Asphyxia PP.pptx study hard this morning

Skills

1. ASPHYXIA NEONATORUM

2. INTRODUCTION Asphyxia neonatorum is an emergency because the newborn suffers from a lack of oxygen and if the infant is not treated, or if treatment is unsuccessful, serious complications or even death of the infant can result.

3. GENERAL OBJECTIVE At the end of this lecture/discussion/session, student nurses should be able to demonstrate an understanding of neonatal asphyxia

4. SPECIFIC OBJECTIVES At the end of the lecture/discussion student nurses should be able to: Define Asphyxia Neonatorum State the classification of Asphyxia Neonatorum State the predisposing factors of Asphyxia Neonatorum State the clinical features of Asphyxia Neonatorum Discuss the management of Asphyxia Neonatorum State the prevention and complications of Asphyxia Neonatorum

5. DEFINITIONS Asphyxia Neonatorum is a condition in which a viable newborn infant fails to initiate and /or sustain respirations after delivery (Sellers P.M, 2010). Asphyxia Neonatorum is failure to establish and sustain respiration at birth (Smith, 1996). Asphyxia of the newborn is a condition in which a viable newborn infant fails to initiate and sustain respiration within ONE minute after delivery.

6. Classification of Asphyxia Neonatorum Classification is normally done basing on the Apgar scoring. The Apgar scoring is a tool used to assess the baby’s condition at birth. 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 on the next slide ) Assessment is done at 1 minute, 5 minutes and at 10 minutes

7. APGAR SCORE SIGN 1 2 Heart rate ABSENT <100bpm >100bpm Respiratory effort ABSENT SLOW, IRREGULAR GOOD OR CRYING Muscle tone LIMP SOME FLEXION OF LIMBS ACTIVE Reflex response to stimulus NONE MINIMAL GRIMACE COUGH OR SNEEZE Colour BLUE, PALE BODY- PINK EXTREMITIES- BLUE COMPLETELY PINK

8. MEANING OF APGAR A= Appearance which is colour P= Pulse rate which is heart rate G= Grimace which is responding to stimuli A= Active which is shows tone R= Respirations

9. Normal score A/S of 8-10 is normal at 1 minute. The body is pink, B lue extremities, breathes and good cry G ood muscle tone, H eart beat is greater than 100 A ctive response to stimuli.

10. Classification of Asphyxia There are two main types of asphyxia namely: Mild asphyxia (Asphyxia Livida ) Moderate asphyxia Severe asphyxia (Asphyxia Palida )

11. Mild Asphyxia (Asphyxia Livida) It is often caused by obstruction to the airway. It is of short duration and responds to prompt and adequate treatment especially suctioning. 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)

12. Moderate asphyxia Apgar Score is 4-6 Heart beat is about 100 bpm or more, Has slow or irregular respiratory effort, Has some flexion of limbs, Shows minimum grimace and Colour is pale/ blue

13. S EVERE A SPHYXIA (ASPHYXIA PALIDA) Apgar Score is 0-3 Here the baby has slow, irregular respiratory effort or makes no attempt to breath Shows flexion of limbs or has poor muscle tone Shows no response to stimulus Body is pale blue or grey Heart beat is less than 100 bpm Oxygen lack has been prolonged before or after delivery, circulatory failure is present. Baby in shock. Asphyxia Pallida (pallor and apnoea)

14. PREDISPOSING FACTORS/CAUSES OF ASPHYXIA NEONATOTUM Predisposing Factors associated with Neonatal asphyxia These factors result into intra-uterine hypoxia (deficiency of oxygen in the tissue) and hypercapnea (an excessive concentration of carbon dioxide in the blood) prior to or at delivery. The cause may be maternal, placental and cord, fetal and teratogenic causes.

15. Maternal causes Conditions that result in deficient oxygen supply to the mother include; Severe anaemia Severe cardiac disease, Respiratory diseases e.g PTB.

16. Maternal Causes cont.. A reduction in uterine blood flow due to vaso- constriction conditions which lead to placental insufficient such as; Pre-eclampsia Eclampsia Diabetes mellitus Prolonged labour can lead to fetal distress and asphyxia. Hypertonic uterine action, obstructed labour. Shock

17. Maternal Causes cont... Mothers who are younger than 16 years old or over 40 years - young mothers have under developed pelvis which may cause prolonged labour and an elderly mother have weak uterine muscles which tend to delay labour and hence distresses the baby .

18. Maternal Causes cont... Low social economic status-mothers from poor families usually have poor nutrition leads to poor immunity which can mimic conditions such as anaemia predisposing to placenta insufficiency and asphyxia at birth.

19. Placenta and Cord causes Antepartum haemorrhage (placenta abruption and previa ). Cord prolapse Cord entanglement (particularly around the neck) can lead to hypoxia. Short cord may lead to early separation of the placenta.

20. Placenta and Cord causes Compression of the cord for any reason either at birth or in utero interferes with gaseous exchange to the fetus. True knots of the cord can lead to hypoxia. Rupture of the cord or vasa previa leads to compromised placental function which leads to poor gaseous exchange.

