Discussion: 2.1 Tutorial Data

CHAPTER II
DISCUSSION
2.1 Tutorial Data

Tutor : dr. Vina Pramayastri
Moderator : Muhammad Adamas
Secretary : Bella Juni Safira
Notulis : Fadhila Anggarini
Day and date : Tuesday, September 18th, 2018
(08.00-10.30)
Thursday, September 20th, 2018
(08.00 – 10.30)
Rule of tutorial : 1. Gadget should be nonactive or in silent mode.
2. Everyone in the group should express their
opinion.
3. ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.
2.2 Case Scenario

Two days old baby boy brought by his family and a midwife to Talang
Banten Puskesmas, with a chief complain of sluggishness to breastfeed and a
frequent “cycling” motion on the legs since 12 hours ago. The baby birth
spontaneously with a breech presentation helped by the midwife, not crying
immediately. His APGAR score was 3 on the first minute, 5 on the fifth
minute, and 8 on the tenth minute. The mother profile is G1P0A0 39 weeks
pregnant with breech presentation. There is no hypertension, diabetes, asthma,
and heart disease during pregnancy.
Physical Examination
Activity : Hypoactive
Sucking response : Weak
3 Scenario A Class of 2015

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Cries : Weak
Heart rate : 150x/minutes
Respiratory rate : 42x/minutes
Temperature : 36,6ºC
Cyanosis (-)
Dyspneu (-)
Icteric (-)
Bodylength : 47 cm
Birth weight : 2800 gram
Head circumference : 34 cm
Specific Examination:
Head : Nose: Nasal flaring (-), grunting (-)
Thorax : Chest retraction (-), Heart: heart sound I and II Normal, There’s no
murmur, Lungs: Normal vesicular and no ronchi
Abdomen : Flat, supple, bowel movement (+), umbilical cord normal
Extremity : Inspection: cycling motion of the leg was observed, there’s
no congenital defect
Genitalia : Anus: (+), meconium (+)
2.3 Clarification of Terms

There are six terms that we already clarified, those are show in the table 2.1
below.
Tabel 2.1 Clarification of Terms
No Terms Clarifications
1. Cycling motion Sign of neonatal seizure, caused by sudden
abnormal and excessive electrical activity in the
brain.
Scenario A Class of 2015

5
2. Breech presentation Fetus in longitudinal line with the buttocks or

feet closes to the cervix.
3. Meconium The first substance discharge from the
gastrointestinal tract in the perinatal period.
4. APGAR score (Activity, Pulse, Grimace, Appearance,
Respiration) is a test given to newborn soon after
birth. This test checks the baby heart rate, muscle
tone, and other sign to see if extra care or
emergencey care is needed.
5. Bowel movement Last stop in the movement of food through in
digestive tract.
6. Sucking response Behavior reflex in newborn, includes finding and
grusting the nipple in mouth and sucking on it
and swallowing the milk.
Sumber: Dorland, 2008
2.4 Problem Identification

1. Two days old baby boy brought by his family and a midwife to Talang
Banten Puskesmas, with a chief complain of sluggishness to breastfeed
and a frequent “cycling” motion on the legs since 12 hours ago.
2. The baby birth spontaneously with a breech presentation helped by the
midwife, not crying immediately. His APGAR score was 3 on the first
minute, 5 on the fifth minute, and 8 on the tenth minute.
3. The mother profile is G1P0A0 39 weeks pregnant with breech
presentation. There is no hypertension, diabetes, asthma, and heart
disease during pregnancy.
4. Physical Examination
Cries : Weak

6

Cyanosis (-)
Dyspneu (-)
Icteric (-)
Bodylength : 47 cm
5. Specific Examination:
Thorax : Chest retraction (-), Heart: heart sound I and II Normal,
There’s no murmur, Lungs: Normal vesicular and no ronchi
2.5 Analysis of Problem

1. Two days old baby boy brought by his family and a midwife to Talang
Banten Puskesmas, with a chief complain of sluggishness to breastfeed
and a frequent “cycling” motion on the legs since 12 hours ago.
a. What is the meaning of two days old baby sluggishness to
breastfeed and a frequent “cycling” motion on the legs since
12 hours ago?
Answer:
Sluggishness to breastfeed means that there are the
disturbances of sucking reflex due to the cerebral ischemia after
suffering from neonatal asphyxia. While a frequent “cycling”
motion on the legs means that the baby suffering a neonatal seizure
type subtle.

7
Synthesis:
Seizures are paroxysmal alterations in neurologic function
caused by excessive synchronous depolarization of neurons within
the central nervous system (Krakauer and Carter, 2012). There are
four types of neonatal seizure, one of the type is subtle seizure
Usually occurs in association with other types of seizures and may
manifest with stereotypic movements of the extremities such as
bicycling or swimming movements (Dahlan, 2008; Sheth, 2017).
Birth asphyxia, although the correct definition is imprecise,
is an insult to the fetus or newborn due to failure to breath or
breathing poorly leading to decrease oxygen perfusion to various
organ. Asphyxia is a condition that occur when there is an
impairment of blood-gas exchange, resulting in hypoxemia (lack
of oxygen) and hypercapnia (accumulation of carbon dioxide).
The combination of the decrease in oxygen supply (hypoxia) and
blood supply (ischaemia) results in a cascade of biochemical
changes inside the body, whose events lead to neuronal cell death
and brain damage (Aslam et al., 2014).
b. What is the possible causes of sluggishness to breastfeed?

Answer:
In this case, the possible causes of sluggish to breastfeed is
due to the hypoxia after suffering neonatal asphyxia.
Synthesis:
A neonate with mild HIE may present with absent rooting
and sucking reflexes initially. However, rooting and sucking
remained inadequate for breastfeeding well into the first week of
the participant’s life. An absent rooting reflex may not impact an
infant’s feeding functionally, but short sucking bursts may be
related to swallowing difficulties. Cerebral depression may cause
reduced alertness and a lower level of consciousness in infants

8
(Genna et al., 2013). In this study, it appears that state regulation

may have affected the participant’s ability to feed successfully
(Kruger et al., 2017).
c. What is the possible causes of a frequent “cycling” motion on

the legs?
Answer:
The possible causes of neonatal seizures are shown in table 2.2.
Table 2.2 Causes of neonatal seizures
Cause Frequency
Hypoxic-ischaemic encephalopathy 30-53%
Intracranial haemorrhage 7-17%
Cerebral infarction 6-17%
Cerebral malformation 3-17%
Meningitis/septicemia 2-14%
Metabolic
Hypoglycaemia 0,1-5%
Hypocalcaemia, hypomagnesaemia 4-22%
Hypo-/hypernatremia 3-4%
Inborn errors of metabolism (such as pyridoxine dependency,
folinic-acid responsive seizures, glucose transporter defecr, non-
ketotic hyperglycinaemia, proprionic aciduria)
Kern icterus
1%
Maternal drug withdrawal 4%
Idiopathic 2%
Benign idiopathic neonatal seizures 1%
Neonatal epileptic syndromes
Congenital infections
Source: Pressler, 2003
According to Dahlan (2008) and Jensen (2009) the possible

causes of seizures are:
Most common causes of seizures:
- HIE (Hypoxic-Ischemic Encephalopathy)
- Infections (TORCH, meningitis, septicemia)

