Neonatology: Asphyxia of The Newborns at birth

1. Neonatology: Asphyxia of The Newborns at birth

2. 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

3. 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

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

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

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

7. Pathophysiology Hypoxic/ Ischemia  Failure to initiatebreath  O2, CO2 Exchange Obstacle  Hypoxemia/acidosis  Organ/system injury

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

9. Apgar Scoring System

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

11. 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

12. 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

13. Reevaluation of Apgar Score 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. American Academy of Pediatrtics, American College of Obstetricians and Gynecologists. Pediatrics 1996,98:141-2

14. Reevaluation of Apgar Score The relevance to the outcome of asphyxia with survival and system/organ function • Umbilical arteryPH＜7.00 • BE: -20mEq/L Papile LA. The Apgar score in the 21st century. N Engl J Med 2001;344:519-20

15. NRP 5th edition 2006 • 2006: 5th edition; • Suction when • Meconium present • Resuscitation with • oxygen or room air • Epinaphrine for • bradycardia or cardiac • arrest

16. NRP 5th edition 2006

17. Neonatal Resuscitation 5th edition Birth • Routine care • Provide warmth • Clear airway • Dry • Assess color • Term gestation ？ • Clear amniotic fluid？ • Breathing or crying？ • Good muscle tone？ yes No

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

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

20. 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

21. Meconium-stained fluid

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

23. Suctioning Meconium

24. 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.

25. Neonatal Resuscitation 5th edition SpO2 Monitoring: • Once per 30Sec. • To 95% for new a born baby: 10 min. • Premature: • Use Blend and Oxygen air • Adjust the oxygen air to SpO2 near 90% International Liaison Committee on Resuscitation.Part 13: Neonatal resuscitation guidelines.Circulation 2005:112(24, Suppl):IV188-IV195

26. Resuscitation technology Suction：beginning from Oral then Nasal

27. Resuscitation technology • Tactile stimulation：Tap the plantar

28. Resuscitation technology • Tactile stimulation：Rubber the Back

29. Resuscitation technology • O2supply viaPPV bag

30. Resuscitation technology Chest compress:

31. Resuscitation technology Endotracheal intubation： • Method：by nasal or by oral • Indication： • Meconium aspiration • Normal SaO2 onlymaintained by PPV • Serious hypoxemia • Persistent irregular breathing

32. Resuscitation technology Endotracheal intubation by oral：

33. Resuscitation technology Endotracheal intubation: Vocal and Tracheal

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

35. Prognosis • 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 American Academy of Pediatrtics, American College of Obstetricians and Gynecologists. Pediatrics 1996,98:141-2

36. 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

37. 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

38. Thanks and questions?