Author:
EricaLash
NehaRaukar
Description
- Annually, almost 1 million deaths worldwide are related to birth asphyxia. ∼10% of newborns require some assistance at birth and 1% of newborns require extensive resuscitation
- An APGAR score (Activity, Pulse, Grimace, Appearance, Respiration) is calculated for all infants at 1 and 5 min of life
- The APGAR score is a tool used to quantify an infant's clinical status. It should not be utilized to predict outcomes or guide resuscitation
- 5 categories with score of 0, 1, or 2 assessed at 1 and 5 min
- Do not wait to assign APGAR scores before starting resuscitation
- An APGAR score that remains a 0 after 10 min of resuscitation suggests that further resuscitation is unlikely to be successful and may be a useful tool in determining when to withdraw care
- The health care provider and parents of a high-risk newborn must discuss the appropriateness of resuscitative measures. This is ideally done prior to delivery:
- Newborns confirmed to be <23-wk gestation or 400 g
- Anencephaly
- Babies with confirmed trisomy 13 or 18
- A physician is not ethically or legally required to perform futile or potentially harmful interventions, or to withhold beneficial treatment at the request of the parents
| Heart Rate (HR) | Score |
|---|
| 0 | 0 |
| <100 bpm | 1 |
| >100 bpm | 2 |
| |
| Respiration | Score |
| Absent | 0 |
| Slow, irregular | 1 |
| Good, crying | 2 |
| |
| Muscle Tone | Score |
| Limp | 0 |
| Some flexion | 1 |
| Active motion | 2 |
| |
| Reflex Irritability | Score |
| No response | 0 |
| Grimace | 1 |
| Cough, sneeze, cry | 2 |
| |
| Color | Score |
| Blue or pale | 0 |
| Pink body, blue extremities | 1 |
| All pink | 2 |
Etiology
- Fetal-maternal gas exchange is facilitated by two right-to-left shunts:
- Ductus arteriosus: Deoxygenated blood flows from the pulmonary artery to the descending aorta, bypassing the carotid arteries
- Foramen ovale: Oxygenated blood flows from the placenta, through the fetal vasculature, into the right atria and is shunted through the foramen ovale to the left atria and aorta, bypassing the fetal lungs
- The first spontaneous respirations by the infant initiate a cascade of physiologic changes including fluid clearance from the alveoli, lung expansion, decrease in pulmonary vascular resistance, and closure of the right-to-left shunts
- Any problem with the respiratory effort, airway, or lung function portends a problematic transition to extrauterine life, leading to neonatal hypoxia and the need for resuscitation. Hypoxia may initially cause tachypnea followed by primary apnea
- Antepartum risk factors associated with the need for resuscitation include:
| Maternal diabetes |
| Pregnancy-induced or chronic hypertension |
| Anemia |
| Previous fetal or neonatal death |
| Bleeding in second or third trimester |
| Maternal infection |
| Maternal cardiac, renal pulmonary, thyroid, or neurologic disease |
| Polyhydramnios or oligohydramnios |
| Premature rupture of membranes |
| Post-term gestation |
| Multiple gestation |
| Size-dates discrepancy |
| Drug therapy |
| Maternal substance abuse |
| Fetal malformation |
| Diminished fetal activity |
| No prenatal care |
| Maternal age <16 or >35 yr |
- Intrapartum risk factors associated with need for resuscitation include:
| Emergency C-section |
| Forceps or vacuum assist |
| Breech or other abnormal presentation |
| Premature labor |
| Precipitous labor |
| Chorioamnionitis |
| Prolonged rupture of membranes |
| Prolonged second stage of labor |
| Fetal bradycardia |
| Nonreassuring fetal heart tracing |
| General anesthesia |
| Uterine tetany |
| Narcotics administered to mother within 4 hr of delivery |
| Meconium-stained amniotic fluid |
| Prolapsed cord |
| Abruptio placenta |
| Placenta previa |
Signs and Symptoms
Compromised infants requiring resuscitation often exhibit:
- Decreased muscle tone
- Depressed respiratory drive
- Bradycardia
- Hypotension
- Tachypnea
- Cyanosis
History
Risk factors delineated above predict the need for resuscitation
Physical Exam
- Respirations - rate and effectiveness
- HR - by auscultation or palpation of umbilical cord
- Color
- Muscle tone, activity, grimace
Essential Workup
- Three essential questions guide workup and treatment:
- Is the infant full term?