9
- Hypoglycemia, hypocalcemia, hypomagnesemia

- CNS bleed (intraventricular, subdural, trauma, etc.)
Less common causes of seizures:
- Congenital brain anomalies
- Inborn errors of metabolism
- Maternal drug withdrawal (heroin, barbiturates, methadone,
cocaine, etc.)
- Kernicterus
- Pyridoxine (B6) dependency, and hyponatremia
Synthesis:
According to Kosim, et al (2008), the etiology of neonatal
seizures are:
- Asphyxia
Perinatal asphyxia causes hypoxic-ischemic
encephalopathy and is an important neurological problem in
the neonatal period, and causes neurological sequelae later
on. Intrauterine asphyxia is the most common cause of
hypoxic-ischemic encephalopathy. This is because
hypoxemia occurs, lack of oxygen to brain tissue. Both of
these conditions can occur together, one can be more
dominant but the ischemic factor is the most important factor
compared to hypoxemia.
- Intracranial Trauma and Bleeding
Trauma and intracranial bleeding usually occur in large
infants born to mothers with primiparous pregnancies. This
occurs during prolonged labor, difficult labor caused by fetal
position abnormalities in the uterus or precipitous birth
before the uterine cervix opens wide enough. In low birth
weight babies with a body weight of <1500 grams usually
bleeding occurs preceded by asphyxia. Intracranial

10
hemorrhage can occur in the arachnoid, subdural, and

intraventricular spaces or brain parenchyma.
- Infection
In newborns infection can occur in the uterus, during
labor, or immediately after birth. Infections in the uterus
occur due to primary maternal infections such as
toxoplasmosis, rubella, cytomegalovirus, and herpes. During
labor or immediately after birth, the baby can be infected by
the herpes simplex virus, Coxsackie virus, E. Colli, and
Streptococcus B which can cause encephalitis and
meningitis.
- Metabolic Disorder
Metabolic disorders that cause seizures in newborns
are disorders of metabolism of glucose, calcium,
magnenisum, electrolytes, and amino acids. This metabolic
disorder is present in 73% of newborns with brain damage.
Reduced glucose levels from normal values are the most
common cause of metabolic disorders in newborns. Various
conditions of metabolic disorders associated with seizures in
neonates are:
Hypoglycemia: Hypoglycemia in newborns is when in the
first three days after birth, blood sugar levels are less than 20
mg% in under-month infants or less than 30 mg% in term
infants on examination of blood sugar levels 2 times in a row,
and less than 40mg% in infants over 3 days. Hypoglycemia
often occurs in small babies during pregnancy, babies of
mothers with diabetes, or babies with severe diseases such as
asphyxia and sepsis.
Hypocalcaemia: Hypocalcaemia is rarely the sole cause of
neonatal seizures. usually hypocalcemia is accompanied by
other disorders, such as hypoglycemia, hypomagnersemia,
or hypophosphatemia. The diagnosis of hypocalcemia is

11
when the blood calcium level is less than 7 mg%.

Hypocalcemia occurs early in infants with low birth weight,
hypoxic-ischemic encephalopathy, infants of mothers with
diabetes mellitus, babies born due to severe complications
mainly due to asphyxia.
- Electrolyte Disorders
Disorders of electrolyte balance, especially sodium,
cause hyponatremia or hypernatremia, both of which cause
seizures. Hyponatremia can occur if there is an imperfect
secretion from hormone diuretics (ADH). This often occurs
together with meningitis, meningoencephalitis, sepsis, and
intracranial bleeding. Hyponatremia can occur in diarrhea
due to excessive sodium secretion, errors in fluid
administration in infants, and due to excessive sweating.
Hypernatremia occurs when excessive administration of
sodium bicarbonate in correction of acidosis with
dehydration.
d. What is the classification of neonatal seizures?

Answer:
According to Sheth (2017) and Dahlan (2008), neonatal
seizure are classified into:
- Subtle seizures (Preterm and term)
Usually occurs in association with other types of
seizures and may manifest with: Stereotypic movements of
the extremities such as bicycling or swimming movements.
Deviation or jerking of the eyes with repetitive blinking.
Drooling, sucking or chewing movements. Apnea or sudden
changes in respiratory patterns. Rhythmic fluctuations in
vital signs.

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- Clonic seizures
These movements most commonly are associated with
electrographic seizures. They often involve 1 extremity or 1
side of the body. The rhythm of the clonic movements is
usually ,.slow, at 1-3 movements per second.
- Tonic seizures
These may involve 1 extremity or the whole body.
Focal tonic seizures involving 1 extremity often are
associated with electrographic seizures. Generalized tonic
seizures often manifest with tonic extension of the upper and
lower limbs and also may involve the axial musculature in
an opisthotonic fashion. Generalized tonic seizures mimic
decorticate posturing; the majority are not associated with
electrographic seizures.
- Myoclonic seizures
These may occur focally in 1 extremity or in several
body parts (in which case they are described as multifocal
myoclonic seizures). Focal and multifocal myoclonic
seizures typically are not associated with electrographic
correlates. These movements are thought to be non-epileptic
in nature and a reflection of severe encephalopathy.
Synthesis:
Neonatal seizures can be classified into four categories:
subtle, clonic, tonic, or myoclonic. Subtle seizures are more
common in premature infants and manifest most often as ocular
phenomena (tonic horizontal eye deviation with or without eye
jerking, sustained eye opening with ocular fixation), oral-buccal-
lingual movements (chewing or tongue thrusting), or “bicycling”
or stepping movements of the lower extremities. Subtle seizures
are not consistently associated with EEG changes (Krakauer and
Carter, 2012).

13
Clonic seizures tend to manifest as focal, slow, rhythmic

jerks of the face, unilateral upper or lower extremities, trunk, or
neck, and the infant usually remains conscious. With focal
seizures, there is often a corresponding underlying focal condition,
such as a cerebral infarct changes (Krakauer and Carter, 2012).
Tonic seizures can be focal or generalized. Focal tonic
seizures result in sustained posturing of a limb or asymmetrical
posturing of the trunk or neck, whereas generalized tonic seizures
manifest as tonic extension of both upper and lower extremities.
Tonic flexion of the upper extremities with extension of lower
extremities actually may represent posturing, a movement
frequently associated with severe intraventricular hemorrhage, but
not necessarily resulting from a seizure changes (Krakauer and
Carter, 2012).
Picture 2.1 Classification of neonatal seizure

Source: Pressler, 2003

14
Myoclonic seizures usually involve the flexor muscle groups

and can be focal, multifocal, or generalized. These movements
have a faster jerk speed than clonic seizures and are not commonly
associated with EEG manifestations. Seizures can manifest as
apnea. Apnea secondary to seizures is more common in the term
than the preterm infant. Most infants who have apnea secondary
to a seizure also exhibit other subtle phenomena, such as eye
opening, staring, and deviation or stereotypical mouth movements
during the apneic episode, which can guide the clinician to the
diagnosis. In the premature infant, most apnea is not related to
seizures. Bradycardia is less likely to be associated with apnea
from a seizure than with nonconvulsive apnea changes (Krakauer
and Carter, 2012).
e. What is the sign of neonatal seizure?

