Update: November 2018
The birth of a long-awaited baby is a joyous event, but far from
In all cases, childbirth ends successfully, not only for the mother, but also
for a child. One of these complications is fetal asphyxia,
which originated in childbirth. This complication is diagnosed in 4 –
6% of the newly born children, and according to some
authors frequency of neonatal asphyxia is 6 – 15%.
Determination of newborn asphyxia
Translated from Latin, asphyxia means choking, that is, lack
oxygen. Asphyxia of the newborn is called this pathological
a state in which gas exchange in the body is disturbed
newborn, which is accompanied by a lack of oxygen in the tissues
child and his blood and the accumulation of carbon dioxide.
Resulting in a newborn who was born with signs
live births either cannot breathe on their own for the first minute
after the birth, or he has a separate,
superficial, convulsive and irregular breathing movements on
background heartbeat available. So children immediately spend
resuscitation, and the prognosis (possible consequences)
in this pathology depends on the severity of asphyxia, timeliness and
quality of resuscitation.
Classification of neonatal asphyxia
By the time of occurrence, there are 2 forms of asphyxia:
- primary – develops immediately after the birth of the baby;
- secondary – diagnosed during the first days after birth
(that is, at first the child breathed independently and actively, and then
there was suffocation).
The severity (clinical manifestations) are as follows:
- mild asphyxia;
- moderate asphyxia;
- severe asphyxia.
Factors provoking the development of asphyxia
This pathological condition is not independent.
diseases, and is only a manifestation of the complications of the course
pregnancy, diseases of the woman and the fetus. For causes of asphyxia
- birth trauma (cranial) in a child;
- rhesus conflict pregnancy;
- abnormalities of the bronchopulmonary system;
- intrauterine infections;
- intrauterine growth retardation;
- airway obstruction (mucus, amniotic fluid,
meconium) or aspiration asphyxia;
- malformations of the heart and brain of the fetus.
- severe gestosis occurring against the background of high blood
pressure and pronounced edema;
- decompensated extragenital pathology
(cardiovascular diseases, pulmonary diseases
- anemia of pregnant women;
- endocrine pathology (diabetes, thyroid disease
glands, ovarian dysfunction);
- shock of the woman during childbirth;
- disturbed ecology;
- bad habits (smoking, alcohol abuse,
- insufficient and inadequate nutrition;
- medication, contraindicated in the period
- infectious diseases.
Factors contributing to the development of disorders in
- postponed pregnancy;
- premature aging of the placenta;
- premature detachment of the placenta;
- umbilical cord pathology (cord entanglement, true and false
- permanent threat of interruption;
- placenta previa and bleeding associated with it;
- multiple pregnancy;
- excess or lack of amniotic fluid;
- anomalies of labor forces (weakness of labor and
discoordination, fast and rapid delivery);
- drug administration less than 4 hours before completion
- general anesthesia of a woman;
- cesarean section;
- rupture of the uterus;
Secondary asphyxia is provoked by the following diseases and
pathology in the newborn
- impaired cerebral circulation in a child due to
residual damage to the brain and lungs during childbirth;
- not detected and not immediately manifested at birth
- aspiration of milk or mixture after the feeding procedure or
poor-quality sanitation of the stomach immediately after birth;
- respiratory distress syndrome due to pneumopathies:
- the presence of hyaline membranes;
- edema-hemorrhagic syndrome;
- pulmonary hemorrhage;
- atelectasis in the lungs.
Asphyxia development mechanism
No matter what caused the lack of oxygen in the body
just born child, in any case, metabolic processes,
hemodynamics and microcirculation are rebuilt.
The severity of pathology depends on how
hypoxia was long and intense. Due to exchange and
hemodynamic changes develops acidosis, which
accompanied by a lack of glucose, azotemia and hyperkalemia
In acute hypoxia, the circulating blood volume increases, and
in chronic and then asphyxia developed blood volume
decreases. As a result, the blood thickens, its viscosity increases,
platelet and erythrocyte aggregation increases.
