POST-RESUSCITATION MANAGEMENT

OF AN ASPHYXIATED NEONATE
CHAPTER 9

Perinatal asphyxia is a common neonatal problem and contributes significantly to neonatal morbidity and
mortality. It ranks as the second most important cause of neonatal deaths after infections, accounting for around
20% mortality worldwide. Perinatal asphyxia is an insult to the fetus or the newborn due to lack of oxygen
(hypoxia) and perfusion (ischemia) to various organs.

Learning objectives

After completion of this chapter the participant should be able to:

• Perform initial stabilization and management of an asphyxiated neonate

• Monitor an asphyxiated neonate
• Recognize poor prognostic factors in asphyxia

Definition of asphyxia

Clinically a neonate should be labeled as having suffered perinatal asphyxia if there is presence of any one of the
following:

• Gasping or ineffective breathing or lack of breathing at one minute of life.

• Need for positive pressure ventilation for > 1minute.
• Apgar Score <3 at 5 minutes or longer.

Other features which evolve over time include

• Clinical: neurologic manifestations such as seizures, hypotonia, coma or hypoxic ischemic encephalopathy
(HIE) in the immediate neonatal period (First 72 hours of life).
• Evidence of multi-organ system dysfunction manifested as breathing difficulty or renal failure or feeding
intolerance or hepatic dysfunction or hematological abnormality in the immediate neonatal period.

Clinical presentation

• Perinatal asphyxia may result in adverse effects on all major body systems including the kidney, brain, heart
and lungs. The clinical features in asphyxiated babies range from mild to severe impairment.
• The extent of multi-organ dysfunction determines the early outcome of an asphyxiated neonate.
• The most severely affected babies may manifest with stupor or coma, periodic breathing or irregular
respiration, hypotonia and loss of neonatal reflexes like Moro’s and suck.
• About 50 % of the moderate to severely asphyxiated babies may have seizures.

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• Severely affected babies may have progressive deterioration of the CNS function in terms of decreasing tone,
increasing degree of coma and prolonged apnea over the next 48-72 hours. These neonates would eventually
die or have permanent neurologic sequelae.

Grading of severity of hypoxic ischemic encephalopathy

Levene’s system of grading clinical severity of HIE is functionally appropriate, easy to use and serves as a
useful clinical guide which is based on assessment of consciousness, tone, seizure, autonomic disturbances and
abnormalities of peripheral and brain stem reflexes.

Table 9.1: Grading of HIE (Levene)

Feature Mild Moderate Severe

Consciousness Irritable Lethargy Comatose
Tone Hypotonia Marked hypotonia Severe hypotonia (Flaccid)
Seizures No Yes Prolonged or uncontrolled
Sucking Poor suck Unable to suck Absent suck
Respiration Spontaneous Periodic or Irregular Unable to sustain
spontaneous respiration

Initial stabilization and management

The management consists of supportive care to maintain temperature, perfusion, ventilation and a normal
metabolic state including glucose, calcium and acid-base balance. Early detection by clinical and biochemical
monitoring and prompt management of complications must be done to prevent extension of cerebral injury.

a. Temperature: Baby should be placed under radiant warmer. The temperature should be maintained in the
normal range of 36.5-37.50C.
Uncontrolled hypothermia and hyperthermia are both detrimental. If therapeutic hypothermia facility is
available in a nearby higher centre, referral may be considered.
b. Airway and breathing: Patent airway should be maintained by appropriate positioning and any secretions
should be cleared. The breathing should be monitored and supported as required.
c. Oxygenation: Should be kept in the normal range by monitoring oxygen saturation by pulse oximetry. SpO2
should be maintained between 91-95%. Hypoxia should be treated with oxygen supplementation if the baby
does not improve, he/she may need referral for CPAP or mechanical ventilation. Hyperoxia should always be
avoided.
d. IV fluids and Enteral Feeding: Initiate IV fluids as per day’s requirement. (Refer to chapter 6). Not all babies
require prolonged IV fluids and many can be fed enterally by gavage, spoon or at the breast. Assess for
feeding every 4-6 hrs. As soon as the baby is hemodynamically stable, there is no abdominal distension and
the baby has passed meconium, start enteral feeds with expressed breast milk (EBM) @ 30ml/kg/day and
increase daily by 20-30 ml/kg/day or more as the baby tolerates. In those feeding directly at the breast allow
feeding ad libitum.