Answer:
According to Dahlan (2008) the sign of neonatal seizures are:
- Tonic Seizures
Generalized tonic seizures:
 Mainly manifest in preterm neonates (< 2500 grams).
 Tonic flexion or extension of the upper extremities, neck,
or trunk and
 are associated with tonic extension of the lower
extremities.In 85% of cases are not associated with any
autonomic changes such as increases in heart rate or
blood pressure, or skin flushing.
Focal tonic seizures:
 Present with asymmetrical posturing of one of the limbs
or trunk or with tonic head or eye deviation.
 Mostly occur with diffuse central nervous system disease
and intraventricular hemorrhage.

15
- Clonic Seizures
 Consist of slow (1-3 /minute) rhythmic jerking
movements of the extremities. They may be focal or
multi-focal. Each movement is composed of a rapid
phase followed by a slow one.
 Changing the position or holding the moving limb does
not suppress the movements. They are commonly seen in
full-term neonates >2500 grams
 There is no loss of consciousness and they are associated
with focal trauma, infarction or metabolic disturbances.
- Myoclonic Seizures
 Focal myoclonic seizures typically involve the flexor
muscles of the extremities.
 Multi-focal myoclonic seizures present as asynchronous
twitching of several parts of the body.
 Generalized myoclonic seizures present as massive
flexion of the head and trunk with extension or flexion of
the extremities. They are associated with diffuse CNS
pathology.
- Subtle (Fragmentary) Seizures
Usually occurs in association with other types of seizures and
may manifest with:
 Stereotypic movements of the extremities such as
bicycling or swimming movements.
 Deviation or jerking of the eyes with repetitive blinking.
 Drooling, sucking or chewing movements.
 Apnea or sudden changes in respiratory patterns.
 Rhythmic fluctuations in vital signs.

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f. What is the effect of seizure?

Answer:
According to Dahlan (2008), the effect of neonates seizures
are:
- Hypocalcemia
- Pyridoxine dependency
- Subarachnoid hemorrhage
- Hypoglycemia
- Anoxia
- Brain malformation
- Mental retardation
- Cerebral palsy
Neonates with clinical seizures are at higher risk for

morbidity and mortality. Neonates with clinical seizures are
associated with developed epilepsy, developed cerebral palsy,
mental retardation, and learning disorders. Neonates with hypoxic-
ischemic encephalopathy, seizures are associated with impaired
brain metabolism (Abend and Wusthoff, 2012).
Synthesis:
Both clinical and laboratory studies demonstrate that
seizures early in life can result in permanent behavioral
abnormalities and enhance epileptogenicity. In experimental
rodent models, the consequences of seizures are dependent upon
age, etiology, seizure duration, and frequency. Recurrent seizures
in immature rats result in long-term adverse effects on learning
and memory. These behavioral changes are paralleled by changes
in brain connectivity, dendritic morphology, excitatory and
inhibitory receptor subunits, ion channels, and neurogenesis.
These changes can occur in the absence of cell loss. Although
impaired cognitive function and brain changes have been well

17
documented after early onset seizures, the mechanisms of seizure-

induced injury remain unclear. Recent studies have demonstrated
abnormalities in single cell function that parallel behavioral
changes (Holmes, 2005).
Brief, recurrent seizures in the neonatal period not only
appear to exhibit plasticity that can be anatomically and
physiologically meaningful but also seem to produce cognitive
deficits. Translation of these findings into clinical practice is
limited by the effects chronic therapy may have on brain
development (Holmes, 2005).
The underlying etiology has been determined to be one of
the main prognostic factors for long-term sequelae in survivors of
neonatal seizures. HIE, hemorrhage, CNS infection, and cerebral
malformations are known to be associated with adverse outcomes
compared to other etiologies of neonatal seizures. Grades of
neonatal encephalopathy assessed by encephalopathy scores or
Sarnat staging are often used to predict neurodevelopmental
outcome (Kang and Kadam, 2015).
The effect of hypothermia on improved AED efficacy was
shown to depend on the severity of HIE, effective only in neonates
with moderate, but not in severe HIE. However, the standardized
methodology for identifying the severity of HIE is not uniform.
Additionally, severe HIE tends to associate with higher seizure
burdens, as is the case in the study by Srinivasakumar et al.
Therefore, it is difficult to conclude that etiology was the sole main
factor and seizure burden did not exacerbate the encephalopathy
(Kang and Kadam, 2015).
Neonatal seizures are a significant risk factor for long-term
sequelae, especially in the setting of HIE. The recurrent seizures
themselves appear to cause additional neurodevelopmental
consequences beyond that due to the underlying etiology.
Prolonged seizures were shown to worsen brain damage in HIE

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brain; indicating seizures themselves may have a harmful effect.

HIE associated with status epilepticus frequently results in adverse
neurodevelopmental outcomes. The severity of clinical seizures
comprehensively measured by seizure frequency, onset, EEG
abnormalities, and number of AEDs used, was independently
associated with the brain injury in HIE-neonates. The temporal
profile of electrographic seizure burdens in neonatal HIE has also
been evaluated (Kang and Kadam, 2015).
Differential outcomes associated with the differential timing
of onset of seizures, however, are not clear from these studies.
Hence, increasing evidence suggests that neonatal seizures need to
be controlled, to lessen the long-term co-morbidities above and
beyond those associated with the underlying etiology alone.
Additionally, seizures in a developing brain can beget seizures,
and, therefore, it is difficult to delineate the role of the underlying
etiology vs. prolonged repetitive seizures under these conditions
(Kang and Kadam, 2015).
Neonatal seizures, especially those that are PB resistant,
significantly correlate to moderate–severe brain injury rather than
mild or no injury. This study found that, the efficacy of a single
dose of 20 mg/kg PB significantly differed by the severity of
injury. Seizures were readily controlled in neonates with mild or
no injury, whereas only 30% of neonates with moderate–severe
injury responded to PB. Similarly, the severity of brain injury
dictated the seizure burden recorded by video-EEG. The presence
of brain injury and status epilepticus were highly predictive of the
development of epilepsy later on in life. Neonatal MRI has
demonstrated its possible clinical use for early identification of
preterm babies at risk for later cognitive impairment. Similar
protocols scanning neonates with seizures will help assess long-
term outcomes more reliably (Kang and Kadam, 2015).

