Neonatology: Asphyxia of The Newborns at birth

Lecture PointsClinical definition and Epidemiology: incidence/mortalityEtiology and Pathophysiology Apgars score significance of clinical use reevaluation of the scoreResuscitation Complication and prognosis

Clinical Definition/EpidemiologyClinical definition Failure to initiate respiration no / irregular breathing with hypoxemia and acidosis Incidence : 6-10%, in live birthMortality: leading death in neonates account for 1/3 in neonates death

EtiologyMaternalSystematic diseases hypertension/hypoxia Obstetric/pregnant complication Addiction Age at pregnancy/multiple pregnancy

EtiologyIntrapartumAbnormal umbilical cord Abnormal fetal positionProcedure: ForcepsMedicationnarcoticSedatives

EtiologyFetusPremature, SGA, LGA, MacrosomiaVarious abnormality Intrauterine aspirationNerves injury

Pathophysiology Hypoxic/ IschemiaOrgan/system injuryHypoxemia/acidosisO2, CO2 Exchange ObstacleFailure to initiate breath

Pathophysiology

Apgar Scoring System

Apgar Scoring SystemApgar ScoreMethods: at 1 and 5 min. post birth till >7 min. or 20 min. after birth

Clinical ManifestationFetal distress Fetal motion or no Fetal HR orMeconium-stained amniotic fluid Apgar Score

Reevaluation of Apgar ScoreDoes 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 basedLow scoring always for prematuresAmerican Academy of Pediatrtics, American College of Obstetricians and Gynecologists. Pediatrics 1996,98:141-2

Reevaluation of Apgar Score Inconsistent of the Apgar score with brain damage If lower score at 5 min. , >4 at 10 min.Brain Damage only 1% in children at 7 years oldIn brain damaged children 75% were normal for Apgar score.American Academy of Pediatrtics, American College of Obstetricians and Gynecologists. Pediatrics 1996,98:141-2

Reevaluation of Apgar Score The relevance to the outcome of asphyxia with survival and system/organ functionUmbilical artery PH7.00BE: -20mEq/LPapile LA. The Apgar score in the 21st century. N Engl J Med 2001;344:519-20

NRP 5th edition 20062006: 5th edition; Suction when Meconium present Resuscitation with oxygen or room air Epinaphrine for bradycardia or cardiac arrest

NRP 5th edition 2006

Neonatal Resuscitation 5th edition Birth Term gestation Clear amniotic fluid Breathing or crying Good muscle tone yesNoRoutine care Provide warmth Clear airway Dry Assess color

Neonatal Resuscitation 5th edition Provide warmth Position Clear airway EIT (if necessary) Drystimulate RepositionNo Evaluate respiration HR and colorApnea Or HR100 and pinkCyanosis30s Persistent cyanosis Pink

Neonatal Resuscitation 5th edition Positive pressure ventilation EIT Administer chest compressions EITHR60Apnea Or HR

Oxygen Concentration for PPV2006 GuidelineSupplementary 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 < 100% - acceptable alternative 21% - acceptable alternative

Meconium-stained fluid

Suction when Meconium present Meconium present? Baby vigorous ? Suction mouth and tracheaContinuo with remainder of initial stepsClear mouth and nose secretionDry, stimulate and repositon Respiration effortHR>100 bpmGood muscle toneNoYesYesNo

Suctioning Meconium

Epinephrine for Bradycardia2006 GuidelineIntravenous 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.

Neonatal Resuscitation 5th editionSpO2 Monitoring:Once per 30Sec.To 95% for new a born baby: 10 min.Premature:Use Blend and Oxygen airAdjust the oxygen air to SpO2 near 90%International Liaison Committee on Resuscitation.Part 13: Neonatal resuscitation guidelines. Circulation 2005:112(24, Suppl):IV188-IV195

Resuscitation technologySuctionbeginning from Oral then Nasal

Resuscitation technologyTactile stimulationTap the plantar

Resuscitation technology

Tactile stimulationRubber the Back

Resuscitation technologyO2 supply via PPV bag

Resuscitation technologyChest compress:

Resuscitation technologyEndotracheal intubationMethodby nasal or by oralIndicationMeconium aspiration Normal SaO2 only maintained by PPVSerious hypoxemia Persistent irregular breathing

Resuscitation technologyEndotracheal intubation by oral

Resuscitation technologyEndotracheal intubation: Vocal and Tracheal

Resuscitation technologyMonitoring post resuscitationTemp, Respiration, HRBP, Urine volumeSkin color CNS signsAcid base, Balance of electrolytes, Infection

PrognosisAmerican Academy of Pediatrtics, American College of Obstetricians and Gynecologists. Pediatrics 1996,98:141-2 Indications of poor outcome or CNS damage Umbilical artery showed severe acidosis (PH 3

Prevention of AsphyxiaAntenatal careTo avoid premature delivering and obstetric procedure (forceps)Monitoring high risk prehnentPre and post born preparations and adequate care

SummaryThe importance of early detection and recognition of the fetal distressPathophysiological Changes of the asphyxiaUse and reevaluation of the Apgars scoreMain procedure of the delivery resuscitation (New guideline and ABCs sequence)Prognosis

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