Birth Asphyxia

Definition
Failure to initiate and sustain breathing at birth is called birth asphyxia.
Magnitude
Of the 5 million neonatal deaths that occur worldwide, 19% death occur due
to birth asphyxia (WHO 1995).
Factors associated with birth asphyxia
1. Fetal distress
Meconium
Abnormal presentation
2.
3.
4.
5.
6.
7.
8.

Prolonged or obstructed labor

Complicated, traumatic or instrumental delivery
Severe maternal infections
Maternal sedation, analgesia or anesthesia
Antenatal or Intrapartam hemorrhage
Pre-term or post-term birth
Congenital anomalies

Who will need resuscitation?

1. 80 - 90% of newborns require no assistance to initiate breathing at birth
2. 10% require some assistance to begin breathing.
3. 1% among them requires extensive resuscitative measures to survive.
Sometimes the need for resuscitation can be predicted, but often it cannot, so...
PREPARE FOR RESUSCITATION AT EVERY BIRTH

Neonatal Resuscitation

Introduction:
We cannot tell which babies will have asphyxia at birth. Therefore we must prepared to
do newborn resuscitation at all births. If a few minute pass before the starts to breath,
baby can suffer from brain damage or die. Preparing for resuscitation include, warming
the resuscitation area, preparing clean surface for the resucitation and collecting the
equipments and supply.

Principles of Newborn Resuscitation

According to Pediatric working Group of the International Liaison Committee on
Resuscitation (ILCOR) the principles of newborn resuscitation are as follows:
1. Personal capable of initiating resuscitation should attend every delivery to
establish a vigorous cry or regular respiration, to maintain a heart rate >100 beats
per minute and achieve good color and tone.

2.
Preparation of newborn resuscitation
We cannot predict which baby will have asphyxia at birth. Therefore, we must be
prepared to do newborn resuscitation at all births. When certain preparations are not
done the time will be lost.
Preparations for newborn resuscitation include:
1.
2.
3.
4.

Warming the resuscitation area

Preparing a clean surface for resuscitation
Collecting equipment and supplies
Be prepared to cut the cord immediately if the baby needs resuscitation

Warming the resuscitation area:

Keeping a newborn baby warm saves his/her energy for breathing. There are many
ways to keep the baby warm.

 Keep the room warm and free from drafts and fans.
Heat should avoided near the resuscitation area if possible
The heater or light should not use above the baby but turned on before delivery
and during resuscitation.
Use a warm cloth to wrap the baby

Prepare clean surface for doing the resuscitation

Use a flat surface that is clean, dry and covered with warm cloth such as table.
Prepare equipment and supplies
Ambu bag
Face mask size 1 for normal weight newborn baby and size 0 for low birth weight
i.e. <2.5 kg baby.
Bag volume should be 250-400 ml
Two pieces of gauze or clean cloth: one to dry the babys mouth and one to use as

protective barrier if doing mouth to mouth and nose resuscitation

Two pieces of cloths: one to dry the baby, one to cover the baby after drying.
A cap to cover the babys head.
A clock or watch
Suction equipment, bulb, mucus extractor or mechanical suction.
Gloves if available (do not need to be sterile)
Oxygen if available, oxygen is not needed for successful resuscitation.

Be prepared to cut the cord immediately if the baby needs resuscitation.

STEPS FOR RESUSCITATION

I. Assessment at birth to decide need for resuscitation
II. Initial steps of resuscitation

Evaluation
III. Provide positive pressure ventilation

Evaluation
IV. Provide positive pressure ventilation and chest compressions

STEPS IN NEONATAL RESUSCITATION

Initial Assessment:
Meconium not present?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?

No
Initial Steps:

Yes
Routine Immediate Newborn Care Steps

Dry & stimulate the baby*

Warm the baby
Position the baby
Clear airway (as necessary)
Give oxygen (as necessary and if available)
*Important: If meconium present, baby not vigorous - do not stimulate until after
clearing airway

Evaluate
Respiration, heart rate, color & decide action
If normal breathing, HR>100 &Pink give Supportive Care
If Apnea or HR <100, Ventilate with bag and mask.

