Neonatology: Asphyxia of The Newborns at birth

Lecture Points Clinical definition and Epidemiology: incidence/mortality Etiology and Pathophysiology Apgar’s score significance of clinical use reevaluation of the score Resuscitation Complication and prognosis

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

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

Etiology Intrapartum Abnormal umbilical cord Abnormal fetal position Procedure: Forceps Medication ： narcotic ， Sedatives

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

Pathophysiology Hypoxic/ Ischemia  Organ/system injury Hypoxemia/acidosis  O 2, CO 2 Exchange Obstacle  Failure to initiate breath 

Pathophysiology repiration change HR  HR   stop Primary apneaSecondary apnea System/organ Ischemia/hypoxicBiochemical/metabolism ________  Hypoxemia, acidosis Organ/system damage Blood redistribution: compensation decompensation Catecholamine  Glucagon  Free fatty acids  ANP  PCO2  Acidosis Hyperglycemia Hypoglycemia Hypocalcemia Hyponatremia

Apgar Scoring System SCORE012 Heart rateAbsent<100/min> 100/min RespirationsAbsentSlow, irregularGood, crying Muscle tone LimpSome motionActive motion Reflex irritability No response GrimaceCough, sneeze, cry ColorBlue, pale Body pink, blue limbs Completely pink

Apgar Scoring System Apgar Score –Methods: at 1 and 5 min. post birth till >7 min. or 20 min. after birth

Clinical Manifestation Fetal distress ： –Fetal motion  or no –Fetal HR  or  –Meconium-stained amniotic fluid Apgar Score – <3 at 1 or 5 min. : severe – 4-7 at 1 or 5 min. : slight

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 1996,98:141-2

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 old – In brain damaged children 75% were normal for Apgar score. Reevaluation of Apgar Score American Academy of Pediatrtics, American College of Obstetricians and Gynecologists. Pediatrics 1996,98:141-2

The relevance to the outcome of asphyxia with survival and system/organ function –Umbilical artery PH ＜ 7.00 –BE: -20mEq/L Papile LA. The Apgar score in the 21st century. N Engl J Med 2001;344: Reevaluation of Apgar Score

NRP 5th edition : 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 ？ yes No Routine care Provide warmth Clear airway Dry Assess color

Neonatal Resuscitation 5th edition Provide warmth Position ， Clear airway EIT (if necessary) Dry ， stimulate Reposition No Evaluate respiration ， HR and color Apnea Or HR<100 Give supplemental oxygen Observational care Breathing HR>100 and pink Cyanosis 30s Persistent cyanosis Pink

Neonatal Resuscitation 5th edition Positive pressure ventilation EIT Administer chest compressions EIT HR<60 Administer epinephrine EIT HR<60 30s Positive pressure EIT ventilation 30s Effective ventilation HR>100 and pink Post resuscitation care Persistent cyanosis HR>60 Apnea Or HR<100

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 – < 100% - acceptable alternative – 21% - acceptable alternative

Meconium-stained fluid

Suction when Meconium present Meconium present? Baby vigorous ? Suction mouth and trachea Continuo with remainder of initial steps Clear mouth and nose secretion Dry, stimulate and repositon Respiration effort HR>100 bpm Good muscle tone No Yes No

Suctioning Meconium

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.

Neonatal Resuscitation 5th edition SpO 2 Monitoring: Once per 30Sec. To 95% for new a born baby: 10 min. Premature: –Use Blend and Oxygen air –Adjust the oxygen air to SpO 2 near 90% International Liaison Committee on Resuscitation.Part 13: Neonatal resuscitation guidelines. Circulation 2005:112(24, Suppl):IV188-IV195

Resuscitation technology Suction ： beginning from Oral then Nasal

Resuscitation technology Tactile stimulation ： Tap the plantar

Resuscitation technology Tactile stimulation ： Rubber the Back

Resuscitation technology O 2 supply via PPV bag

Resuscitation technology Chest compress:

Resuscitation technology Endotracheal intubation ： Method ： by nasal or by oral Indication ： –Meconium aspiration –Normal SaO 2 only maintained by PPV –Serious hypoxemia –Persistent irregular breathing

Resuscitation technology Endotracheal intubation by oral ：

Resuscitation technology Endotracheal intubation: Vocal and Tracheal

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

American 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 <7.00) Apgar score 0-3 persists over 5 min. Manifesting signs of acute CNS damage (convulsion) MODS>3 Prognosis

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

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

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