BIRTH ASPHYXIA

BY
MRS P CHAIRE
OBJECTIVES
• Define birth asphyxia
• Outline the predisposing of birth asphyxia
• Classify birth asphyxia
• State the clinical manifestations of birth asphyxia
• Describe the management of birth asphyxia
• Outline the complications of birth asphyxia
Introduction
• Birth asphyxia it is one of the leading causes of
neonatal death and neurodevelopmental disabilities
• It accounts to an estimates of 900,000 deaths each
year
• It is associated with metabolic acidosis, low Apgar and
organ damage
• 1 in 500 term babies will have HIE severe enough to
lead to convulsions or coma
Definition
• Birth asphyxia is failure of the baby initiate or
establish spontaneous respirations as a result of
intra uterine hypoxia.
• It results from a reduction of oxygen and an
accumulation of carbon dioxide in the organs of a
new-born baby due to reduced or cessation of
blood supply to the foetus before, during or just
after birth.
Predisposing of Birth Asphyxia
Antenatal
• Maternal medical conditions - PIH, DM, anaemia,
heart disease, nephritis, smoking
• Placental conditions - Placenta abruption,
placenta praevia
• Foetal causes - congenital malformations e.g.
hydrocephalus, anencephaly, IUGR
Predisposing of Birth Asphyxia
• Intra uterine infections
Labour
• Hypertonic uterine contractions
• Placenta abruption
• Premature rupture of membranes
• Cord prolapse
• Compression of the umbilical cord
Predisposing of Birth Asphyxia
• Drugs such as pethidine, morphine and general
anaesthesia that may depress the respiratory
centre
Puerperium
• Blockage of airways due to meconium aspiration
• Congenital abnormalities such as choanal
atresia, diaphramic hernia and TOF
Predisposing of Birth Asphyxia
• Hypoplastic lungs lead to failure of air to reach
the lungs resulting in hypoxia
• Lung immaturity with reduced surfactant-
preterm infant
Pathophysiology
• Initially when hypoxia occurs the natural defence
mechanism comes into play
• The body tries to shunt down oxygen to the vital
organs especially the brain, heart and liver
• However if hypoxia persist the vital organs are
also affected
Pathophysiology
• Hypoxia may decrease the production of ATP
resulting in reduction of cellular function
• These changes can be reversible if hypoxia is
reversed in the early stages
• If hypoxia is prolonged, the cellular damage will
become irreversible which means even if the
hypoxia disappears the cellular damage can not be
reversed.
Pathophysiology
• There is production of free radicals after
circulation is revived and these further damage
the cells ( perfusion injury)
Clinical manifestations
• Grunting respirations (baby tries to exhale air
against a closed glottis to retain air in the alveoli)
• Apnoeic episodes
• Sternal or intercostal respirations- when the baby
uses accessory muscles to improve oxygenation
• Abnormal state of consciousness e.g. hyper alert,
irritable, lethargic or obtunded
Clinical manifestations
• Peripheral and central cyanosis
• Nasal flaring
• Low Apgar and weak or absent cry
• Poor tone, absent primitive reflexes
• Abnormal posturing (opisthotonus)
• Feeding difficulties
Classification
• It is according the severity and also depending
on the Apgar scoring system which was devised
by Virginia Apgar in 1953.
Mild (stage1)
• Apgar score is 6/10 to 7/10
• Hyper alert, irritable, normal muscle tone and
reflexes, no seizures
Classification
Moderate (stage11)
• Apgar score is 4/10 to 5/10
• Lethargic, hypotonia ,weak sucking and often
seizures
Severe ( stage 111)
• Apgar score is 3/10 and below- coma, absent
muscle tone and reflex, persistent seizures.
Apgar score
Management
• Resuscitation of a baby with birth asphyxia is
started within the first minute of birth’
• Immediately call for help
• Clamp and cut the cord, dry the baby quickly
• Change wet towel, then put a warm towel, Apply
a hat on the baby’s head and place the baby in a
warm resuscitaire
Management
• Clear air way under direct vision starting with the
mouth, then nose to avoid initiating breathing
which may result in meconium aspiration
• Position the baby by placing a towel on its back
with the head in a neutral position so as to open
airway
• Avoid over extension or flexion of head
Management