- Is the infant breathing and /or crying?
- Does the infant have good tone?
- If the answer is yes to all three questions, stimulate, dry, and warm the infant and proceed with routine care
- If the answer is no to any of the questions, dry and warm the infant and proceed with resuscitation. Stimulation may cause resumption of breathing
Diagnostic Tests & Interpretation
Lab
- Bedside blood glucose measurement
- Blood gas, oximetry
Diagnostic Procedures/Surgery
- Endotracheal intubation:
- Miller 1 for full term, Miller 0 for preterm
- Endotracheal tubes (ETTs):
- 2.5 for <1,000 g or <28 wk
- 3 for 1,000-2,000 g or 28-34 wk
- 3.5 for 2,000-3,000 g or 34-38 wk
- 4 for >3,000 g or >38 wk
- Have stylet, end-tidal CO2 detector, suction, tape, meconium aspirator available
- Umbilical vein catheterization:
- Tie umbilical tape around base of cord
- Prefill syringe attached to umbilical catheter (3.5F or 5F)
- Cut cord on clean edge below clamp
- Identify umbilical vein (large, thin walled, and single)
- Insert catheter into umbilical vein directed cephalad
- Advance 2-4 cm until blood flows freely into syringe
- Secure the catheter with umbilical tape or a purse-string suture
- Check position with plain film
- Inject drugs/fluids as appropriate
Prehospital
- Resuscitation should be started by prehospital personnel
- Neonatal resuscitation equipment should be available. Anticipation and preparation required
- Pay particular attention to heat dissipation and maintain a low threshold to warm
Initial Stabilization/Therapy
- The 2015 AHA/AAP/ILCOR guidelines recommend a stepwise approach to resuscitation. Initial steps should be performed within the first 60 s (“the golden minute”)
- Initial steps include: Warm, dry, clear airway, and stimulate:
- Warm and dry: Maintain temperature to decrease oxygen and metabolic demand s: Dry, swaddle, use a warmer to increase radiant heat, and increase room temperature
- Clear the airway: Rolled blanket or towel beneath the shoulder blades provides slight neck extension and aligns posterior pharynx, larynx, trachea. Perform suction of the mouth with bulb syringe first, and if the airway is still obstructed, then suction the nose
- Stimulate: Tactile stimulation with drying, suction, flicking of the soles of the feet and rubbing of the back
- If re-evaluation after warming, drying, clearing the airway and stimulation reveals apnea or HR <100 bpm, resuscitation should proceed by supporting breathing, chest compressions, and other adjuncts as needed
- Support breathing with oxygenation and ventilation
- In the term infant, room-air resuscitation may be advantageous to avoid hyperoxia
- In premature infants, blended oxygen with close monitoring of oximetry is appropriate
- For hypoxic infants, 100% oxygen is permissible to achieve oxygen saturation within goal range:
- Normal SpO2 is 65% at 1 min after birth, 90% at 5 min, and >95% by 15 min of life
- In premature infants, blended oxygen with close monitoring of oximetry is appropriate
- Positive-pressure ventilation with 100% oxygen
- Self-inflating or flow-inflating (anesthesia type) bag
- Proper-fitting mask
- First breath may require high pressure, necessitating occlusion of “pop-off” valve
- Rate of 40-60 breaths/min
- Pressure of 30-40 cm H2O
- If prolonged ventilation or chest compressions are indicated, endotracheal (ET) intubation and the placement of a nasogastric (NG) tube are indicated
- Circulation: start chest compressions to achieve a HR >60 after 30 s of positive-pressure ventilation:
- Chest compressions should be delivered via the 2-thumb technique (with hand s encircling the torso) rather than the 2-finger technique whenever possible
- Compress the anterior-posterior diameter of the chest ∼1/3 and release