All these processes lead to the breakdown of microcirculation in the vital
important organs (brain, heart, kidneys and adrenal glands,
liver). Microcirculation disorders cause swelling, hemorrhage and
pockets ischemia, which leads to impaired hemodynamics, disorder
functioning of the cardiovascular system, and as a result, all
other systems and organs.
The main sign of neonatal asphyxia is considered
respiratory failure which causes malfunction
cardiovascular system and hemodynamics, and also upsets
neuromuscular conduction and severity of reflexes.
To assess the severity of the pathology, neonatologists use
assessment of the newborn on the Apgar scale, which is carried out on the first
and the fifth minute of the child’s life. Each attribute is estimated at 0 – 1 –
2 points. A healthy newborn in the first minute is gaining 8 – 10
points by Apgar.
The degree of asphyxia of the newborn
With mild asphyxia, the number of points in a newborn
Apgar is 6 – 7. The first breath a child commits to
throughout the first minute, but there is a decrease in breathing
slight acrocyanosis (cyanosis in the nose and lips) and
reduced muscle tone.
Apgar score is 4 – 5 points. Marked significant
weakening of breathing, possible disturbances and irregularities.
Heartbeat rare, less than 100 per minute, cyanosis is observed
faces, hands and feet. Movement increases,
muscular dystonia develops with a predominance of hypertonus. Available
tremor of chin, arms and legs. Reflexes can be reduced as well.
The condition of the newborn is heavy, the number of Apgar scores on
the first minute does not exceed 1 – 3. The child does not commit respiratory
movement or produces separate breaths. Heartbeat less
100 per minute, severe bradycardia, deaf and heart tones
arrhythmic. The cry of a newborn is absent, muscle tone
muscle atony is significantly reduced or observed. The skin is very
pale, the umbilical cord does not pulsate, reflexes are not detected.
Eye symptoms appear: nystagmus and floating eyeballs,
possible development of seizures and swelling of the brain, DIC syndrome (violation
blood viscosity and increasing platelet aggregation). Hemorrhagic
the syndrome (multiple hemorrhages on the skin) is increasing.
A similar diagnosis is made when evaluating all indicators for
Apgar to zero points. The condition is extremely difficult and requires
When making a diagnosis: “Asphyxia of the newborn” take into account
data of obstetric history, how the childbirth proceeded
Apgar on the first and fifth minutes and clinical laboratory
Definition of laboratory parameters:
- pH, pO2, pCO2 (blood test obtained from
- determination of base deficit;
- urea and creatinine levels, diuresis per minute and per day
(work of the urinary system);
- electrolyte level, acid-base status, glucose
- ALT, AST, bilirubin and blood coagulation factors
- assessment of the cardiovascular system (ECG, blood pressure control,
pulse, chest x-ray);
- assessment of neurological status and brain
(neurosonography, encephalography, CT and NMR).
All newborns born asphyxiated are administered
immediate resuscitation. It is from the timeliness and
the adequacy of the treatment of asphyxia depends on the further prognosis.
Resuscitation of newborns is carried out by the ABC system (developed by
Primary care for a newborn
- ensure the correct position of the child (lower head,
putting a cushion under the shoulder girdle and tilting it slightly);
- suck mucus and amniotic fluid from mouth and nose, sometimes from
trachea (aspirated with amniotic fluid);
- intubate the trachea and sanitize the lower respiratory
of the way.
- conduct tactile stimulation – slap on the heels of a child (if
cry is absent for 10 – 15 seconds after appearing on
light, the newborn is placed on the resuscitation table);
- oxygen supply jet;
- implementation of auxiliary or artificial ventilation
lungs (Ambu bag, oxygen mask or endotracheal
- conducting an indirect heart massage;
- drug administration.
Decision on the termination of resuscitation
проводится через 15 – 20 минут, если новорожденный не
reacts to resuscitation actions (breathing is absent and
persists bradycardia). Termination of resuscitation
due to the high probability of brain damage.
