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.
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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

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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
no respiration
decreasing heart rate
BP maintained
responds to stimulus

Secondary Apnea
no respiration
heart rate very low
BP low
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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