Management of the infant with asphyxia

Perinatal Education Programme - Care of infants at birth

36-13 WHEN DOES A NORMAL INFANT START BREATHING AFTER DELIVERY?

The normal, healthy newborn infant usually starts to breathe immediately after birth. Sometimes gentle stimulation, such as drying, is needed before the infant breathes well. By 1 minute after delivery the infants should be breathing well or crying.

36-14 WHAT IS ASPHYXIA?

If an infant does not breathe well by 1 minute after birth, the infant is said to have ASPHYXIA (birth asphyxia or asphyxia neonatorum).

ASPHYXIA IS DEFINED AS THE FAILURE TO BREATHE WELL WITHIN ONE MINUTE AFTER DELIVERY

36-15 WHAT IMPORTANT CLINICAL SIGNS SHOULD BE LOOKED FOR IN THE INFANT AFTER DELIVERY?

There are 5 important clinical signs, which should be present after birth. These are called vital signs:

Breathing.
Heart rate.
Colour.
Tone.
Response.

36-16 WHAT IS THE APGAR SCORE?

The Apgar score uses the 5 vital signs at birth to give a score, which is very useful in assessing an infant's condition after delivery. It also helps to decide which infants need resuscitation. The famous Apgar score is named after Virginia Apgar, who described the score in 1953.

36-17 HOW IS THE APGAR SCORE MEASURED?

Each of the 5 vital signs is given a score of 0, 1 or 2. If the sign is normal a score of 2 is given. Mildly abnormal signs are given a score of 1. If the vital sign is very abnormal a score of 0 is given.
The scores for each vital sign are then added together to give the Apgar score out of 10. The best possible Apgar score is 10 and the worst is 0.

36-18 HOW SHOULD YOU ASSESS AN INFANT'S BREATHING AFTER BIRTH?

Look at the infant's chest movements. Both sides of the chest should move well when the infant breathes. A normal infant will cry or take at least 40 breaths a minute.
If the infant breathes well or cries a score of 2 is given. If there is poor or irregular breathing, or the infant only gives an occasional gasp, a score of 1 is given. A score of 0 is given if the infant makes no attempt to breathe.

36-19 HOW SHOULD YOU COUNT AN INFANT'S HEART RATE AFTER BIRTH?

Feel the base of the umbilical cord or listen to the infant's heart with a stethoscope to count the heart (pulse) rate. It often is very difficult to feel peripheral pulses immediately after birth. The normal infant has a heart rate of 140 (120 to 160) beats per minute. It saves time to count the heart rate for 30 seconds and then multiply the rate by 2 to give the heart rate per minute. A wall clock is useful when counting the heart rate.
If the heart rate is above 100 per minute a score of 2 is given. A score of 1 is given if a heart beat is present but the rate is slower than 100 per minute, while a score of 0 is given if no heart beat can be heard or umbilical pulse felt.

36-20 HOW SHOULD YOU ASSESS AN INFANT'S COLOUR AFTER BIRTH?

Look at the infant's tongue and also at the hands and feet. The tongue should always be pink. It is not helpful to look at the colour of the lips or mucus membranes. If the tongue is blue the infant has central cyanosis. This shows that important organs like the brain are not getting enough oxygen. Almost all newborn infants have peripheral cyanosis with blue hands and feet immediately after delivery. This is normal and within minutes the hands and feet should become pink. A pink tongue indicates that enough oxygen is reaching the brain.
If the hands and feet are pink a score of 2 is given. If the tongue is pink,but the hands and feet are still blue, a score of 1 is given. When the tongue, hands and feet are all blue a score of 0 is given.

36-21 HOW SHOULD YOU ASSESS AN INFANT'S TONE AFTER BIRTH?

Normal infants should have good muscle tone at birth and move their arms and legs actively. They should not lie still. Normally the arms and legs are flexed and held above the body, with the knees held together, in a term infant.
If the infant moves well a score of 2 is given. If there is only some movement, and the arms and legs are not pulled up against the body or lifted off the surface, a score of 1 is given. A score of 0 is given if the infant is completely limp and does not move at all.

36-22 HOW SHOULD YOU ASSESS AN INFANT'S RESPONSE TO STIMULATION AFTER BIRTH?

If you handle or gently stimulate the infant there should be a good response. Usually the infant moves a lot or cries. The best method of stimulation is to dry the infant well with a towel. Smacking the infant or flicking the feet are not recommended.
If the infant responds well to stimulation and cries or moves a lot a score of 2 is given. If there is only some response a score of 1 is given while a score of 0 is given if the infant does not respond to stimulation at all.