If Normal breathing, HR>100 continue ventilate with bag and mask

If HR < 60 or HR >60, Ventilation and Chest compressions
OngoingCare
Stop resuscitation if baby not breathing or gasping after 20 minutes
without heartbeat
Drugs like epinephrine and volume expanders like normal saline may
be tried at this point depending on expertise of the birth attendant
Evaluate respiration, heart
rate, color and decide action

Step I: On Initial Assessment ask the

following:
Meconium not present?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?
If the answer is yes, proceed with routine immediate newborn care, If the
answer to any one question is no, then go to the next step.
Step II: Initial Steps of Resuscitation
Dry, stimulate*, warm
Position, clear airway (as necessary)

 Reposition
Give O2 (as necessary and if available)
* If meconium is present, do not stimulate until after clearing airway
Evaluate
After initial steps and also after every action (ventilation with/without chest
compressions) it is necessary to evaluate the color, respirations and heart
beat and then decide what to do further and take appropriate action.
. Evaluation
. Decision
. Action
Prevent heat loss by:
Placing newborn under radiant warmer or other heat source
Drying thoroughly
Removing wet towel

TA
CTILESTIMULATION

Open the airway by

Positioning on back or side
Slightly extending neck
Aligning posterior pharynx, larynx and trachea

If the newborn is breathing but central cyanosis is present, give oxygen

oxygen mask

oxygen tubing

Meconium Present at Delivery

NO

Yes
Suction mouth, nose and posterior pharynx
after delivery of head but before delivery of
shoulders
Baby vigorous?(strong respiratory effort
and good muscle tone with heart rate > 100)

Yes

NO
Suction mouth and trachea

Continue with initial steps of resuscitation

Suction

mouth

first,

then

nose

Step III. Provide positive pressure ventilation

If not breathing or heart rate <100 bpm:
Assist newborn by providing positive-pressure ventilation
with a bag and mask for 30 seconds.*

Then, evaluate again

* Babies born outside the hospital may still require positive pressure
ventilation to ventilate the lungs. If a bag and mask in unavailable,
ventilation can be delivered by mouth to mouth. Care to prevent infection
must be undertaken with this technique
Before assisting ventilation with bag and mask
Select appropriate-sized mask
Clear airway
Position newborns head
Position yourself at the side or head of the baby

Positioning of Bag and Mask on Face

Step IV. Provide positive pressure ventilation with chest compression

If heart rate < 60 bpm despite adequate ventilation:

 Support circulation by starting chest compressions while continuing

ventilation.
Then, evaluate again
Chest Compression:
Techniques

Positioning of thumb and fingers for chest compression

Apply pressure to lower third of sternum
Avoid xiphoid process

Thumb technique
Pressure must remain on sternum

Two finger technique

Tips of middle finger and index or ring finger of one hand compress sternum

Other

hand

Post-Resuscitation Care
Supportive Care
A baby who is breathing, heart rate >100, color is
pink with good tone may be given to mother for
warmth and breastfeeding.
Frequent assessments of color, tone and vital
signs for the first six hours needed.

supports

back

 Ongoing Care:
These babies have had active resuscitation (bag
and mask ventilation and/or chest compressions)
They may need more monitoring before giving to
mother or going to higher level care and therefore
need to be transferred to the Baby Unit for further
observation, evaluation and action based on their
condition.
42
Care After Unsuccessful Resuscitation
(If the baby is not breathing or not gasping after 20
minutes without heartbeat, stop resuscitation)
- Talk with mother/family about the babys death and
answer their questions
- Ask if they want to see and hold the baby
- Explain to the mother and family about the mothers
care:
Rest, support and good diet
Management of engorged breasts
Records
- Recording and notification of baby's birth and death
- Completion of required medical records for the
delivery