19
The risk factors that can be used as parameters for predicting

chronic outcomes of neonatal seizures remain unclear. A large
cohort study at a tertiary center by Nunes et al. reported that the
development of postnatal epilepsy and global developmental delay
are common following neonatal seizures. For both co-morbidities,
low birth weight, abnormal postnatal EEG and neuroimaging were
also significant risk factors. Follow-up MRIs at 1 and 2 years of
age with no evidence of lesion has been reported to indicate better
prognostication compared to those with detectable lesions. In a
similar study, evaluating risk factors for the long-term sequelae
following neonatal seizures, low Apgar score at 5 min, cesarean
section, time of seizure onset, seizure type, and the abnormal
background EEG were independently predictive of worse long-
term outcome following neonatal seizures (Kang and Kadam,
2015).
g. What is the mechanism of sluggishness to breastfeed and a

frequent “cycling” motion on the legs in this case?
Answer:
There is breech presentation as a risk factor of asphyxia in
this case, based on the the research by Putriana (2016) one of the
causes of asphyxia is breech presentation. Breech presentation
cause the compression of umbilical cord, which can cause the
alterations of circulation on the umbilical cord vessels and disturb
the gas exchange between maternal and fetus circulation.
The compression of umbilical cord leads to decrease of blood
flow, oxygen, and nutrients to the fetus and leads to asphyxia.
Asphyxia leading to decrease oxygen perfusion to various organ
especially brain and heart. When there is an impairment of blood-
gas exchange, resulting in hypoxemia (lack of oxygen) and
hypercapnia (accumulation of carbon dioxide). The combination
of the decrease in oxygen supply (hypoxia) and blood supply

20
(ischaemia) (Aslam et al., 2014). When the oxygen supply is

decrease, cell will change their aerobic metabolism to anaerobic
metabolism which leads to the accumulation of secondary product
such as glutamate, and also leads to the imbalance of ATP
(Adenosine triphosphate) production.
Glutamate will interact to their receptors and increase cell
permeability to sodium and calcium and leads to the imbalance of
these electrolyte. Then, this process cause excessive accumulation
of intracellular sodium and leads to depolarization. This manifest
as neonatal seizures (cycling motion). leading to decrease oxygen
perfusion to various organ. The combination of the decrease in
oxygen supply (hypoxia) and blood supply (ischaemia) results in
a cascade of biochemical changes inside the body, whose events
lead to neuronal cell death and brain damage (Aslam et al., 2014).
Synthesis:
Extracellular accumulation of excitatory amino acids
(mainly glutamate) due to increased release as well as impaired
uptake; this causes the overactivation of neuronal glutamate
receptors, mainly the N-methyl-D-aspartate (NMDA) receptor,
which results in an excessive intracellular influx of calcium
(Antonucci et al., 2014).
The resulting intracellular calcium accumulation has the
following effects: (a) activation of celldegrading enzymes (lipases,
phospholipases, proteases and endonucleases); (b) production of
oxygen free radicals through activation of Xanthine oxidase,
increased prostaglandin synthesis, and activation of Nitric Oxide
(NO) synthase (Antonucci et al., 2014).
Peroxidation of membrane lipids and direct damage of
protein and DNA as a result of the increase in free radical
formation and the subsequent depletion of normal antioxidant
defenses. Impaired mitochondrial function as a combined result of

21
intracellular calcium accumulation and excessive amounts of free

radicals (Antonucci et al., 2014).
h. How is the physiology of newborn?

Answer:
The immediate postpartum period is a time of significant
physiological adaptation for both the mother and baby. The
newborn must adapt from being completely dependent on another
for life sustaining oxygen and nutrients to an independent being, a
task accomplished over a period of hours to days. Successful
transition from fetal to neonatal life requires a complex interaction
between the following systems
- Respiratory
- Cardiovascular
- Thermoregulatory
- Immunologic
Establishing respirations is critical to the newborn’s
transition, as lungs become the organ of gas exchange after
separation from maternal uteroplacental circulation. Over 90% of
newborns make the transition from intrauterine life to extrauterine
life without difficulty, requiring little to no assistance (NRP,
2010). However, for the 10% of newborns who do require
assistance, about 1% require extensive resuscitative measures to
survive.
Neonatal circulation
With the infant’s first breath and exposure to increased
oxygen levels, there is an increased blood flow to the lungs causing
the closure of the foramen ovale. Constriction of the ductus
arteriosus is a gradual process that results from a reduction of
pulmonary vascular resistance (PVR), increasing systemic
vascular resistance (SVR) and sensitivity to a rise in arterial PaO2

22
levels. The removal of the placenta decreases prostaglandin levels

(which helped to maintain ductal patency) further influencing
closure (Alvaro & Rigatto, 2005; Kenner, 2003).
At birth, the clamping of the umbilical cord eliminates the
placenta as a reservoir for blood, triggering an increase in systemic
vascular resistance (SVR), an increase in blood pressure, and
increased pressures in the left side of the heart. The removal of the
placenta also eliminates the need for blood flow through the ductus
venosus, causing functional elimination of this fetal shunt.
Systemic venous blood flow is then directed through the portal
system for hepatic circulation. Umbilical vessels constrict, with
functional closure occurring immediately. Fibrous infiltration
leads to anatomic closure in the first week of life (Alvaro &
Rigatto, 2005).
Successful transition and closure of fetal shunts creates a
neonatal circulation where deoxygenated blood returns to the heart
through the inferior and superior vena cava. Blood then enters the
right atrium to the right ventricle and travels through the
pulmonary artery to the pulmonary vascular bed. Oxygenated
blood returns through pulmonary veins to the left atrium, the left
ventricle, and through the aorta to systemic circulation. Hypoxia,
acidosis and congenital heart defects are conditions that lead to a
sustained high PVR and may interfere with the normal sequence
of events (Askin, 2008).
The Respiratory Adaptation

The initiation of breathing is a complex process that involves
the interaction of biochemical, neural and mechanical factors
(Alvaro & Rigatto, 2005). Pulmonary blood flow, surfactant
production, and respiratory musculature also influence respiratory
adaptation to extrauterine life.