In the umbilical vein on the background of artificial ventilation of the lungs (mask
or endotracheal tube) cocarboxylase injected diluted 10
ml of 15% glucose. Also 5% -hydrocarbonate is injected intravenously.
натрия для коррекции метаболического ацидоза, 10%-глюконат
calcium and hydrocortisone in order to restore vascular tone. If a
bradycardia appeared, 0.1% is injected into the umbilical vein – sulfate
If a частота сердечных сокращений меньше 80 в минуту,
Indirect cardiac massage with a mandatory continuation
artificial ventilation of the lungs. Through endotracheal tube
0.01% adrenaline is injected (possible into the umbilical vein). As soon as the heart rate
reached 80 beats, heart massage is stopped, mechanical ventilation continues until
achieving a heart rate of 100 beats and the appearance of spontaneous breathing.
Further treatment and observation
After primary resuscitation care and recovery
cardiac and respiratory activity of the newborn is transferred to
intensive care unit (PIT). PIT conducts further
acute period asphyxia therapy:
Special care and feeding
The child is placed in a incubator, where the permanent
heating. Craniocerebral hypothermia is carried out simultaneously.
the head of the newborn is cooled, which prevents swelling of the brain.
Feeding infants with mild to moderate asphyxia begins not
earlier than 16 hours, and after severe asphyxia feeding
allowed after a day. Feed the baby through a tube or
bottle. Attaching to the chest depends on the condition of the child.
Prevention of brain edema
Intravenously, albumin, plasma and
cryoplasma, mannitol. Also prescribed drugs to improve
blood supply to the brain (cavinton, cinnarizine, vinpocetine,
sermion) and antihypoxants (vitamin E, ascorbic acid,
cytochrome C, aevit). Diuretic and hemostatic agents are prescribed.
drugs (dicine, rutin, vikasol).
Conducting oxygen therapy
Moisturized and heated oxygen supply continues.
Conducted therapy aimed at preventing convulsions and
hydrocephalic syndrome. Anticonvulsants prescribed
(GHB, phenobarbital, Relanium).
Correction of metabolic disorders
Intravenous administration of sodium bicarbonate continues.
Infusion therapy is carried out with saline solutions (physical solution and
Twice a day, the child is weighed, the neurological and
somatic status and the presence of positive dynamics, control
incoming and released fluid (diuresis). On the devices
heart rate, blood pressure, respiratory rate, central
venous pressure. From laboratory tests are determined daily
complete blood count with hematocrit and platelets, acid-base
condition and electrolytes, blood biochemistry (glucose, bilirubin, AST,
ALT, urea and creatinine). Also evaluated indicators
blood clotting and tank. crops from the oropharynx and rectum.
X-ray examination of the chest and abdomen, ultrasound
brain, ultrasound of the abdominal organs.
Asphyxia of newborns rarely passes without consequences. In this or
different degree of lack of oxygen in the baby during and after childbirth
affects all vital organs and systems. Special
dangerous severe asphyxia, which always takes place with polyorgan
insufficiency. The forecast for the life of the baby depends on the degree
Apgar scores. In case of an increase in the score in the fifth minute of life
The prognosis for the child is favorable. In addition, the severity and frequency
developmental consequences depend on the adequacy and timeliness
the provision of resuscitation and further therapy, as well as
from the severity of asphyxia.
The frequency of complications after suffering hypoxic
- with I degree of encephalopathy after hypoxia / asphyxia
newborns – child development is no different from development
- with grade II hypoxic encephalopathy – 25–30% of children in
further have neurological disorders;
- with grade III hypoxic encephalopathy, half the children
dies during the first week of life, and the rest in 75 – 100%
severe neurological complications appear with cramps and
increased muscle tone (late mental retardation)
After postponed asphyxia at birth, the consequences can be
early and late.