APGAR SCORE

	1 MINUTE		5 MINUTES
Heart rate per minute	None Less than 100 More than 100	0 1 2	None Less than 100 More than 100	0 1 2
Respiratory rate	Absent Weak or irregular Good or cries	0 1 2	Absent Weak or irregular Good or cries	0 1 2
Colour	Centrally cyanosed Peripherally cyanosed Peripherally pink	0 1 2	Centrally cyanosed Peripherally cyanosed Peripherally pink	0 1 2
Muscle tone	Limp Some flexion Active and well flexed	0 1 2	Limp Some flexion Active and well flexed	0 1 2
Response to stimulation	None Some response Good response	0 1 2	None Some response Good response	0 1 2
TOTAL SCORE:		/10		/10

36-23 WHEN SHOULD THE APGAR SCORE BE MEASURED?

All infants should have their Apgar score measured at 1 minute after delivery. The 1 minute Apgar score is a good method of measuring the infant’s general condition after birth and is one of the best ways of deciding whether the infant needs resuscitation. If the Apgar score is normal, the score usually does not need to be repeated. However, in many clinics and hospitals the Apgar score is still repeated routinely at 5 minutes. Unfortunately many of these normal infants are needlessly removed from their mother’s skin-to-skin care to have the 5 minute Apgar score determined.
However, if the 1 minute Apgar score is low, the score must be repeated every 5 minutes while the infant is being resuscitated. This gives a very good assessment of the success or failure of the attempts at resuscitation. With successful resuscitation the Apgar score will increase to normal.

36-24 WHAT IS A NORMAL APGAR SCORE?

The Apgar score at 1 minute should be 7 or more out of a possible 10. As almost all infants have blue hands and feet immediately after birth, a 1 minute Apgar score of 10 is rare. The Apgar score at 5 minutes, and thereafter, should be 7 or more.
A 1 minute Apgar score of 4 to 6 indicates moderate asphyxia while a score of 0 to 3 indicates severe asphyxia.
A low 5 minute Apgar score is worrying as it suggests that the infant is not responding well to resuscitation. The longer the score remains low, the greater is the risk of death or brain damage.

THE APGAR SCORE SHOULD BE 7 OR MORE AT 1 MINUTE

36-25 WHAT ARE THE IMPORTANT CAUSES OF A LOW APGAR SCORE?

Fetal hypoxia.
Maternal general anaesthesia.
Maternal sedation or analgesia with pethidine or morphine given within the last 4 hours.
Excessive suctioning of the infant’s mouth and throat.
Delivery of a low birth weight infant.
Difficult or traumatic delivery.
Severe respiratory distress.

36-26 WHAT IS HYPOXIA?

Hypoxia is defined as TOO LITTLE OXYGEN IN THE CELLS OF THE BODY. If the infant failures to breathe well after delivery the infant will develop hypoxia. As a result of hypoxia, the infant’s heart rate falls, breathing is poor, central cyanosis develops and the infant becomes hypotonic (floppy) and unresponsive. Asphyxia, if not correctly managed, will lead to hypoxia and possible brain damage or death.

36-27 WHAT IS FETAL HYPOXIA?

If the placenta fails to provide the fetus with enough oxygen, fetal hypoxia will result. Fetal hypoxia presents with meconium stained liquor and late fetal heart rate decelerations or bradycardia. These are the signs of fetal distress (or more accurately, stress). Therefore, fetal hypoxia results in fetal distress. As hypoxia may damage or kill the fetus, it is very important that each infant is well monitored during labour so that any signs of fetal distress can be detected, as soon as possible, so that the correct management can be given.
Fetal hypoxia is the most important cause of asphyxia.

36-28 ARE ASPHYXIA AND FETAL HYPOXIA THE SAME CONDITION?

No. Asphyxia and fetal hypoxia are not the same although severe fetal hypoxia usually results in asphyxia after delivery. Some infants with mild fetal hypoxia breathe well after birth and do not have asphyxia. There are also many causes of asphyxia other than fetal hypoxia. Therefore, some infants have asphyxia even though they have not had fetal hypoxia.

36-29 CAN ASPHYXIA BE PREVENTED?

Good management during labour and the early detection of fetal distress are the best methods of preventing asphyxia. However, some cases of asphyxia cannot be predicted nor prevented.

36-30 HOW IS ASPHYXIA MANAGED?

Asphyxia is corrected by resuscitating the newborn infant. Only about 5% of newborn infants have asphyxia and, therefore, need resuscitation.

Text prepared by Dave Woods

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Edited by Aldo Campana,