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- Umbilical cord clamping decreases oxygen concentration,

increases carbon dioxide concentration, and decreases the
blood pH. This stimulates the fetal aortic and carotid
chemoreceptors, activating the respiratory centre in the
medulla to initiate respiration.
- Mechanical compression of the chest during the vaginal birth
forces approximately 1/3 of the fluid out of the fetal lungs.
As the chest is delivered, it re-expands, generating a negative
pressure and drawing air into the lungs. Passive inspiration
of air replaces fluid. As the infant cries, a positive
intrathoracic pressure is established which keeps the alveoli
open, forcing the remaining fetal lung fluid into the
lymphatic circulation.
- In order for the respiratory system to function effectively, the
infant must have adequate pulmonary blood flow, adequate
amount of surfactant, and respiratory musculature strong
enough to support respiration (Askin, 2008).
Newborn Reflexes
One of the neonate’s greatest strengts is a full set of useful
reflexes. A reflex is an involuntary and automatic response to a
stimulus.
Table 2.2 Major reflexes present in full term neonates
Development
Name Response Significance
and course
Survival reflex
Breathing Repetitive inhalation Provides oxygen and
Permanent
reflex and expiration expel carbon dioxide
Eye-blink Closing or blinking Protect the eyes from
Permanent
reflex the eyes bright lights, adapt visual
Constriction of pupils
Pupilary reflex Protect against bright
to bright;dilatation to Permanent
lights
dark

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Disappears
Rooting reflex over the first
Turning the head in
few weeks of
the direction of a
life and is Orients baby to the breast
tactile (touch)
replaced by
stimulus to the cheek
voluntary
head turning.
Sucking on object
Sucking reflex Allows baby to take in
placed (or taken ) into Permanent
nutrients
the mouth
Swallowing Allows baby to take in
Swallowing Permanent
reflex nutrients
Primitive reflexes
Usually
Its presence at birth and
Fanning and then disappears
disappearance in the first
curling the toes when within the
Babinsky reflex year are an indication of
the bottom of the foot first 8 months
normal neurogical
is stroked to 1 year of
development
life
Disappears in
first 3-4 Its presence at birth and
Curling of the fingers
months and is later disappearance in the
Palmar around object (such a
then replaced first year are an indication
grasping reflex finger) that touch the
by a of normal neurogical
baby’s palm
voluntary development
grasp
The arm
movements
and arching
of the back
disappear
A loud noise or
over the first
sudden change in the
4-6 months;
position of the baby’s
however, the
head will cause the
child
baby to throw his or Its presence at birth and
continues to
Moro reflex her arms outward, later disappearance are an
react to
arch the back, and indication of normal
unexpected
then bring the arms neurological development
noises or a
toward each other as
loss of bodily
if to hold onto
support by
something.
showing a
startle reflex
(which does
not
disappear).
An infant immersed
in water will display, Disappears in Its presence at birth and
Swimming
active movements of the first 4-6 later disappearance are an
reflex
the arms and legs and months. indication of normal
involuntarily hold his neurological development
or her breath (thus

25
giving the body

buoyancy); this
swimming reflex will
keep an infant afloat
for some time,
allowing easy rescue.
Disappears in
the first 8 Its presence at birth and
Infants held upright weeks unless later disappearance are an
so that their feet touch the infant has indication of normal
Stepping reflex
a flat surface will step regular neurological
as if to walk. opportunities development.
practice this
response.
Source: Shaffer and Kipp, 2010
2. The baby birth spontaneously with a breech presentation helped by the

midwife, not crying immediately. His APGAR score was 3 on the first
minute, 5 on the fifth minute, and 8 on the tenth minute.
a. What is the meaning of the baby birth spontaneously with a
breech presentation helped by the midwife, not crying
immediately?
Answer:
- Spontaneous birth means vaginal delivery is a natural
process that usually does not require significant medical
intervention. Management guided by current knowledge of
the relevant screening tests and normal labor process can
greatly increase the probability of an uncomplicated delivery
and postpartum course (Patterson et al., 2008).
- Breech presentation is defined as a fetus in a longitudinal lie
with the buttocks or feet closes to the cervix (Fischer, 2016).
- Not crying immediately means suffer neonatal asphyxia.
Synthesis:
According to Kotaska et al (2009) For a woman with
suspected breech presentation, pre- or early labour ultrasound

26
should be performed to assess type of breech presentation, fetal

growth and estimated weight, and attitude of fetal head. If
ultrasound is not available, Caesarean section is recommended.
The contraindications to labour include cord presentation, fetal
growth restriction or macrosomia, any presentation other than a
frank or complete breech with a flexed or neutral head attitude,
clinically inadequate maternal pelvis, and fetal anatomy
incompatible with vaginal delivery. Vaginal breech delivery can
be offered when the estimated fetal weight is between 2500 g and
4000 g.
Ultimately, if the obstetrical operator is not experienced or
comfortable with vaginal breech deliveries, cesarean delivery may
be the best choice. Unfortunately, with the dwindling number of
experienced obstetricians who still perform vaginal breech
deliveries and who can teach future generations of obstetricians,
this technique may soon be lost due to attrition.
b. What is the classification of asphyxia?

Answer:
According to Dahlan (2008), asphyxia are classified into:
- Vigorous baby with Apgar score 7-10
- Mild-Moderate asphyxia with Apgar Score 4-6 and Physical
examination was HR <100/minute cyanosis and muscle tone
good.
- Severe Asphyxia Apgar Score 0-3 and Phisical Examination
HR >1000/minute, severe cyanosis and weak muscle tone.
- Severe Asphyxia with cardiac arrest.
c. What is the possible causes of asphyxia?

Answer:
According to Antonucci et al (2014), the etiology of asphyxia are:

27
- In term newborns, asphyxia can occur in utero and during

labor and delivery as a result of impaired placental gas
exchange.
- Preconceptional risk factors for asphyxia are maternal age ≥
35 years, social factors, family history of seizures or
neurologic disease, infertility treatment, previous neonatal
death etc.
- Antepartum risk factors include maternal prothrombotic
disorders and proinflammatory states, maternal thyroid
disease, severe preeclampsia, multiple gestation,
chromosomal/ genetic abnormalities, congenital
malformations, intrauterine growth restriction, trauma,
breech presentation and antepartum hemorrhage.
- Numerous intrapartum risk factors for asphyxia are
recognized, including abnormal fetal heart rate during labor,
chorioamnionitis/maternal fever, thick meconium, operative
vaginal delivery, general anesthesia, emergency cesarean
delivery, placental abruption, umbilical cord prolapse,
uterine rupture, maternal cardiac arrest, and fetal
exsanguination.
- Asphyxia can also occur in the immediate postnatal period,
usually secondary to pulmonary, neurological or
cardiovascular abnormalities. It should be noted that, in
many cases, the timing of asphyxia cannot be established
with certainty.
In this case, the possible causes of asphyxia is due to breech

presentation with spontaneously birth.

28
d. What is the meaning his APGAR score was 3 on the first

minute, 5 on the fifth minute, and 8 on the tenth minute?
Answer:
The baby boy suffered a neonatal asphyxia if APGAR score
is 3 on the first minute and these result indicate the baby needs
medical intensive care. But, this score is not indicate to longterm
effect especially if the scores is increase on the fifth minute. But,
if the APGAR scores is still below 3 on the next test (tenth,
fifteenth, and thirtieth minute) there will be a higher risk for the
baby has a longterm neuron damages and a small risk but
significantly will suffer a brain damage.
That document considers an Apgar score of 0-3 at 5 minutes
or more as a nonspecific sign of illness, which “may be one of the
first indications of encephalopathy” (American Academy of
Pediatrics, 2015).
e. What is the purpose of APGAR score?