Early complications are reported when they appear throughout
the first 24 hours of a baby’s life and, in fact, are manifestations
- swelling of the brain;
- cerebral hemorrhage;
- increased intracranial pressure and hand tremor (first
small, then large);
- episodes of apnea (respiratory arrest);
- meconium aspiration syndrome and consequently the formation
- transient pulmonary hypertension;
- due to the development of hypovolemic shock and blood thickening
the formation of polycythemic syndrome (a large number of
red blood cells);
- thrombosis (violation of blood clotting, reduced tone
- heart rhythm disorders, post-hypoxic development
- disorders of the urinary system (oliguria, thrombosis
renal vessels, edema interstitial kidney);
- gastrointestinal disorders (enterocolitis and paresis
intestinal dysfunction of the digestive tract).
Late complications диагностируют после трех суток жизни ребенка
and later. Late complications могут быть инфекционного и
neurological genesis. To the neurological effects that
appeared due to hypoxia of the brain and
Posthypoxic encephalopathy include:
- Syndrome hyperactivity
The child has signs of increased excitability,
pronounced reflexes (hyperreflexia), pupils dilated,
tachycardia. There are no cramps.
- Syndrome сниженной возбудимости
Reflexes are poorly expressed, the child is sluggish and adynamic, muscle tone
lowered, dilated pupils, a tendency to lethargy, present
the symptom of “doll” eyes, periodically slows down and
breathing stops (bradypnea, alternating with apnea), rare
pulse, weak sucking reflex.
- Convulsive syndrome
Characteristic tonic (tension and stiffness of the muscles of the body and
limbs) and clonic (rhythmic contractions in the form
jerking of individual muscles of the arms and legs, face and eyes) convulsions. Also
Opercular paroxysms appear in the form of grimaces, gaze spasm,
bouts of unmotivated sucking, chewing and sticking tongue,
floating eyeballs. Possible attacks of cyanosis with apnea, rare
pulse, increased drooling and sudden pallor.
- Hypertension-hydrocephalic syndrome
The child throws back his head, the fontanelles swell, the cranial sutures
diverge, increasing head circumference, constant convulsive
readiness, loss of function of the cranial nerves (noted
strabismus and nystagmus, smooth nasolabial folds and
- Syndrome вегето-висцеральных нарушений
Characterized by vomiting and constant regurgitation, motor disorders
bowel function (constipation and diarrhea), skin marbling (spasm
blood vessels), bradycardia and rare breathing.
- Syndrome двигательных расстройств
Residual neurological disorders (paresis and
paralysis, dystonia of muscles).
- Subarachnoid hemorrhage
- Intraventricular hemorrhages and hemorrhages around
Possible infectious complications (due to weakened
immunity after suffering multiple organ failure):
- the development of pneumonia;
- lesion of the dura mater (meningitis);
- development of sepsis;
- intestinal infection (necrotic colitis).
Вопрос: Нужен ли ребенку, который перенес асфиксию
in childbirth, special care after discharge?
Ответ: Да, конечно. Such children need
especially careful observation and care. Pediatricians are usually
prescribe a special gymnastics and massage, which normalize
excitability, reflexes in the baby and prevent the development of seizures.
The child must be given maximum rest and preference.
give to breastfeeding.
Вопрос: Когда выписывают из роддома после асфиксии
Ответ: О ранней выписке (на 2 – 3 день) стоит
to forget. The baby will be in the maternity ward at least
week (requires a couvez). If necessary, the baby and mother translate
in the children’s department, where treatment can last up to a month.
Вопрос: Подлежат ли новорожденные, перенесшие
Asphyxia, dispensary observation?
Ответ: Да, все дети, которые перенесли асфиксию
in childbirth, mandatory put on dispensary registration
pediatrician (neonatologist) and a neurologist.
Вопрос: Какие последствия асфиксии возможны у
a child at an older age?
Ответ: Такие дети склонны к простудным
diseases due to weakened immunity, they have reduced
school performance, reactions to certain situations are unpredictable
and often inadequate, possible delay of psychomotor development,
lag in speech. After severe asphyxia often develops.
epilepsy, convulsive syndrome, oligophrenia, cerebral palsy and
paresis and paralysis.