-It may cause collapse of the pharyngeal

airway leading to blockage of airways
• Observe for chest movements ( look ,listen
and feel)
• If baby is floppy apply chin lift and jaw thrust
to bring the tongue forward and open airway
Management
• If still not breathing give 5 inflation breaths using
an ambubag connected to oxygen and a tight
fitting face mask each at 2-3 seconds while
observing the chest rise
• If the chest is not rising check and correct the
seal and position the head and ensure that the
chest rises
Management
• Reassess by listening to the heart rate using a
stethoscope
• If heart rate is present >100b/minute but with
no spontaneous respirations give regular
ventilation breaths at a rate of 30-40 breaths/
minute until the baby starts to breath on its own
• Continue to reassess heart rate every 30 seconds
Management
• If baby is now breathing own its own stop
ventilation, correct position of the head and give
oxygen per face mask or nasal prongs at 2- 3
litres per minute
In severe birth asphyxia
• If the heart rate does not respond and remains
<100b/minute despite effective ventilation
Management
• Proceed to perform chest compressions
• Use forefinger and middle finger
• Encircle the baby’s chest with two hands and the
thumbs meet on the sternum below the line
between nipple
• Compress the chest 1/3
• The ratio of compression to inflation is 3:1
Management
• The chest compressions move oxygenated blood
from the lungs back to the heart.
• Allow enough time of relaxation phase for each
compression cycle for the heart to refill with
blood
• Reassess breathing after 30 seconds
• If heart rate is now >60 b/minute and increasing
Management
• Discontinue chest compression and continue
with regular breaths
• If heart rate does not improve and remain below
60b/minute or absent despite patent airway and
chest compression proceed to give drugs for
resuscitation
Management
• Drugs may be required for very few babies
where inflation of the lungs and chest
compression has not been sufficient to produce
effective circulation
• Adrenaline 0.1mg/kg of 1:10 000- to strengthen
and increase myocardial contraction thereby
increasing blood circulation
Management
• Aminophylline 5-6mg/kg state then 2mg/kg
8hourly iv stat- also give if respirations are
<40b/min
• Sodium bicarbonate 1-2mmol/l to counteract
acidosis
• Dextrose 10% at 2,5mg/kg to correct
hypoglycaemia
Management
• Naloxone hydrochloride 0,01mg/kg is given to
reverse effects of maternal opiates when the is
neonatal respiration depression
• If baby still fails to breath after resuscitation
proceed and perform intubation
Intubation technique
• The person intubating the infant should stand or
sit at the head of the infant
• Make sure the baby is lying on a flat surface with
the heat extended into a sniffing position
• Chin lift and jaw thrust so as to open airway
• Pick up a lighted, straight blade infant
laryngoscope in the left hand and gentle insert the
blade into the right side of the mouth and along
the surface of the tongue
• Advance the blade a few millimetres passing it
beneath the epiglottis- that is pushing the blade
gentle between the root of the tongue and
epiglottis
• The vocal cords should be exposed as the tongue
and the epiglottis move forward
• Apply cricoid pressure using a little finger of the
left hand
• Aspirate the glottis and clear the oropharynx to
identify landmarks
• The glottis is seen as a dimple in a pink mound
between the epiglottis in front
• The oesophagus is seen as a large hole behind, if
the infant gasps the glottis opens
• Select the correct size of the endotracheal tube
(2,5-3,5mm) with correct fitting introducer and
holding it in the right hand, pass it gently down the
vocal cords
• A gentle twist is sometimes necessary to get the
tip of the tube through the cords
• Insert the tube 2cm below the vocal cords and
remove the introducer
• Hold the tube firmly against the right corner of
the mouth while withdrawing the laryngoscope
blade
• Connect oxygen to the tube and test correct
position of the tube to the lungs
• They should be bilateral air entry into the lungs
• If only one side of the chest rises withdraw the
tube up to 1cm, as it means the tube has
entered the right bronchus
• Also check to ensure that the stomach is not
inflating, as it will indicate oesophageal intubation
• Connect positive pressure ventilation (PPV) by
giving 3-4 puffs of oxygen at a pressure of 25-
30cm of H20
• Reassess the infant’s colour and heart after 30-60
seconds
Complications
• Cerebral oedema – due to malfunctioning of the
brain as a result of reduced blood flow to the
brain leading to extravasation of fluids from
blood vessels into the brain tissue
• Hypoglycaemia resulting from reduced
metabolism as a result of low oxygen content in
the body.
Complications
• Hypothermia – due to reduced metabolism
resulting from reduced oxygen tissue perfusion
• Cerebral palsy -due to the disturbance of the
central nervous system function resulting from
oxygen deprivation
• Developmental delay due to cerebral injury
Complications
• Electrolyte imbalance due to malfunction of the
body systems.
• Mental retardation as a result of brain damage
due to reduced oxygen perfusion within the
cells.
• Cardiac arrest due to severe oxygen deprivation
leading to multiple organ failure
Conclusion
• It is very important that midwives are able to
diagnose birth asphyxia early and treat promptly
so as to reduce neonatal morbidity and mortality
RECAP
References
• Collin S and Arulkumara ,K.,2008.The essential guide to Obstetrics and
Gynaecology 4th Edition. United States of America. Pearson Edition.
• Dot Jean and Jean Rankin, 2014. Physiology in childbearing 3rd Edition.
Elsevier Edinburg, London NewYork Oxford Philadephia ST Louis, Sydney
Toronto.
• McKinney, E.S., James,S.R., Murray, S.S, Nelson, K.N., Ashwill, J.W., 2018.
Maternal Child Nursing 5th Edition. Elsevier
• Gillam, K.M.,2023. Birth asphyxia. Available at https://www.ncbi.nlm.nih.gov
• Pauline McCall Sellers,2010.Midwifery Volume1
• Marshall, J., Raynor, M., Nolte, A.,2014. Myles Textbook for Midwives 3rd
Edition. African Edition. Churchill Livingstone Elsevier, London