Answer:
The Apgar score provides an accepted and convenient
method for reporting abstract the status of the newborn infant
immediately after birth and the response to resuscitation if needed.
This scoring system provided a standardized assessment for
infants after delivery (Dahlan, 2008).
f. How to assess the APGAR score?

Answer:
According to CMNRP (2013) and Queensland Government
(2016) the APGAR score is done by a doctor, midwife, or nurse.
The provider examines the baby’s breathing effort, heart rate,
muscle tone, reflexes, and Skin color.

29
Using the table provided, assign the newborn a score (0-2)

for each of the five criteria at 1 minute and again at 5 minute
following delivery. Add all individual scores to calculate the total
APGAR score (0-10).
Breathing effort:
- If the infant is not breathing, the respiratory score is 0.
- If the respirations are slow or irregular, the infant scores 1 for
respiratory effort.
- If the infant cries well, the respiratory score is 2.
Heart rate is evaluated by stethoscope:
- If there is no heartbeat, the infant scores 0 for heart rate.
- If heart rate is less than 100 beats per minute, the infant
scores 1 for the heart rate.
- If heart rate is greater than 100 beats per minute, the infant
scores 2 for heart rate.
Muscle tone:
- If muscles are loose and floppy, the infant scores 0 for
muscle tone.
- If there is some muscle tone, the infant scores 1.
- If there is active motion, the infant scores 2 for muscle tone.
Grimace response or reflex irritability is a term describing
response to stimulation, such as:
- If there is no reaction, the infant scores 0 for reflex
irritability.
- If there is grimacing, the infant scores 1 for reflex irritability.
- If there is grimacing and a cough, sneeze, or vigorous cry,
the infant scores 2 for reflex irritability.
Skin color:
- If the skin color is pale blue, the infant scores 0 for skin color.
- If the body is pink and the extremities are blue, the infant
scores 1 for skin color.
- If the entire body is pink, the infant scores 2 for skin color.

30
Synthesis:
The APGAR score is a valuable method to determine the
health of newborns immediately after birth. It is determined by
allocating score to five (5) simple criteria, colour (Appearance),
heart rate (Pulse), reflex irritability (Grimace), muscle tone
(Activity), and breathing (Respiration). The purpose of the
APGAR score is to determine whether a newly born needs
immediate medical care. It is not designed to make long-term
predictions of child’s health. The APGAR score assessment is
indicated to all newly borns at one minute and five minutes
following delivery. An APGAR score of 0-3 represents severe
distress, 4-7 indicates moderate distress, and 7-10 indicates an
absence of difficuly in adjusting to extrauterine life (Queensland
Government, 2016).
In 1952, dr. Virginia Apgar devised a scoring system that
was rapid method of assessing the clinical status of the newborn
infant at 1 minute of age and the need for prompt intervention to
establish breathing. This scoring system provided a standardized
assessment for infants after delivery. Thus, the Apgar score
quantitates clinical signs of neonatal depression such as cyanosis
or pallor, bradycardia, depresses reflex response to stimulation,
hypotonia, and apnea or gasping respirations. The score is reported
at 1 minute and 5 minutes after birth for all infants, and at 5-minute
intervals thereafter until 20 minutes for infants with a score less
than 7. The Apgar score provides an accepted and convenient
method for reporting the status of the newborn infant immediately
after birth and the response to rescucitation if needed. However, it
has been inappropriately used to predict individual adverse
neurologic outcome. The purpose of this statement is to place the
Apgar score in its proper perspective (American Academy of
Pediatrics, 2015).

31
An Apgar score that remains 0 beyond 10 minutes of age

may, however, be useful in determining whether continued
resuscitative efforts are indicated because very few infants with an
Apgar score of 0 at 10 minutes have been reported to survive with
normal neurologic outcome. In line with this, the 2011 Neonatal
Resuscitation Program guidelines state that “if you can confirm
that no heart rate has been detectable for at least 10 minutes,
discontinuation of resuscitative efforts may be appropriate
(American Academy of Pediatrics, 2015).
Picture 2.2 Expanded APGAR score form

Source: American Academy of Pediatrics, 2015
Neonatal Encephalopathy and Neurologic Outcome, Second

Edition, published in 2014 by the college in collaboration with the
AAP, defines a 5-minute Apgar score of 7-10 as reassuring, a score
of 4-6 as moderately abnormal, and a score of 0-3 as low in the
term infant and late-preterm infant. That document considers an
Apgar score of 0-3 at 5 minutes or more as a nonspecific sign of

32
illness, which “may be one of the first indications of

encephalopathy”. However, a persistently low Apgar score alone
is not a specific indicator for intrapartum compromise. Further,
although the score is used widely in outcome studies, its
inappropriate use had led to an erroneous definition of asphyxia.
Asphyxia is defined as the marked impairment of gas exchange
leading, if prolonged, to progressive hypoxemia, hypercapnia, and
significant metabolic acidosis. The term asphyxia, which describes
a process of varying severity and duration rather than an end point,
should not be applied to birth events unless specific evidence
markedly impaired intrapartum or immediate postnatal gas
exchange can be documented based on laboratory testing
(American Academy of Pediatrics, 2015).
g. What is the possible causes of breech presentation?

Answer:
According to Manuaba (2010) the possible causes of breech
presentation are:
Maternal factors
- Uterus condition (Arcuatus uterus, septum in the uterus,
duplex uterus, myoma in pregnancy)
- State of the birth canal
- Placenta condition (Placenta previa)
Fetus factors
- Short umbilical cord or umbilical cord
- Hydrocephaplus
- Twin pregnancy
- Hidroamnion or oligohidroamnio
- Prematurity
According to Fischer (2016) predisposing factors for breech

presentation include prematurity, uterine malformations or

33
fibroids, polyhydramnios, placenta previa, fetal abnormalities (eg,

CNS malformations, neck masses, aneuploidy), and multiple
gestations.
h. What is the correlation between the complain above and the

chief complain?
Answer:
The correlation between breech persentation and not crying
immediately with seizure is the risk factor of seizure. Which is the
breech persentation causes size of uterine space to small and make
uteri circulation disorder. The umbilical cord compressed between
the baby’s head and pelvic so that blood flow inhibited and caused
asphyxia. The circulation oxf oxygen disturbed and causing
seizure.
3. The mother profile is G1P0A0 39 weeks pregnant with breech

presentation. There is no hypertension, diabetes, asthma, and heart
disease during pregnancy.
a. What is the meaning of the mother profile is G1P0A0, 39 weeks
pregnant with breeh presentation?
Answer:
- G1P0A0
Gravida 1  have been pregnant 1
Partus 0  never given birth
Abortion 0  no abortion
- 39 weeks pregnant  normal, no premature
- Breech presentation  malpresentation
b. What is the meaning of the mother has no hypertension,

diabetes, asthma, and heart disease during pregnancy?
Answer:
The causes of seizure is not from maternal factors.

