Birth Asphyxia
Definition
Failure to initiate and sustain breathing at birth is called birth asphyxia.
Magnitude
Of the 5 million neonatal deaths that occur worldwide, 19% death occur due
to birth asphyxia (WHO 1995).
Factors associated with birth asphyxia
1. Fetal distress
Meconium
Abnormal presentation
2.
3.
4.
5.
6.
7.
8.
Prolonged or obstructed labor
Complicated, traumatic or instrumental delivery
Severe maternal infections
Maternal sedation, analgesia or anesthesia
Antenatal or Intrapartam hemorrhage
Pre-term or post-term birth
Congenital anomalies
Who will need resuscitation?
1. 80 - 90% of newborns require no assistance to initiate breathing at birth
2. 10% require some assistance to begin breathing.
3. 1% among them requires extensive resuscitative measures to survive.
Sometimes the need for resuscitation can be predicted, but often it cannot, so...
PREPARE FOR RESUSCITATION AT EVERY BIRTH
Neonatal Resuscitation
Introduction:
We cannot tell which babies will have asphyxia at birth. Therefore we must prepared to
do newborn resuscitation at all births. If a few minute pass before the starts to breath,
baby can suffer from brain damage or die. Preparing for resuscitation include, warming
the resuscitation area, preparing clean surface for the resucitation and collecting the
equipments and supply.
Principles of Newborn Resuscitation
According to Pediatric working Group of the International Liaison Committee on
Resuscitation (ILCOR) the principles of newborn resuscitation are as follows:
1. Personal capable of initiating resuscitation should attend every delivery to
establish a vigorous cry or regular respiration, to maintain a heart rate >100 beats
per minute and achieve good color and tone.
2.
STEPS IN RESUSCITATION
I. Assessment at birth to decide need for resuscitation
II. Initial steps of resuscitation
Evaluation
III. Provide positive pressure ventilation
Evaluation
IV. Provide positive pressure ventilation and chest compressions
STEPS IN NEONATAL RESUSCITATION
Initial Assessment:
Meconium not present?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?
Yes
Routine Immediate Newborn Care Steps
No
Initial Steps:
Dry & stimulate the baby*
Warm the baby
Position the baby
Clear airway (as necessary)
Give oxygen (as necessary and if available)
*Important:
If meconium present, baby not vigorous - do not stimulate until after clearing
airway
Evaluate respiration, heart
rate, color & decide action
Normal
Breathing
HR>100 &Pink
Supportive
Care
Apnea or HR <100
Ventilate with bag and mask Normal
Breathing
HR>100
HR < 60 HR >60
Ventilation and Chest compressions
Ongoing
Care
Stop resuscitation if baby not breathing or
gasping after 20 minutes without heartbeat
Drugs like
epinephrine and
volume expanders
like normal saline
may be tried at this
point depending on
expertise of the birth
attendant
Evaluate respiration, heart
rate, color and decide action
21
Birth Asphyxia (continued)
WHO 2000.
Step I: On Initial Assessment ask the
following:
Meconium not present?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?
If the answer is yes, proceed with routine immediate
newborn care
If the answer to any one question is no, then go to the next
step
22
Birth Asphyxia (continued)
WHO 2000.
Step II: Initial Steps of Resuscitation
Dry, stimulate*, warm
Position, clear airway (as necessary)
Reposition
Give O2 (as necessary and if available)
* If meconium is present, do not stimulate until
after clearing airway
Evaluate
After initial steps and also after every action (ventilation
with/without chest compressions) it is necessary to
evaluate the color, respirations and heart beat and then
decide what to do further and take appropriate action.
. Evaluation
. Decision
. Action
Prevent heat
loss by:
Placing newborn
under radiant
warmer or other
heat source
Drying thoroughly
Removing wet
towel
TA
CTILE
STIMULATION
Open the airway by
Positioning on back or side
Slightly extending neck
Aligning posterior pharynx, larynx and trachea
If the newborn is breathing but central cyanosis
is present, give oxygen
oxygen mask
oxygen tubing
Meconium Present at Delivery
NO
Yes
Suction mouth, nose and posterior pharynx
after delivery of head but before delivery of
shoulders
Baby vigorous?(strong respiratory effort
and good muscle tone with heart rate > 100)
Yes
NO
Suction mouth and trachea
Continue with initial steps of resuscitation
Suction mouth first,
then nose
Step III. Provide positive pressure ventilation
If not breathing or heart rate <100 bpm:
Assist newborn by providing positive-pressure ventilation
with a bag and mask for 30 seconds.*
Then, evaluate again
* Babies born outside the hospital may still require positive pressure
ventilation to ventilate the lungs. If a bag and mask in unavailable,
ventilation can be delivered by mouth to mouth. Care to prevent infection
must be undertaken with this technique
Before assisting ventilation with bag and mask
Select appropriate-sized mask
Clear airway
Position newborns head
Position yourself at the side or head of the baby
Positioning of Bag and Mask on Face
Step IV. Provide positive pressure ventilation
with chest compression
If heart rate < 60 bpm despite adequate ventilation:
Support circulation by starting chest
compressions while continuing ventilation.
Then, evaluate again
Chest Compression:
Techniques
Positioning of thumb
and fingers for chest
compression
Apply pressure to
lower third of
sternum
Avoid xiphoid
process
Thumb technique
Pressure must remain on sternum
Two finger technique
Tips of middle
finger and index or
ring finger of one
hand compress
sternum
Other hand
supports back
Post-Resuscitation Care
Supportive Care
A baby who is breathing, heart rate >100, color is
pink with good tone may be given to mother for
warmth and breastfeeding.
Frequent assessments of color, tone and vital
signs for the first six hours needed.
Ongoing Care:
These babies have had active resuscitation (bag
and mask ventilation and/or chest compressions)
They may need more monitoring before giving to
mother or going to higher level care and therefore
need to be transferred to the Baby Unit for further
observation, evaluation and action based on their
condition.
42
Care After Unsuccessful Resuscitation
(If the baby is not breathing or not gasping after 20
minutes without heartbeat, stop resuscitation)
- Talk with mother/family about the babys death and
answer their questions
- Ask if they want to see and hold the baby
- Explain to the mother and family about the mothers
care:
Rest, support and good diet
Management of engorged breasts
Records
- Recording and notification of baby's birth and death
- Completion of required medical records for the
delivery
