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1. ASPHYXIA NEONATORUM THE MULAS MANSA SCHOOL OF NURSING - 2011

2. Definition is the failure of the baby to breath at birth or initiate and sustain breathing at birth.

3. Assessment of the condition Apgar score is a means of quickly assessing the presence or absence of anoxia in a new born infant. The assessment is based on 5 factors (refer to the table) Which can be assessment at 1 minute or at 5 minutes. A/S is an objective method of evaluating the newborn condition and it can also be used to evaluate the effectiveness of resuscitation effort or measures.

4. Apgar Score score P R A G A Heart rate Respiratory rate Muscle tone Response to stimulation reflex/irritability colour Absent Absent Limp No response Blue, pale 1 Below 100 Slow irregular weak cry Some flexion of extremities Some mortion Body pink extremities blue 2 Over 100 Good cry Active motion Cry Completely pink

5. Classification of Asphyxia A/S of 8-10 is normal at 1 minute . The body is pink, blue extremities, breathes and good cry good muscle tone, heart beat is greater than 100 active response to stimuli.

6. Mild Asphyxia Has a score of 5-7, heart rate is severely depressed (60 – 80 beats/minute) Short delay in onset of respiration Good muscle tone Responsive to stimuli Deeply cyanosed No significant deprivation of oxygen during labour Asphyxia Livida (cyanosis and apnoea)

7. Severe Asphyxia A/S less than 5 Slow feeble heart rate (less than 40 beats/minute). No attempt to breath . Poor muscle tone Limp, unresponsive to stimuli . Pale, grey due to vasoconstriction. Oxygen lack has been prolonged before or after delivery, circulatory failure is present. Baby in shock. Asphyxia Pallida (pallor and apnoea)

8. Causes of Neonatorum Asphyxia Fetal causes blocked air passages by liquor, meconium Birth trauma – after coming head of breech Prematurity Congenital anomalies – encephaly Diseases of foetus IUGR Rhesus isoimmunisation

9. Maternal Causes Deficient o2 supply to mother e.g. severe anaemia, hptn , cardiac diseases, PTB Placental insufficiency e.g. eclampsia, pre eclampsia, diabetes Prolonged labour. Hypertonic uterine action, obstructed labour. Shock

10. Placental Causes. APH placental previa & abruptio placental Infarction Diseases like syphilis or haemolytic disease of the new born.

11. Umbilical Causes Cord presentation, cord prolapse Compression of the cord for any reasons especially in cord prolapse and malpresentation. True knots to the cord.

12. Drug causes Valium, pethedine, morphine taken by the mother shortly before delivery Anaesthesia – depresses the respiratory centre of the featus Misuse of oxytocic drugs in labour. Other causes include; instrumental deliveries such as forceps.

13. Management Good preparation and skilled staff. Have the following equipment as asphyxia is anticipated. Suction machine with catheters, cloth or gauze, flat surface and ambubag, oxygen face masks, endotracheal tubes, neonatal laryngoscope – 2.0mm 2.5mm 3mm 3.5mm, stethoscope, syringes and needles, warm room.

14. Mgt cont. Aims of resuscitation To establish & maintain a clear air way, ventilation & oxygenation To ensure effective circulation To correct acidosis 4. To prevent infection 5. To prevent retrolentalfibroplasia

15. Immediate Mgt. As soon as the baby is born – wipe eyes, mouth, nose to remove secretion. Feel the cord around the neck Deliver the child onto the abdomen Time of delivery and A/S, wipe the baby, clump the cord, cut long, show sex to the mother and wrap the baby. Put baby on resuscitare for suction Give o2 and reassess at 5 minutes.

16. Mgt Cont . Give drugs 50% (2-3mls), sodium bicarbonate (2-5mls) Suction the baby – head down @ 5min check for A=air way, B=breathing, C=cardiac function, S=shock. Give narcan 0.01mg/kg iv in cord if mother was given pethedine. Reassess A/S after 5min, if no improvement intubation is done with oxygen. If after 20 min baby doesn't improve transfer to special care unit in pre warmed incubator & commence on a ventilator (IPPV)

17. Mgt Cont. Other drugs (not a priority in resuscitation) Adrenaline 1:1000 – 0.1mg/kg bwt slowly if slow heart as last resort. Sodium bicarbonate to correct respiratory acidosis Calcium gluconate 1ml/kg slowly to correct hypocalcaemia. Dexamethasone 1-2mg (cerebral oedema).

18. Mgt Cont. Reassess the A/S every 5 minutes until 2 successive scores 8 or greater. When the baby improves, the breathing reflexes will return, the muscle tone will return to normal and the baby begins to resist the endotracheal tube and at this time you need to remove it. Maximum resuscitation time is 20 minutes.

19. Subsequent Mgt. Put the baby in an incubator for warmth and easy observations. If no incubator maintain the environmental temperature. Maintain a clear airway Observations General condition Appearance (colour)

20. Observations Cont. Respirations (30-60 breaths/minute) Heart rate (normal – 120-160 beats/minute) Temperature (normal 36.2-36.8oc Bowel action – meconium , consistency, amount, frequency ( meconium stop after 3 days). Bladder – check urine output i.e. amount, colour, frequency.

21. Observations Cont. Cord for bleeding Feeding pattern (if feeding is by the tube check abdomen distension and check skin for dehydration. Chest in drawing and grunting. Irritability/cry (baby crying too much – high pitched cry) which can be suggestive of brain irritation/damage. Reflexes, sleeping pattern

22. Psychological Care Kangaroo method Explain to the mother the management given to the baby and other expectations. Allow the mother to touch the baby that if in the incubator.

23. Infection Prevention Practices Use sterile methods when doing all procedures. Cord care to prevent infection

24. Nutrition Encourage b/feeding, express the b/milk if the baby cant b/feed. Artificial feeding – insert NGT for feeding purposes. Maintain intake and out put to avoid overload and dehydration .

25. Hygiene Top and tail to prevent hypothermia. Baby bath when the condition improves.

26. IEC TO MOTHER Prevention of infections. Danger signs of the baby. Care at home. Explain to her on the milestones ( ie may be delayed according to how long resuscitation took). Check for irritability and convulsions.

27. Prevention of Asphyxia Neonatorum Antenatally Early detection and treatment of illness like ptb , anaemia, hptn , diabetes. Good nutrition to prevent anaemia and malnutrition. Good antenatal care – include head to toe examination. IEC to mothers on effects of traditional oxytocin .

28. Labour Avoid misuse of oxytocic drugs. Avoid prolonged second stage of labour (proper mgt of 1 st stage labour by use of a partogram to rule out deviations from normal). vigilant to ensure that the cord is not tied around the neck.

29. THE END THANK YOU! THE MULAS 2011 -MANSA SCHOOL OF NURSING 29