34
Synthesis:
Asphyxia results due to inadequate placental perfusion and
impaired gaseous exchange that may be caused by fetal factors
(fetal bradycardia, fetal thrombosis, and fetal hemorrhage),
maternal factors (preeclampsia, abruptio-placentae, maternal
hypotension, severe anemia, asthma and chronic vascular disease),
or tight nuchal cord and cord prolapse. Postnatal asphyxia results
from conditions causing neonatal pulmonary failure such as severe
hyaline membrane disease, meconium aspiration syndrome,
pneumonia, or congenital cardiac disease (Bano et al., 2017).
The basic physiologic processes that result in HIE, both in
preterm and term neonate, is asphyxia leading to brain ischemia
(reduced cerebral blood flow) and hypoxia (reduced cerebral
oxygen). Hypoperfusion, in conjunction with hypoxia, leads to a
cascade of events including acidosis, release of inflammatory
mediators and free radical formation. These biochemical
substances result in loss of normal cerebral autoregulation and
diffuse brain injury (neuronal cell death). The exact nature of the
injury depends on the severity and duration of hypoxia and degree
of brain maturation. In term infants, myelinated fibers are more
metabolically active and hence more vulnerable to HIE (Bano et
al., 2017).
4. Physical Examination
Cries : Weak
Cyanosis (-)
Dyspneu (-)

35
Icteric (-)
Bodylength : 47 cm
a. What is the interpretation and mechanism of pathological
finding on physical examination?
Answer:
The interpretation of physical examination on table 2.3 below.
Table 2.3 Interpretation of physical examination
Findings References Result

Activity hypoactive Active Abnormal
Sucking response weak Strong Abnormal
Cries weak Strong Abnormal
Heart rate 150x/minutes 100-160x/minutes Normal
Respiratory rate 42x/minutes 40-60x/minutes Normal
Temperature 36,6 ºC 36,3-37,2 ºC Normal
Cyanosis (-) (-) Normal
Dyspneu (-) (-) Normal
Icteric (-) (-) Normal
Body length 47 cm 46-55 cm Normal
Birth weight 2800 gram 2500-3000 gram Normal
Head circumference 34 cm 32-38 cm Normal
Based on this physical examination result, two days old baby

boy suffer cerebral ischemia. Normal vital sign show that there are
no respiratory distress in this case.
b. How is the classification of birth weight?

Answer:
According to Dahlan (2008) the classification are:
- Extremely low birth weight (ELBW) less than 100g
- Very low birth weight (VLBW) less than 1500gr
- Low birth weight (LBW) less than 2,499gr
- Nomal birth weight 2500-4000gr
- Large for gestational age >4000gr macrosomia

36
5. Specific Examination:
Thorax : Chest retraction (-), Heart: heart sound I and II Normal,
There’s no murmur, Lungs: Normal vesicular and no ronchi
a. What the interpretation and mechanism of the pathological
finding on specific examination?
Answer:
The interpretation of specific examination on table 2.4 below.
Table 2.4 Interpretation of specific examination
Findings References Result

Head
Nose: Nasal flaring (-) (-) Normal
Grunting (-) (-)
Thorax:
Chest retraction (-) (-) Normal
Heart: HS I and II Normal HS I and II normal
No Murmur (-)
Lungs: Normal vesicular, no Normal, ronchi (-)
ronchi
Abdomen
Flat, supple, bowel movement Normal Normal
(+), umbilical cord normal
Extremity
Inspection: cycling motion of No cycling motion Seizure (Subtle)
the leg was observed
No congenital defect
Genitalia Normal
Anus (+) (+)
Meconium (+)
Based on this result, the baby suffer a subtle seizures with no

respiratory distress syndrome.

37
b. What is the meaning of meconium (+) in this case?

Answer:
Meconium is the stool of the fetus, formed before birth and
composed of materials ingested in the uterus, including intestinal
epithelial cells, lanugo, mucus, amniotic fluid, bile and water.
Unlike later faeces it is viscous, sticky and tar-like, and is usually
very dark green in colour. It may be pasty or stringy and tan to
dark tarry in color. The presence of meconium in amniotic fluid in
the second stage of labour is an indication of potential fetal
compromise and experienced obstetric advice must be sought.
Meconium passage in newborn infants is a developmentally
programmed event normally occurring within the first 24 to 48
hours after birth. In normal active neonates, meconium passage
will start within 6 hours after the first feeding (Myles, 2009).
6. What disturbances might happen in this case?

Answer:
Based on the discussion above, the disturbance might happen in
this case are:
- Neonatal seizures
- Neonatal tetanus
- Kern icterus
7. What is the additional examination needed to diagnose this case?

Answer:
The additional examination needed to diagnose this case are:
- Blood: glucose, electrolyte, calcium, magnesium, amonia, lactate,
blood gas analysis.
- Cerebrospinal fluid: cell count, glucose, protein, bacterial culture
test.
- EEG (electroencephalography)

38
8. What disturbance are most likely occur in this case?

Answer:
The disturbances are most likely occur in this case is neonatal
seizures with history of neonatal asphyxia.
9. How does the comprehensive management for this case?

Answer:
According to AIIMS.NICU (2007) and Queensland Guidlines
(2017) the management of neonatal seizure are:
- Resuscitation:
 Establish adequate airway, ventilation and perfusion
(minimise additional postnatal hypoxaemia and hyper or
hypocapnia).
 Commence cardio-respiratory, oxygen saturation and blood
pressure monitoring in babies.
 Obtain intravenous (IV) access.
- Treat other common biochemical derangements such as:
 Hypocalcaemia with 10% calcium gluconate IV 2 mL/kg
over 10 minutes and with cardiac monitoring,
hypomagnesaemia with 50% magnesium sulphate deep
intramuscular injection 100 mg/kg.
- Phenobarbitone is the drug of choice for neonatal seizures. The
dose is 20 mg/kg/IV slowly over 20 minutes (not faster than 1
mg/kg/min). If seizures persist after completion of this loading
dose, repeat dose of phenobarbitone 10 mg/kg may be used every
20-30 minutes till a total dose of 40 mg/kg has been given. The
maintenance dose is 3-5 mg/kg/day in 1-2 divided doses, started
12 hours after the loading dose.
- Phenytoin is indicated if the maximal dose of phenobarbitone (40
mg/kg) fails to resolve seizures or earlier, if adverse effects like
respiratory depression, hypotension or bradycardia ensue with
phenobarbitone. The dose is 20 mg/kg IV at a rate of not more than

