Birth Asphyxia -Asphyxia Neonatorum

Asphyxia Neonatorum is defined as the failure to initiate and sustain spontaneous breathing within one minute of delivery. Asphyxia neonatrum is a clinical term that refers to the failure to establish adequate lung breathing during birth. The heartbeat persists, but the fetus does not attempt to breathe adequately.

Causes

• One of the most common causes of a baby's failure to initiate breathing is obstruction of the baby's airway by mucus, blood, liquor, or meconium.
• Because of improper lung development and a lack of surfactant, the infant's immaturity produces mechanical dysfunction.
• There may be congenital anomalies present, such as tracheal atresia.
• Depression of the respiratory center may be caused by maternal medication, such as narcotics or diazepam, or by cerebral injury during labor.
• Intracranial hemorrhage causes respiratory center depression.
• Forceps or vacuum delivery for traumatic injuries.
• Pre-eclampsia causes a maternal shortage of oxygen.
• Cord prolapse, real knot, or cord round around the neck are all examples of cord prolapse.

Classification of asphyxia

• In mild asphyxia: Sittery or hyper-alert behavior may occur, as well as increased muscle tone, poor eating, and a normal or quick respiration rate. These findings usually linger for 24 to 48 hours before disappearing on their own.
   
• In moderate asphyxia: The baby may be drowsy and have feeding difficulties. The baby may have apnea or seizures on occasion. These issues normally resolve after a week, although long-term neurodevelopmental issues are conceivable.
   
• In severe cases: The infant may be drowsy and floppy, or he may be unconscious and refuses to feed. Convulsions can last for many days, and severe and frequent apnea episodes are prevalent. The baby may improve gradually over several weeks, or he or she may not improve at all.

Clinical features

The clinical aspects are determined by the cause, severity, and duration of oxygen deficiency. The clinical picture is characterized by concurrent fetal shock as a result of birth trauma. They were originally classed as asphyxia livida and asphyxia Pallotta based on the intensity of clinical symptoms.

APGAR Score

This is a means of examining, analyzing, and documenting the baby's status by watching vital indicators such as appearance, pulse, grimace or response to stimuli, activity or muscular tone, and respiratory effort. The baby is given 2, 1 or 0 points for each vital sign, depending on their status, and the points are totaled. The APGAR score is an excellent indicator of a baby's respiratory and circulatory condition.

The examination is performed one minute and five minutes following birth. The most significant observations are the heartbeat and breathing effort. Few APGAR scores are common in high-risk pregnancy and lengthy labor.

Classification of Scoring

1. Severe asphyxia 0-2 APGAR score.
2. Moderate asphyxia 3-4 APGAR score.
3. Mild asphyxia 5-7 APGAR score.
4. No asphyxia 7-10 APGAR score.

Table of APGAR scoring

Management

1. Preventive
   • High-risk patients are screened antenatally.
   • Comprehensive fetal surveillance, especially in high-risk pregnancies, to
   • Guarantee early detection of fetal distress
   • Fetal monitoring and Ph evaluation during labor.
   • Cautious use of anesthetic and antidepressant drugs during labor
2. Curative
   • The chord is swiftly clamped and the infant is removed.
   • Baby is positioned supine, neck extended, and wrapped in a warm, dry towel.
   • After birth, the baby's mouth and nostrils are suctioned.
   • Immediately after freeing the airway, administer oxygen.
   • All resuscitation equipment should be available.
   • Keep away from
   • Defeat defeat
   • The Ambu bag mask is lightly pushed against the baby's face. By pressing the bag, oxygen is delivered to the baby's face.
   • At positive pressure, an ambu bag can supply air to a baby, causing the majority of them to start breathing and crying.

Newborn resuscitation

Newborns with intrapartum indications of considerable fetal impairment, babies delivering before 35 weeks gestation, babies delivering vaginally via the breech, maternal infection, and multiple pregnancies are more likely to require resuscitation or transition care.

Furthermore, cesarean delivery is related to an increased risk of issues with the respiratory transition at birth, which necessitates medical intervention, particularly for deliveries before 39 weeks gestation.

