1. รองศาสตราจารย์ นายแพทย์ อติวุทธ กมุทมาศ
Birth asphyxia
รองศาสตราจารย์ นายแพทย์ อติวุทธ กมุทมาศ

2. Asphyxia APGAR score at 1 minute < 7
Interruption in oxygen delivery to the fetus
• Hypoxia
• Hypercapnia
Birth asphyxia เป็นภาวะที่ทารกแรกเกิดไม่สามารถปรับตัวในการเปลี่ยนแปลงทางระบบหายใจและการไหลเวียนเลือดจากครรภ์มารดา มาสู่ภาวะแวดล้อมภายนอก

3. Neonatal Evaluation and Resuscitation
APGAR Scoring
A Appearance
P Pulse
G Grimace
A Activity
R Respirations
Take the APGAR score at one minute and five minutes.

4. APGAR Score APGAR Score: Appearance
The skin of a newborn should be pink. Assess the newborn’s skin color and score as follows:
Entire body blue or pale - 0 points
Blue hands and feet - 1 point
Entire body pink - 2 points
APGAR Score: Pulse
The pulse of a newborn should be greater than 100 beats per minute. Assess the newborn’s brachial pulse or use a stethoscope and score as follows:
Pulse absent - 0 points
Pulse less than point
Pulse greater than points
APGAR Score: Activity
A newborn should exhibit active flexion and extension of the extremities. Assess the newborn’s activity and score as follows:
No extremity movement - 0 points
Minimal activity - 1 point
Strong activity - 2 points
APGAR Score: Respirations
A newborn should breathe between 30 and 60 times a minute or exhibit a strong cry. Assess the newborn’s breathing and score as follows:
No respiratory effort - 0 points
Slow (<30/minute), irregular, or weak cry - 1 point
Normal respirations or strong cry - 2 points
APGAR Score
At the conclusion of the APGAR score, add the numbers together and consider the following:
7-10 points - The newborn should be active and vigorous. Provide routine care.
4-6 points - The newborn is moderately depressed. Provide stimulation and oxygen.
0-3 points - The newborn is severely depressed and requires extensive resuscitation.

5. Apgar Score Total Score = 10 score 7-10 normal
score 5-6 mild birth asphyxia
score 3-4 moderate birth asphyxia
score 0-2 severe birth asphyxia

6. Causes of Neonatal Mortality
Source: WHO 2001 estimates (based on data collected around 1999)

7. Etiology Birth asphyxia in undeveloped countries
10% of newborns suffer mild to moderate birth asphyxia
1% of newborns suffer severe birth asphyxia

8. Risk factors Antepartum : Maternal diabetes post-term gestation
Pregnancy induced hypertension multiple gestation
Chronic hypertension size-dates discrepancy
Previous Rh sensitization maternal drug abuse
Previous stillbirth maternal age >35 or<16
Bleeding in second or third trimester no prenatal care
Maternal infection
Polyhydramnios or oligohydramnios

9. Risk factors Intrapartum : Elective or emergency c/s
Precipitous labour, prolonged labour
Prolonged second stage of labour
Premature labour
Abnormal presentation
Rupture of membranes > 24 hours
Foul-smelling amniotic fluid
Non reassuring fetal heart rate patterns
Use of general anesthesia
Prolapsed cord

10. Assessment Fetal heart rate slows Electronic fetal monitoring
• persistent late deceleration of any magnitude
• persistent severe variable deceleration
• prolonged bradycardia
• decreased or absent beat-to-beat variability
Thick meconium-stained amniotic fluid
Fetal scalp blood analysis show pH less than 7.2

11. Effects of Asphyxia Central nervous system
• infarction, intracranial hemorrhage, cerebral edema, seizure, hypoxic- ischemic encephalopathy
Cardiovascular
• bradycardia, ventricular hypertrophy, arrhythmia, hypotension, myocardial ischemia

12. Effects of Asphyxia Respiratory system
• apnea, respiratory distress syndrome
cyanosis
KUB
• acute tubular necrosis, bladder paralysis
Gastrointestinal tract
• necrotizing enterocolitis , stress ulcer

13. Effects of Asphyxia Hematology
• Disseminated intravascular coagulation
Metabolic
• hypoglycemia, hyperglycemia, hypocalcemia, hyponatremia
Integument
• subcutaneous fat necrosis

14. Neonatal Resuscitation
Administer blow-by oxygen if the newborn displays:
Cyanosis of the skin
Spontaneous and adequate breathing
Heart rate above 100 beats per minute
Ventilation with the Bag Mask
Provide ventilations with the bag mask at a rate of 30 to 60 breaths per minute if:
The newborn’s breathing is slow or otherwise inadequate.
The newborn’s heart rate is less than 100 beats per minute.
The newborn’s trunk remains cyanotic despite the administration of blow-by oxygen.
Reassess the infant’s color, respiratory effort, and heart rate after 30 seconds of ventilation.
Cardiopulmonary Resuscitation
Provide CPR if:
The newborn’s heart rate is less than 60 beats per minute.
Reassess the infant’s color, respiratory effort, and heart rate after 30 seconds of CPR and treat according to findings.
Advanced Providers: See protocols for medications/dosages

15. Newborn Resuscitation AHA/AAP Guidelines
Meconium -stained amniotic fluid: endotracheal suctioning of the depressed - not the vigorous child
Hyperthermia should be avoided
100% oxygen is still recommended, however if supplemental oxygen is unavailable room air should be used
Chest compression: Initiated if heart rate is absent or remains < 60 bpm despite adequate ventilation for 30 sec
Medications: Epinephrine mg/kg if heart rate < 60 bpm in spite of 30 seconds adequate ventilation and chest compression
Volume: Isotonic crystalloid solution or 0-neg blood

16. Prognosis Apgar score < 5 at 10 minutes : nearly 50 %
death or disability (Leicester)
No spontaneous respiration after 20 min : 60
% disability in survivors (USA).
No spontaneous respiration after 30 minutes :
nearly 100 % disability in survivors (Newcastle).

17. Facts About Newborn Resuscitation
The most important is to get air into the lungs
Facts About Newborn Resuscitation

18. Hypoxic-ischemic encephalopathy(HIE)
Hypoxic-ischemic encephalopathy is an important cause of permanent damage to central nervous system cells, which may result in
- neonatal death
- manifest later as cerebral palsy or mental deficiency

19. Essential criteria:
1. Metabolic acidosis on cord blood or very early (1 hour) neonatal blood (pH 7.0 or base deficit > 12 mmol/l.)
2. Early onset of severe or moderate neonatal encephalopathy in infants of > 34 weeks gestation.
3. Cerebral palsy of the spastic quadriplegic or
dyskinetic type.

20. Criteria that together suggest
A sentinel hypoxic event immediately before or during labour.
A sudden, rapid and sustained deterioration of fetal heart rate.
Apgar scores of 0-6 for longer than 5 minutes.
Early evidence of multisystem involvement.
Early imaging evidence of acute cerebral abnormality.