Neonatology: Asphyxia of The Newborns at birth

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Neonatology Asphyxia of The Newborns at birth
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Lecture Points

• Clinical definition and Epidemiology
• incidence/mortality
• Etiology and Pathophysiology
• Apgars score
• significance of clinical use
• reevaluation of the score
• Resuscitation
• Complication and prognosis

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Clinical Definition/Epidemiology

• Clinical definition
• Failure to initiate respiration
• no / irregular breathing
• with hypoxemia and acidosis
• Incidence 6-10, in live birth
• Mortality
• leading death in neonates
• account for 1/3 in neonates death

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Etiology

• Maternal
• Systematic diseases
• hypertension/hypoxia
• Obstetric/pregnant complication
• Addiction
• Age at pregnancy/multiple pregnancy

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Etiology

• Intrapartum
• Abnormal umbilical cord
• Abnormal fetal position
• Procedure Forceps
• Medicationnarcotic,Sedatives

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Etiology

• Fetus
• Premature, SGA, LGA, Macrosomia
• Various abnormality
• Intrauterine aspiration
• Nerves injury

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Pathophysiology

• Hypoxic/ Ischemia
• ?

Failure to initiate breath ?
O2, CO2 Exchange Obstacle ?
Hypoxemia/acidosis ?
Organ/system injury
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Pathophysiology

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Apgar Scoring System
SCORE 0 1 2
Heart rate Absent lt100/min gt 100/min
Respirations Absent Slow, irregular Good, crying
Muscle tone Limp Some motion Active motion
Reflex irritability No response Grimace Cough, sneeze, cry
Color Blue, pale Body pink, blue limbs Completely pink
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Apgar Scoring System

• Apgar Score
• Methods at 1 and 5 min. post birth
• till gt7 min. or 20 min. after birth

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Clinical Manifestation

• Fetal distress
• Fetal motion? or no
• Fetal HR ?or?
• Meconium-stained amniotic fluid

• Apgar Score
• lt3 at 1 or 5 min. severe
• 4-7 at 1 or 5 min. slight

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Reevaluation of Apgar Score

• Does Apgar Score reflect
• Accuracy of Predict the death
• The severity of perinatal hypoxic
• The process and severity of intrauterine fetal
  hypoxic
• Facts
• The subjectivity of the scoring and experience
  based
• Low scoring always for prematures

American Academy of Pediatrtics, American College
of Obstetricians and Gynecologists. Pediatrics
1996,98141-2
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Reevaluation of Apgar Score

• Inconsistent of the Apgar score with brain
  damage
• If lower score at 5 min. , gt4 at 10 min.
• Brain Damage only 1 in children at 7 years old
• In brain damaged children 75 were normal for
  Apgar score.

American Academy of Pediatrtics, American College
of Obstetricians and Gynecologists. Pediatrics
1996,98141-2
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Reevaluation of Apgar Score

• The relevance to the outcome of asphyxia with
  survival and system/organ function
• Umbilical artery PHlt7.00
• BE -20mEq/L

Papile LA. The Apgar score in the 21st century. N
Engl J Med 2001344519-20
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NRP 5th edition 2006

• 2006 5th edition
• Suction when
• Meconium present
• Resuscitation with
• oxygen or room air
• Epinaphrine for
• bradycardia or cardiac
• arrest

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NRP 5th edition 2006
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Neonatal Resuscitation 5th edition

• Birth

• Routine care
• Provide warmth
• Clear airway
• Dry
• Assess color

• Term gestation ?
• Clear amniotic fluid ?
• Breathing or crying?
• Good muscle tone?

yes
No
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Neonatal Resuscitation 5th edition
No

• Provide warmth
• Position, Clear airway EIT
• (if necessary)
• Dry,stimulate
• Reposition

• Evaluate respiration,
• HR and color

Breathing
Observational care
30s
HRgt100 and pink
Cyanosis
Apnea Or HRlt100
Pink

• Give supplemental
• oxygen

Persistent cyanosis
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Neonatal Resuscitation 5th edition
Apnea Or HRlt100
Persistent cyanosis
Effective ventilation
Post resuscitation care
Positive pressure EIT ventilation
HRgt100 and pink
30s
HRlt60
HRgt60

• Positive pressure ventilation EIT
• Administer chest compressions EIT

HRlt60
30s
Administer epinephrine EIT
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Oxygen Concentration for PPV

• 2006 Guideline
• Supplementary oxygen is recommended whenever
  positive-pressure ventilation is indicated for
  resuscitation.
• There is insufficient evidence to specify the
  concentration of oxygen to be used at the
  initiation of resuscitation.
• 100 - standard approach
• lt 100 - acceptable alternative
• 21 - acceptable alternative

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Meconium-stained fluid
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Suction when Meconium present

• Meconium present?

Yes
No
Baby vigorous ?
No
Yes

• Respiration effort
• HRgt100 bpm
• Good muscle tone

Suction mouth and trachea

• Continuo with remainder of initial steps
• Clear mouth and nose secretion
• Dry, stimulate and repositon

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Suctioning Meconium
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Epinephrine for Bradycardia

• 2006 Guideline
• Intravenous administration of epinephrine 0.01
  0.03 mg/kg/dose is the preferred route (Class
  IIa).
• While access is being obtained, administration of
  a higher dose (up to 0.1 mg/kg) through the
  endotracheal tube may be considered.

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Neonatal Resuscitation 5th edition

• SpO2 Monitoring
• Once per 30Sec.
• To 95 for new a born baby 10 min.
• Premature
• Use Blend and Oxygen air
• Adjust the oxygen air to SpO2 near 90

International Liaison Committee on
Resuscitation.Part 13 Neonatal resuscitation
guidelines.Circulation 2005112(24,
Suppl)IV188-IV195
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Resuscitation technology

• Suctionbeginning from Oral then Nasal

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Resuscitation technology

• Tactile stimulationTap the plantar

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Resuscitation technology

• Tactile stimulationRubber the Back

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Resuscitation technology

• O2 supply via PPV bag

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Resuscitation technology

• Chest compress

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Resuscitation technology

• Endotracheal intubation
• Methodby nasal or by oral
• Indication
• Meconium aspiration
• Normal SaO2 only maintained by PPV
• Serious hypoxemia
• Persistent irregular breathing

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Resuscitation technology

• Endotracheal intubation by oral

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Resuscitation technology
Endotracheal intubation Vocal and Tracheal
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Resuscitation technology

• Monitoring post resuscitation
• Temp, Respiration, HR
• BP, Urine volume
• Skin color
• CNS signs
• Acid base, Balance of electrolytes, Infection

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Prognosis

• Indications of poor outcome or CNS damage
• Umbilical artery showed severe acidosis
• (PH lt7.00)
• Apgar score 0-3 persists over 5 min.
• Manifesting signs of acute CNS damage
• (convulsion)
• MODSgt3

American Academy of Pediatrtics, American College
of Obstetricians and Gynecologists. Pediatrics
1996,98141-2
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Prevention of Asphyxia

• Antenatal care
• To avoid premature delivering and obstetric
  procedure (forceps)
• Monitoring high risk prehnent
• Pre and post born preparations and adequate care

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Summary

• The importance of early detection and recognition
  of the fetal distress
• Pathophysiological Changes of the asphyxia
• Use and reevaluation of the Apgars score
• Main procedure of the delivery resuscitation
• (New guideline and ABCs sequence)
• Prognosis

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Thanks and questions?