• Blood glucose: Blood glucose should be monitored for at least first 48 hrs. If the baby is hypoglycemic,
treat appropriately. (Refer to chapter 7 on Hypoglycemia)

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 • Blood glucose: Blood glucose should be monitored for at least first 48 hrs. If the baby is hypoglycemic,
treat appropriately. (Refer to chapter 7 on Hypoglycemia)
• Calcium: If a neonate has jitteriness or seizures check serum calcium (if facility is available). Manage
hypocalcemia. (Refer to chapter 10 on neonatal seizures). Give it as slow bolus under cardiac monitoring
preferably using syringe infusion pump.
• Inj. Vitamin K1 mg IM must be administered to all those babies who have not received Vit K at birth.
• Blood Pressure: In an asphyxiated neonate cerebral blood flow depends on systemic blood pressure.
Hence, maintain systemic mean arterial BP at 40 mm of Hg for term infants. The mean BP for preterm
neonates should be maintained equal to gestational age in weeks as mmHg. If the neonate is in shock
manage as per chapter 8 on shock.
• Seizures: For management of seizures refer to chapter 10 on Neonatal seizures.

Steroids, Mannitol, Furosemide and Sodium-bicarbonate HAVE NO ROLE in Management of Asphyxia

Monitoring

Clinical monitoring
All neonates who have suffered asphyxia must be closely monitored clinically as well as by performing certain
bedside tests.

• Neurological status should be monitored by using Levene’s staging every 8 hrs which has been found to be
useful to detect improvement or further deterioration.
• Respiratory status must be monitored by meticulous record of the respiratory score (Downe’s score) every
2-3 hours.
• Cardiovascular status assessment should include heart rate, color, CRT, peripheral pulses, pulse oximetry and
non-invasive blood pressure (NIBP).
• Abdominal circumference should be recorded to rule out any ileus due to gut ischemia. (Refer to chapter 4)
• Urine output should be measured daily. It should normally be > 1ml/kg/hr after the first 24 hrs of life. If it
remains < 1mL/kg/hr, check serum electrolytes, blood urea and serum creatinine every 48 hours.
• Blood sugar should be monitored every 6-8 hrs during the first 24 hrs and then as required.

Facilitator will now demonstrate the monitoring chart for a sick neonate
(Annexure 5).
Poor prognostic factors
The presence of one or more of the following features may point towards poor neurodevelopmental outcome in
the long term. These are:

1. Need for PPV for 5 minutes or longer.

2. Onset of seizures within 12 hours.
3. Refractory seizures (uncontrolled with Phenobarbitone and Phenytoin).
4. Severe HIE (See Levene Chart).
5. Inability to establish direct oral feeds by 1 week.

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When to refer
• Need for respiratory support.
• Refractory seizures (uncontrolled with Phenobarbitone and Phenytoin).
• Shock unresponsive to vasopressors.
• Renal failure.

Post discharge and follow-up advice

• All neonates discharged with diagnosis of Perinatal asphyxia must attend the follow-up clinic for monitoring
of their growth and development, and to identify post asphyxia sequelae.

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EXERCISE

1. Baby Kumud was born to a primigravida through vaginal delivery, needed positive pressure ventilation for
five minutes, and was admitted to NICU. How will you manage this baby?

2. After 24 hours the baby is haemodynamically stable. How will you take care of the fluid requirement?

3. How will you counsel the parents of this baby?

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