renal failure
13
Gastrointestinal system
Paralytic ileus or delayed (5-7 days)

necrotizing enterocolitis.
14
Blood
Disseminated intravascular coagulation

Thrombocytopenia can result from shortened
platelet survival
Bone Marrow recovers over time
15
Consequences of Asphyxia Metabolic
Acidosis
Hypoglicemia (hyperinsulinism)
Hypocalcemia
Hyponatremia/ Syndrome of inappropriate
antidiuretic hormone secretion (SIADH)
16
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
17
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)
18
Neonatal Resuscitation
19
Primary versus Secondary Apnea
Primary Apnea
no respiration
decreasing heart rate
BP maintained
responds to stimulus
Secondary Apnea
no respiration
heart rate very low
BP low
No response to stimulation
20
Signs of a Compromised Newborn
Cyanosis
Bradycardia
Low blood pressure
Depressed
respiratory effort
Poor muscle tone
21
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
22
2000 AAP/AHA
Evaluating the Newborn

Immediately after birth, the following
questions must be asked:
23
2000 AAP/AHA
Evaluation
Action
Decision
24
2000 AAP/AHA
Initial Steps
25
2000 AAP/AHA
Provide Warmth
Prevent heat loss by
Placing newborn under

radiant warmer
Drying thoroughly
Removing wet towel
26
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
27
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
28
2000 AAP/AHA
Clear Airway: No Meconium Present

Suction mouth first,
then nose
29
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
30
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
31
2000 AAP/AHA
Management of Meconium
32
2000 AAP/AHA
Dry, Stimulate to Breathe, Reposition
33
2000 AAP/AHA
Tactile Stimulation
Potentially Hazardous Stimulation

shaking
slapping the back
squeezing the rib cage
hot and cold compresses
dilating anal sphincter
34
2000 AAP/AHA
Resuscitation Flow Diagram
35
2000 AAP/AHA
Post - Resuscitation Care
36
2000 AAP/AHA
37

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Division of Perinatology

Department of Child Health Medical School

fetus/newborn, due to:

Apgar score (1952)

A scoring system to help assessing a

Pink body with Completely

Slow, irregular Good, crying

Organ effects of asphyxia

Consequences of Asphyxia CNS

Fetal pO2, pCO2, pH, BP

Cerebral tissue pressure

Focal Cerebral blood flow

Generalized brain swelling

Generalized cerebral blood flow

Fetal pO2, pCO2, pH, BP

Loss of vascular autoregulation

Cerebral blood flow

Delayed onset of respiration

Paralytic ileus or delayed (5-7 days)

Disseminated intravascular coagulation

Consequences of Asphyxia Metabolic

Optimal management is prevention: identify the fetus being subjected

Maintain a normal serum glucosa level (75-100

Primary versus Secondary Apnea

Signs of a Compromised Newborn

Low blood pressure

Poor muscle tone

Preparation for Resuscitation Personnel

Trained person to initiate

Recruit additional personnel,

Prepare necessary equipment

Evaluating the Newborn

Placing newborn under

Removing wet towel

Preventing Heat Loss

Raise environment temperature

Positioning on back or side

Slightly extending neck

Aligning posterior pharynx, larynx and trachea

Clear Airway: No Meconium Present

If meconium present and

Insert laryngoscope, use 12F or 14F suction

Insert endotracheal tube

Attach endotracheal tube to suction source

Apply suction as tube is withdrawn

Dry, Stimulate to Breathe, Reposition

Potentially Hazardous Stimulation

Resuscitation Flow Diagram

Post - Resuscitation Care

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