Asphyxia and resuscitation

of the newborn
 Asphyxia
 Asphyxia is an important disease of
neonate.its morbidity rate is high.
 Of the 26 million infants born in
India ,3~5%experience asphyxia at
birth.
 In USA,the incidence has fallen to
1.5~6‰ live birth.but it remains an
important cause of brain damage in
newborn babies.
 Asphyxia
 Asphyxia literally means-absent pulse and
was a term for –suffocation.
 Birth asphyxia refers to a condition in
which the fetus is acutely deprived of
oxygen and is commonly due to
uteroplacental insufficiency.
 Asphyxia is characterized by progressive
hypoxia,hypercapnia,hypoperfusion and
acidosis.it may lead to multi-organ system
dysfunction including hypoxic-ischemic
encephalopathy(HIE).
 causes
 Hypoxia is the most important
cause,which can happen in
uterus,during delivery or after birth.
 The causes which can lead to
hypoxia can also make asphyxia.
 causes
 Fetal hypoxia may be detected by:
1)Abnormalities in fetal heart rate:
Fetal bradycardia(rate under
120beats/min)
Fetal tachycardia(rate over
160beats/min)
Abnormal pattern of deceleration
during or after uterine contractions.
2) acidosis:
sampling of fetal blood from scalp
or umbilical cord will demonstrate
significant acidosis.
3)meconium staining of the liquor:
the asphyxiated infant usually
passes meconium.
Pathophysiology of asphyxia
1)Apnea
 Initial brief period of rapid breathing
occurs when an infant is deprived of
oxygen.
 If the asphyxia continues,the respiratory
movements cease,the heart rate begins to
fall,neuromuscular tone gradually
diminishes,and the infant enters a period
of apnea known as primary apnea.
In most instances stimulation and
exposure to oxygen during this period will
induce respiration.
If the asphyxia continues,the infant
develops deep gasping respiration,the heart
rate continues to decrease,the BP begins to
fall,and the infant becomes nearly
flaccid,the respiration become weaker and
weaker until the infant takes a last gasp and
enters a period of secondary apnea.
The infant is unresponsive to stimulation
and will not spontaneously resume
respiratory efforts unless resusciatation
with assisted ventilation,and oxygen is
initiated promptly.
It is important to note that as a result of
fetal hypoxia,the infant may go through
primary apnea and into secondary
apnea while in utero.
The two are virtually indistinguishable
from one another.
2)lungs and the circulation
During intrauterine life the lungs don’t play a
role in gas exchange because the placenta
supplies the fetus with oxygen and removes
carbon dioxide.
The alveoli of the fetus are filled with fluid.
The first few breaths of neonate are
effective,expanding the alveoli and replacing
the lung fluid with air.
Those who are apneic at birth or have a weak
respiratory effort can not expand their lungs.
3)pulmonary circulation
Not only enough air entering the lungs,but
there must be an adequate supply of blood
flowing through the capillaries of the lungs
so that oxygen can pass into the blood and
be carried throughout the body.
An asphyxia infant has hypoxemia(low
oxygen content of the blood)and
acidosis.the arterioles of the lungs remain
constricted and the fetal circulation
pathways are maintained and decrease
pulmonary perfusion.
In mildly asphyxiated infants whose oxygen
and PH are only slightly lowered,it may be
possible to increase pulmonary perfusion by
acting quickly and properly ventilating the
infant with 100% oxygen.
In severely asphyxiated infants , pulmonary
perfusion may not improve with ventilation
alone.
4)cardiac function and circulation
Early in asphyxia arterioles in the
kidneys,muscles,bowels and skin constrict.
The resulting redistribution of blood flow
helps preserve function by supplying oxygen
and substrate to the heart and brain.
As asphyxia is prolonged,myocardial function
and cardiac output deteriorate,and blood flow
to all organs is reduced.this sets the stage for
progressive organ damage.
 Complication of perinatal asphyxia(severe)

organ complication

brain Hypoxic-ischemic encephalopathy

heart Hypoxic cardiomyopathy,hypotension

lungs Persistent pulmonary hypotention

guts Ileus and necrotizing enterocolitis

kidneys Acute tubular necrosis

blood Disseminated intravascular coagulation

 Clinical features(1)

 History of asphyxia
The postnatal symptoms and signs of
intrapartum asphyxia vary with the
degree of asphyxia,which may be
classified as mild,moderate,or
severe.
 Clinical features(2)
 Apgar score
It is a useful quantitative
assessment of the infant’s
condition and is commonly
determined at 1 and 5 minutes after
birth.
 Apgar score evaluation of the newborn

criteria score
0 1 2

Heart rate absent <100 beats/min >100 beats/min

Respiratory Absent/weak Slow,irregular/gasping Good,regular

effort
Muscle tone Limp,flaccid Some flexion Active
movements
Reflex none weak Cries,coughs or
response to sneezes
stimulation
Colour of the Blue or pale Extremities blue pink
body
 Apgar score

