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. Define perinatal asphyxia
2. Know the criteria to diagnose asphyxia
3. 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. Abnormal plasentation
2. Pricipitate or prolonged delivery
3. Difficult delivery
4. Post term delivery
5. Forceps or vacum delivery

C. Fetal or neonatal conditions

1. Prematurity
2. Respiratry distress syndrome
3. Meconium aspiration syndrome
4. Sepsis, pneumonia, hemolitic disease
5. 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 Balon Tidak
Sendiri (BMS) Mengembang Sendiri
(BTMS)
T-piece resuscitator

9
 All O2 difuse across the palcental membrane
from the mother’s 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. Cardiac output is maintenaned early, but
changes radically
2. Selective vasocontrictor to gut, kidneys,
muscles, skin
3. Pulmonary blood flow ↓ by hypoxia and
asidosis
4. Respiration center is depressed
5. Severe stage of asphyxia  O2 ↓ to the heart
& brain  - myocardial function ↓ 
O2 ↓↓ to the vital organ
- brain injury
 Score
Sign 0 1 2
Heart Rate Absent < 100/ m ≥ 100/ m
Respiratons - Slow, irregular Good, crying
Muscle tone Limp Some flexion Active motion
Reflex irritability No response Grimace Cough,
sneeze,cry
Colour Blue or pale Pink body, blue Completely pink
extremitas

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
3. 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
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. Prevention in the best management
2. 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