21. Fetal causes Prematurity with an immature respiratory centre. Birth trauma-brain damage during birth which may be due to difficult delivery. Blockage of the airway by mucus, aspirated amniotic fluid, blood or meconium. Congenital abnormalities such as atresia Rhesus iso-immunisation can cause haemolysis leading to placental insufficiency.

22. Drug causes /Teratogenic causes Depression of the baby's respiratory centre by drugs or anaesthesia given to the mother few hours (4 hours) before delivery 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.

23. Clinical features of Asphyxia Neonatorum Apnoea due to obstruction of the airway, Bradycardia due to hypoxia and acidosis Cyanosis due to asphyxiation/chocking Hypotonia due to decreased oxygen perfusion Unresponsiveness due to hypoxia Profound metabolic acidosis

24. MANAGEMENT OF ASPHYSIA NEONATORUM Asphyxia Neonatorum is an emergency in obstetrics and neonatal care and so it needs quick intervention to avoid complications.

25. AIMS OF MANAGEMENT To establish and maintain a clear airway ventilation and oxygenation, To ensure effective circulation, To correct acidosis, To prevent hypothermia, hypoglycaemia, and haemorrhage. To prevent infection To prevent retrolentalfibroplasia

26. PREPARATION TO RECEIVE AN ASPHYXIATED BABY Asphyxia is either anticipated (if there are signs of foetal hypoxia) or can occur unexpectedly. For this reason, labour room should be fully prepared for such a baby at every given time. Good preparation and skilled staff. It is essential that resuscitation equipment is always available and in working order.

27. PREPARATION TO RECEIVE AN ASPHYXIATED BABY Staff present at the delivery of this baby need to be familiar with the equipment, resuscitation techniques and local policies . The paediatrician, neonatal nurse or midwife, anaesthetist and support staff must be readily available.( In hospital setting )

28. RESUSCITATION EQUIPMENT Resuscitaire with working warmer, light, oxygen apparatus, suction apparatus, and clock timer, Paediatric laryngoscopes, with straight blades ( size 0 and 1), spare bulb and batteries Neonatal endotracheal tubes (sizes 2,2.5,3, 3.5, 4 mm) Endotracheal introducer, Mucus extractor/suction apparatus and Suction catheters, Neonatal bag and face masks. Adhesive taps and scissors

29. RESUSCITATION EQUIPMENT Stethoscope, Cord clumps, Umbilical vessel catheters Warm dry towels and head sock Nasogastric tubes Face masks(size 0 and 1) Gloves Syringes and needles, IV Infusion sets and cannulars

30. Immediate Care of an asphyxiated Baby As soon as the baby is born, wipe nostril and face to clear the airway. Note the time as the baby is born and start the stop watch so that baby’s condition can be assessed at specific times. Place the baby unto the mother’s abdomen and wipe thoroughly. Clamp and cut the cord long for resuscitation.

31. Immediate Care of an asphyxiated Baby cont.. While drying the baby assess the following; Colour Muscle tone Breathing Heart rate Response to stimuli Cover the baby with dry flannel to prevent hypothermia.

32. Immediate Care of an asphyxiated Baby cont.. If the baby does not breathe well, stimulate him by flicking the feet. Drying the baby and flicking the baby on the back may also stimulate the onset of respirations. Show the baby to the mother for sex identification and explain to her that the baby will be taken to the resuscitaire for resuscitation. Baby is transferred to the pre warmed resuscitaire and placed on a firm flat surface, at a comfortable working height and under radiant heat to prevent hypothermia .

33. Immediate Care of an asphyxiated Baby cont.. Baby’s shoulders may be elevated on a small towel, which causes slight extension of the head and straightens the head. Clear the airway by first suctioning the mouth and then the nose. This has to be done gently. Reassess the Apgar score after 5 minutes to ascertain if regular respirations have been established. When the above measures do not result in adequate respirations, give oxygen via a face mask and again stimulate the baby.

34. Immediate Care of an asphyxiated Baby cont.. If no improvement, use an ambu bag with the mask applied tightly over the baby’s face. Gently pump oxygen into the infant’s mouth and nose at the rate of 50 – 60 breaths per minute. If the respirations and circulation continue to deteriorate, then intubation and artificial ventilation will have to be instituted. Intubate with 2.0 or 2.5mm endotracheal tube using a laryngoscope with a size “0” straight blade.

35. Immediate Care of an asphyxiated Baby cont.. Give 3-4 puffs of 100% oxygen via bag while listening to the chest for air entry. The chest should move and air entry should be heard on both sides of the chest.40 breathes a minute is recommended. After doing the above measures reassess the infants colour and heart rate. Depending on the baby’s response transfer the baby to neonatal intensive care unit, nursery room or take the baby to the mother for bonding.