- 3:1 compression-to-ventilation ratio is recommended, with ∼90 compressions/minute, and 30 breaths/minute
- If HR remains <60 bpm after 30 s of compressions, proceed to administration of IV epinephrine, volume expansion, as below meconium:
- Risk of meconium aspiration increases with postterm delivery
- Routine intubation and suctioning of newborns with meconium-stained amniotic fluid is no longer recommended
- Infants presenting with respiratory distress or apnea in this setting should be managed following the same resuscitation algorithm as infants with clear amniotic fluid
ED Treatment/Procedures
- If evidence of blood loss or poor response to resuscitation, administer volume expand er
- NS, lactated Ringer, O-negative blood (cross-matched if time permitting)
- If severe metabolic acidosis is suspected or proven:
- If hypoglycemia is proven or suspected, treat with IV dextrose
- Routine administration of naloxone is not recommended
- Persistent distress may indicate pneumothorax
- Known or suspected diaphragmatic hernias should be treated with immediate endotracheal intubation and placement of NG tube
- Consider discontinuation of resuscitation after 10 min of asystole
Medication
- Dextrose: 2-4 mL/kg of D10W given IV (umbilical vein)
- Epinephrine: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution), may be given IV; or via ETT (0.1 mg/kg or 0.1 mL/kg of 1:1000 solution if giving via ETT)
- Sodium bicarbonate: 2 mEq/kg (4 mL/kg of 4.2% solution) (0.5 mEq/mL). Administer slowly via IV route (umbilical vein)
- Volume expand ers: NS, lactated Ringer, blood. Initial dose 10 mL/kg, may be repeated, all given IV through the umbilical vein
- Other agents as specifically indicated by newborn's underlying condition
- American Academy of Pediatrics Committee On Fetus and Newborn, BellEF. Noninitiation or withdrawal of intensive care for high-risk newborns . Pediatrics. 2007;119(2):401-403.
- American Academy of Pediatrics Committee on Fetus and Newborn. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. The Apgar score . Pediatrics. 2015;136:819-822.
- FowliePW, McGuireW. Immediate care of the preterm infant . BMJ. 2004;329(7470):845-848.
- KamlinCO, O'DonnellCP, DavisPG, et al. Oxygen saturation in healthy infants immediately after birth . J Pediatr. 2006;148:585-589.
- KattwinkelJ, ed. Overview and principles of resuscitation. Textbook of Neonatal Resuscitation. 7th ed.American Academy of Pediatrics; 2011.
- KubickaZJ, LimauroJ, Darnall , RA . Heated, humidified high-flow nasal cannula therapy: Yet another way to deliver continuous positive airway pressure ? Pediatrics. 2008;121:82-88.
- NooriS, WlodaverA, GottipatiV, et al. Transitional changes in cardiac and cerebral hemodynamics in term neonates at birth . J Pediatr. 2012;160(6):943-946.
- PerlmanJM, WyllieJ, KattwinkelJ, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations . Circulation. 2015;132:S204-S241.
- RileyLE, StarkAR, KilpatrickSJ, et al.; AAP Committee on Fetus and Newborn. ACOG Committee on Obstetric Practice. Guidelines for Perinatal Care, 7th ed.American Academy of Pediatrics, 2012.
- VaucherYE, Peralta-CarcelenM, FinerNN, et al. Neurodevelopmental outcome in the early CPAP and pulse oximetry trial . N Engl J Med. 2012;36:2495-2504.
- WyckoffMH, AzizK, EscobedoMB, et al. Part 13: Neonatal Resuscitation: 2015 american heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care . Circulation. 2015;132:S543-S560.
See Also (Topic, Algorithm, Electronic Media Element)
ICD9
768.5 Severe birth asphyxia
768.6 Mild or moderate birth asphyxia
768.9 Unspecified severity of birth asphyxia in liveborn infant
ICD10
P84 Other problems with newborn
SNOMED
28314004 asphyxia, in liveborn infant (disorder)
77362009 mild to moderate birth asphyxia (disorder)
57284007 severe birth asphyxia (disorder)