39
1 mg/kg/min under cardiac monitoring. It should not be made in

dextrose as it precipitates in it. A repeat dose of 10 mg/kg may be
tried in refractory seizures. The maintenance dose is 3-5 mg/kg/d
(maximum of 8 mg/kg/d) in 2-4 divided doses. Oral suspension
has very erratic absorption from gut in neonates, so it should be
avoided. Thus only IV route is preferred in neonates and it should
preferably be discontinued before discharge.
Synthesis:
- Phenorbarbital
Mechanism of Action Depresses sensory and motor cortex,
cerebellum Antiseizure activity occurs primarily where GABA
mediates neurotransmission Hypnotic effects of barbiturates result
from activity at GABA receptor in the polysynaptic midbrain
reticular formation (controls CNS arousal) Off-label use for
hyperbilirubinemia: Phenobarbital induces glucuronyl transferase
and hepatic bilirubin-binding Y-protein to lower serum bilirubin
concentrations (Sheth, 2017).
Absorption Bioavailability: 70-90% Onset: 5 min (IV)
Duration: 4-6 hr (IV/IM) Peak plasma time: 8-12 hr Therapeutic
plasma concentration: 10-40 mcg/mL; may require 3-4 weeks of
treatment to achieve therapeutic levels Distribution Protein bound:
20-45% Metabolism Metabolized by hepatic oxidative
hydroxylation Metabolites: Inactive enzymes induced: CYP1A2,
CYP2B6, CYP2C19, CYP2C9/10, CYP3A4 Elimination Half-
life: 50-140 hr Excretion: Urine (major) (Sheth, 2017).
- Phenytoin
Mechanism of action with promotes Na+ efflux or decreases
Na+ influx from membranes in motor cortex neurons; stabilizes
neuronal membrane slows conduction velocity (Sheth, 2017).
Absorption bioavailability: may vary between different
manufacturers; dependent on formulation Onset: 1 week (PO); 2-

40
24 hr (PO with loading dose); 0.5-1 hr (IV) Peak plasma time: 1.5-
3 hr (immediate-release); 4-12 hr (extended-release) Distribution
Protein bound: 95% (adults); 85% (infants); 80% (neonates) Vd:
0.6-0.7 L/kg (adults); 0.7 L/kg (children); 0.7-0.8 L/kg (infants);
0.8-0.9 L/kg (full-term neonate); 1-1.2 L/kg (premature neonate).
Metabolized by hepatic P450 enzyme CYP2C9 Metabolites:
Inactive Enzymes induced: CYP3A4 Elimination Half-life: 22 hr
(PO); 10-15 hr (IV) Excretion: Urine (Sheth, 2017).
10. What will happen if these circumstance are not managed

comprehensively?
Answer:
Neonates with clinical seizures are at higher risk for morbidity and
mortality. Neonates with clinical seizures are associated with developed
epilepsy, developed cerebral palsy, mental retardation, and learning
disorders. Neonates with hypoxic-ischemic encephalopathy, seizures
are associated with impaired brain metabolism (Abend and Wusthoff,
2012).
11. Is this disorder can be overcome thoroughly how the odds?

Answer:
Quo ad vitam: dubia ad bonam
Quo ad fungsionam: dubia ad bonam
Quo ad sanationam: dubia ad bonam
12. How does the competences of general practitioner for this case?
Answer:
The competences of general practicioner for this case is 3B (KKI, 2012).
Synthesis:
General practitioner be able to make a clinical diagnosis based on
physical examination and examination additional checks requested by

41
doctors such as lab or x-ray examination. Doctors can decide and give
preliminary therapy, and refer to a specialistrelevant (emergency case).
13. What is the Islamic point of view of this case?

Answer:
Q.s: Al-Baqarah verse 153 means that Allah SWT. asks us to be
patience and always prayer as our helper in life. Allah SWT.always be
with those who are patient.
2.6 Conclusion
Two days old baby boy sluggish to breastfeed and a frequent “cycling”
motion on the legs due to suffering from neonatal seizure with history of
neonatal asphyxia.
2.7 Conceptual Framework

Breech presentation
Asphyxia
Hypoxia
Cerebral ischemia Sluggishness

to breastfeed
Seizure
Cycling
motion

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CHAPTER II

2.1 Tutorial Data

2.2 Case Scenario

3 Scenario A Class of 2015

2.3 Clarification of Terms

Tabel 2.1 Clarification of Terms

Scenario A Class of 2015

2. Breech presentation Fetus in longitudinal line with the buttocks or

2.4 Problem Identification

Scenario A Class of 2015

Respiratory rate : 42x/minutes

2.5 Analysis of Problem

Scenario A Class of 2015

b. What is the possible causes of sluggishness to breastfeed?

Scenario A Class of 2015

(Genna et al., 2013). In this study, it appears that state regulation

c. What is the possible causes of a frequent “cycling” motion on

Table 2.2 Causes of neonatal seizures

According to Dahlan (2008) and Jensen (2009) the possible

Scenario A Class of 2015

- Hypoglycemia, hypocalcemia, hypomagnesemia

Scenario A Class of 2015

hemorrhage can occur in the arachnoid, subdural, and

Scenario A Class of 2015

when the blood calcium level is less than 7 mg%.

d. What is the classification of neonatal seizures?

Scenario A Class of 2015

Scenario A Class of 2015

Clonic seizures tend to manifest as focal, slow, rhythmic

Picture 2.1 Classification of neonatal seizure

Scenario A Class of 2015

Myoclonic seizures usually involve the flexor muscle groups

e. What is the sign of neonatal seizure?

Scenario A Class of 2015

Scenario A Class of 2015

f. What is the effect of seizure?

Neonates with clinical seizures are at higher risk for

Scenario A Class of 2015

documented after early onset seizures, the mechanisms of seizure-

Scenario A Class of 2015

brain; indicating seizures themselves may have a harmful effect.

Scenario A Class of 2015

The risk factors that can be used as parameters for predicting

g. What is the mechanism of sluggishness to breastfeed and a

Scenario A Class of 2015

(ischaemia) (Aslam et al., 2014). When the oxygen supply is

Scenario A Class of 2015

intracellular calcium accumulation and excessive amounts of free

h. How is the physiology of newborn?

Scenario A Class of 2015

levels. The removal of the placenta decreases prostaglandin levels

The Respiratory Adaptation

Scenario A Class of 2015

- Umbilical cord clamping decreases oxygen concentration,

Table 2.2 Major reflexes present in full term neonates

Scenario A Class of 2015

Scenario A Class of 2015

giving the body

Source: Shaffer and Kipp, 2010

2. The baby birth spontaneously with a breech presentation helped by the

Scenario A Class of 2015

should be performed to assess type of breech presentation, fetal

b. What is the classification of asphyxia?