Steps of doing newborn resuscitation

Step 1: Position the Baby

• On a flat surface, place the infant on his back.
• Place the head in such a way that the neck is slightly stretched. To keep the position, place a rolled towel beneath the shoulder.
• The resuscitation surface should be well-lit and comfortable.
• To keep the baby warm, cover his head and lower torso.

Step 2: Clear the Airway

• Using a clean piece of gauze or cloth, wipe the baby's face.
  suction the infant
• It is possible to employ bulb suction.
• After use, throw away the bulb syringe.
• Mechanical suction using a De Lee suction device or a mucus extractor.
• A clean soft suction tube or catheter size 12 F can be utilized with machine suction.
• Suction the baby's mouth first, followed by the nose.
• A suction tube should not be inserted more than 5 cm into the mouth and 3cm into the nose.
• After you've positioned the baby and cleaned the airway, quickly reassess the breathing.
• If the baby is breathing normally, no more resuscitation measures are required.
• Begin ventilation if a baby is having difficulties breathing or is not breathing.

Step 3: Ventilate

Ventilate once or twice, keeping an eye on the baby's chest to see if it rises. If the chest does not rise with each breath, check the baby's position, reposition the baby, your mouth, or the mask, and repeat until the chest rises with each breath. Repeat suctioning as necessary;

• In 1 minute, ventilate about 40 times.
• Stop after 1 minute to see if the infant begins to breathe on his or her own.
• Continue to ventilate the baby until he or she spontaneously cries or breathes.

When the baby's breathing is normal, discontinue ventilation and continue to constantly observe the baby. Stop ventilation if there is no breathing or gasping after 20 minutes. The infant has passed away.

Step 4: Monitor

• Even if a newborn appears to be breathing normally, he should be continuously monitored if he has had resuscitation or has poor color.
• Keep an eye out for any of the following symptoms of a respiratory problem: grunting, chest indrawing, quick breathing, slow breathing, and a pale complexion. If a newborn is having trouble breathing, give him or her oxygen.
• Maintain the baby's warmth and dryness.
• If the Baby's condition worsens. Transfer to a hospital for medical treatment as soon as possible.

Post-resuscitation care

Therapeutic hypothermia

Therapeutic hypothermia should be used in term or near-term newborns with moderate to severe hypoxic-ischemic encephalopathy. Both whole-body cooling and selective head cooling are viable options. Cooling should be commenced and carried out in accordance with clearly established protocols, with treatment in neonatal critical care units and the ability to provide multidisciplinary care.

Glucose

Infants who are premature or require substantial resuscitation should be examined and treated to keep blood glucose levels within the normal range. An infusion of 10% glucose, rather than multiple boluses, is usually the most effective at treating low blood glucose levels and maintaining glucose levels in the normal range.

Resuscitation or stabilisation

Most term infants do not require resuscitation and can generally stabilize themselves fairly well during the shift from placental to pulmonary breathing.

Intervention is rarely required if care is taken to limit heat loss (and avoid over-warming) and a little patience is displayed before cutting the umbilical cord. Some infants, however, would have been subjected to stress or insults during labor. Help may then be necessary, which is characterized by interventions meant to save a sick or critically ill infant, and this process is appropriately referred to as resuscitation.

Umbilical cord clamping

Delaying cord clamping for at least one minute, or until the cord stops pulsing, after delivery increases iron status through early infancy in healthy term newborns. Delaying cord clamping for up to 3 minutes for preterm infants in good health at birth leads to improved blood pressure during stabilization, a decreased incidence of intraventricular hemorrhage, and fewer blood transfusions.

Maintaining normal temperature (between 36.5°C and 37.5°C)

In an environment that is comfortably warm for humans, naked, damp newborn infants cannot regulate their body temperature. Infants with impaired immune systems are more prone to the effects of cold stress, which can reduce arterial oxygen tension and exacerbate metabolic acidosis. To avoid hypothermia, active steps must be taken, especially in the preterm infant, where a team approach and a combination of methods may be required.

Complications

1. Cardiovascular - hypotension, cardiac failure.
2. Renal - acute cortical necrosis, renal failure.
3. Liver function - compromised
4. Gastrointestinal - ulcer and necrotizing enterocolitis.
5. Lungs - persistent pulmonary hypertension.
6. Brain - cerebral edema, seizures.