 8~10 normal
 4~7 mild and moderate
 0~3 severe
When the 5-minute Apgar score is less
than 7,additional scores should be
obtained every 5 minutes for up to 20
minutes or until two successive
scores are 8 or more.
 Clinical features(3)
 Multi-organ system dysfunction
CNS: HIE
Respiratory system: meconium
aspiration,lung hemorrhage
Cardiovascular system: heart failure,shock
Metabolism: hypocalcemia,hyponatremia
Gastrointestinal system: necrotizing
enterocolitis
 Resuscitation of the
neonate
 ASSESSMENT
 Is the amniotic fluid clear of meconium and
evidence of infection?
 Is the baby breathing or crying?
 Does the baby have good muscle tone?
 How about skin color ?pink
 Was the baby born after full-term gestation ?
1.The minimum preparation for any
delivery should include:
1) a radiant heat source ready
for use
2) all resuscitation equipment
immediately available and in
working order
3) at least one person skilled in
neonatal resuscitation
2.The Action-Evaluation-Decision cycle:
Resuscitation and evaluation should be
undertaken immediately at birth.
A very important aspect of Resuscitation is
evaluating the infant,deciding what action to
take and then taking action.Further
evaluation data are the basis for more
decisions and further actions.
3.Signs to evaluate:
Evaluation is based primarily on the
following three signs:
1) Respiration
2) Heart rate
3) Color
4.T-ABCDE resuscitation procedure:
T-maintenance of temperature:
1)provision of radiant heat source
2)drying the baby
3)removing wet linen
A-establish an open airway :
1)position the infant
2)suction the mouth,nose and in some
instances the trachea
3)if necessary ,insert an endotracheal(ET)
tube to ensure an open airway
B-initiate breathing:
1)tactile stimulation to respirations
2)positive pressure ventilation(PPV) when
necessary , using either Bag and mask
C-maintain circulation:
Stimulate and maintain the circulation of
blood with chest compressions and
medications
D-use of drugs:
Einephrine ,Naloxone ,Dopamine

E-evaluation
Initial steps of resuscitation
1.Preventing heat loss
To avoid the metabolic problems brought on
by cold stress.This can be especially critical
in a newborn who needs resuscitation.
Following steps can be undertaken to
prevent heat loss:
1)using a radiant heat source
2)drying the infant : to prevent evaporative
heat loss,a prewarmed towel or blanket can
be used.the act of drying can provide gentle
stimulation.
3)removing wet towel:
this is last step of preventing heat
loss.after removing wet towel, heat
loss can be reduced.
2.positioning
The neonate should be placed on her back
or side with the neck slightly extended.care
should be taken to prevent hyperextension or
under extension of the neck since either may
decrease air entry.
To help maintain the correct position, you
may place a rolled blanket or towel under the
shoulders.
3.suctioning
1)if no meconium is present,the mouth and
nose should be suctioned.the mouth is
suctioned first to ensure that there is nothing
for the infant to aspirate.
In some cases, suctioning is the stimulation
needed to initiate respiration in the infant.
A mucus aspirator or mechanical suction
can be used to remove secretion.
2)if meconium is present in the amniotic
fluid,there is a chance the meconium will be
aspirated into the infant’s mouth and
potentially into the trachea and lungs.
Meconium is often described as :thin and
watery or thick and particulate
The risk of aspiration of thick meconium-
amniotic fluid is particularly hazardous for
infants.
Appropriate steps should be taken during and
immediately after the delivery to reduce the
risk of serious consequences resulting from
aspiration of meconium:
(1)intrapartum suctioning :this is most
important.when the head is delivered,
suctioning should take place for all infants
with meconium.
(2) when the head is delivered,thorough of the
mouth,pharynx and nose should be done.
(3)after delivery:
Residual meconium in the hypopharynx
should be removed by suctioning under direct
vision using a laryngoscope.
The trachea should then be intubated and
meconium suctioned from the lower airway.
(4)stomach should be suctioned to prevent
aspiration of the meconium-containing gastric
contents into the lung.
4.evaluation
1)respiration: by observing the chest
movement.
If breathing is spontaneous,go on to check
the heart rate.
If not,begin tactile stimulation.
If still no spontaneous respiration ,start
PPV.
2)heart rate:this is done by auscultating the
heart or by palpating the umbilical pulsations
 If more than 100 beats/min,look for color.
If not,initiate PPV.
3)color:evaluate the infant’s color by looking
for cyanosis at lips/tongue.
If central cyanosis is present,administer
free-flow oxygen.
free-flow oxygen: refers to blowing
oxygen over the infant’s nose so that
the infant breathes enriched air.
This can be accomplished by using(i)
oxygen mask (ii) cupped hand.
The oxygen flow rate should be 5 liters
per minute.
Tactile stimulation: two safe and
appropriate methods
(i) Slapping or flicking the soles of the feet
(ii) rubbing the infant’s back
Once or twice
If infant remains apneic,tactile stimulation
should be abandoned and PPV initiated
immediately.
 Bag and mask ventilation
 Indications :
it is indicated,if after tactile stimulation:
(1) the infant is apneic or gasping.
(2) respiration is spontaneous but heart
rate is below 100 beats/min.
 Methods :
Ventilate at a rate of 40~ 60 breaths/min,
pressure required for 15~30cm of water.
The best guide to adequate pressure
during ventilation is an easy rise and fall
of the chest with each breath.
After the infant has received 15~30
seconds of with 100% oxygen,check the
heart rate and take follow-up action as
follows:
 H e a r t ra te a c tio n