36. SUBSEQUENT CARE Once the condition has improved, transfer baby to SCBU in a warmed cot bed. Continue oxygen therapy Provide warmth Prevent hypoglycaemia by giving IV 5% dextrose Monitor blood electrolytes Observations should include: Vital signs, Neuro-muscular activity, Colour of the skin, Signs of cerebral damage due to hypoxia i.e. twitching, high pitched cry, bulging fontanelle

37. SUBSEQUENT CARE CONT.... Feeding: Initially you can give I.V fluids. As the condition improves, baby can graduate to naso-gastric tube feeding. Monitor fluid intake and output, and bowel activity Oxygen can be removed as condition improves There should be minimal handling Maintain hygiene Continued psychological care to the mother and the family Involve mother in the care of the baby to promote bonding Infection prevention at all levels

38. SUBSEQUENT CARE CONT.... Health education on continued care at home should be given to the mother Follow up care. Encourage mother to keep review date. Encourage careful monitoring of mile stones Immunisation Proper documentation of all findings

39. Use of drugs If the baby’s response is slow or he remains hypotonic after ventilation is achieved, consideration will be given to use of drugs. Naloxone (Narcan) – powerful antiopiod, is used to reverse the effects of maternal narcotics. Dose – 0.75mls to term babies and 0.5mls to preterm babies given IM or IV or through the endotracheal tube. 4%Sodium bicarbonate – given when there is respiratory acidosis. Dose – 5mls, give slowly via the umbilicus or peripheral vein.

40. Use of drugs Adrenaline – indicated if the heart rate is less than 60 despite one minute of effective ventilation and chest compression. Dose – 0.2mls/kg of 1:10000 via the endotracheal tube or IV. 25%Dextrose - given when hypoglycemia is suspected. Dose – 5mls given slowly IV .

41. Throughout resuscitation the baby’s condition should be monitored and recorded. Assess using A, B, C, and S. A – Airway B – Breathing; look at the rate and pattern of the chest movements (breathing). C – Circulation; listen for the heart rate S – Shock; ensure baby is well dried and kept warm at all times.

42. When to stop resuscitation Resuscitation should be stopped if there is no sign of life after 10 minutes of adequate and continuous resuscitation. If the apgar score remains less than 3 after 20 minutes the chance of death or severe brain damage is extremely high and it may be justifiable to stop resuscitation efforts .

43. COMPLICATIONS These complications may be due to the condition itself or procedures done to resuscitate the baby and these are; Hypoxaemia -low oxygen tension arterial blood leading to brain damage, deafness. Hypercapnea -abnormal increase in the amount of carbon dioxide leading to vasodilatation of the cerebral vessels and congestive oedema resulting to rupturing of cerebral vessels. Ischemia can be due to a deficient blood supply to the brain causing cell death.

44. COMPLICATIONS CONT... Acidosis Respiratory acidosis due to a rise of carbon dioxide in the blood and falling of oxygen and PH. The carbon dioxide diffuses into the cerebro - spinal fluid causing the PH of the CSF to drop. Metabolic acidosis -is brought about as result of accumulation of lactic acid and pyruvic acid as a result of anaerobic glycolysis.

45. COMPLICATIONS Aspiration pneumonia – this may result from aspiration of the amniotic fluid in utero or meconium. Pneumo thorax -if endotracheal tube is inserted too far into the right bronchus and inflation pressures are too high. Tracheal perforation -endotracheal tube is inserted with too much force. Oesophageal perforation -endo-tracheal tube is inserted with too much force .

46. PREVENTION OF ASPHYXIA • Good antenatal care -early diagnosis and recognition of predisposing factors/causes. • Treatment of infections such as pneumonia, malaria antenantally. •Take note of high risk pregnancies and these should be delivered in hospital. • Sound management of labour-avoid prolonged labour. • Avoid giving drugs such as pethidine to the mother especially 4 hours before delivery or when cervix is 6cm cm dilated.

47. 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.

48. SUMMARY Asphyxia is a condition in which a viable newborn infant fails to initiate and /or sustain respirations after delivery. Asphyxia is classified into two main types namely mild and severe asphyxia. Clinical signs and symptoms depend on the type of asphyxia. Asphyxia is caused by fetal and cord, maternal, placental and teratogenic factors and its management depends on the severity of the condition. The longer asphyxia persists, the longer resuscitation is required and if not managed well the condition may result into complications such as brain damage as well as death.

49. REFERENCES: Bennet V.R and Brown L.K. (1989), Myles Text book for Midwives, 11th Edition, Longman Group UK Limited, U.K Cooper M. A and Fraser M. D (2008), A text book for Midwives, African edition, Churchill Livingstone. Fraser D.M. and Cooper M.A. (2005), Myles Textbook for Midwives, 14th edition, Elsevier Ltd, China. Sellers, M.P. (1993).Midwifery, A textbook and Reference Book for Midwives in Southern Africa, Volume 1, Normal Childbirth. Juta &CO, LTD. South Africa. Sally Smith,(1996), Maternal Newborn Nursing, A Family- Centred Approach, 5th Edition, Cummings Publishing Company, USA

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