A bov e 100 If s p o n ta n e o u s res p ira tio n s ar

p re s e n t,p ro v id e ta c tile s tim u la tio n a n
m o n ito r h e a r t ra te , re s p iratio n ,a n d c o lo r.
If n o t b r e a th in g o r if g a s p in g ,c o n tin u
v e n tila tio n
6 0 to 1 0 0 a ncdo n tin u e v e n tila tio n
in cre a s in g
6 0 to 1 0 0 da nn o t C o n tin u in g v e n tila-ctio
h enc k a d e q u a c y o f
in cre a s in g v e n tila tio n
B e g in c h e s t c o m p re s s io ns ,if H R is b e lo
8 0 b e a ts /m in
B e lo w 6 0 c o n tin u e to v e n tila te
b e g in c h e s t c o m p re s s io n s
Three signs indicate improvement in
the condition of an infant undergoing
resuscitation:
(i) increasing heart rate
(ii) spontaneous respiration
(iii) improving color
 Chest compressions(CC)
 Chest compressions are used to
temporarily circulation and oxygen
delivery.
 This must always be accompanied by
ventilation with 100% oxygen .
 Chest compressions are indicated if
after 15 to 30 seconds of PPV with 100%
oxygen the HR is: (i) below 60 beats/min
(ii) between 60 to 80 beats/min and not
increasing.
Methods:
Two techniques of chest compressions:
1)thumb technique
2)two finger technique
Pressure is applied to the lower third of
the sternum.
Enough pressure to depress the ½ to ¾
inch.then release the pressure to allow
the heart to refill.
Rate:
A ventilation should follow every third
chest compression.
In 1 minute ,90 chest compressions and
30 PPVs are administered, a total of 120
events.
Your thumbs or the tips of fingers should
remain in contact with the compression
area of the sternum at all times during
both compression and release.
To determine whether the blood is being
circulated effectively by CC,the carotid or
femoral pulse should be checked periodically.
After a period of 30s of CC ,the HR is
checked:
HR<80 beats/min, CC should continue along
with mask ventilation,inaddition,medications
are initiated.
HR>80 beats/min, CC should be
discontinued.until the HR>100 beats/min and
infant is capable of breathing spontaneously.
 Medications
 In those few infants who fail to improve
with ventilation and CC the medication
becomes necessary.
 Indications:
1)HR<80 despite adequate ventilation
with 100%oxygen and CC for a minimum
of 30s.
2)HR is zero.
Medications used in resuscitation:
Epinephrine,Volume expanders ,Sodium
bicarbonate,Naloxone,Dopamine
Route of medication:
Umbilical vein is the preferred route via
a catheter.
Some medications(epinephrine and
naloxone) may be injected directly into
the bronchial tree through endotracheal
tube.
Epinephrine Administration
The recommended IV dose is 0.01 to 0.03 mg/kg per
dose.
The concentration of epinephrine for either route should
be 1:10 000 (0.1 mg/mL).
Volume Expansion
Consider volume expansion when blood loss is suspected
or the infant appears to be in shock (pale skin, poor
perfusion, weak pulse) and has not responded adequately
to other resuscitative measures. An isotonic crystalloid
rather than albumin is the solution of choice for volume
expansion in the delivery room . The recommended dose
is 10 mL/kg, which may need to be repeated.
Naloxone
The recommended dose is 0.1 mg/kg,
Evaluation