Birth asphyxia

Learning objectives

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

Identify birth asphyxia
Classify birth asphyxia
Describe the management of babies who have birth asphyxia

Birth asphyxia is very common in Malawi and the optimal management of these infants is therefore very important.

Lack of oxygen supply to organs before, during or immediately after birth results in asphyxia which is recognized by either delayed onset of breathing/ cry with/ without need for assisted ventilation.

Clinical features that these babies evolve over the first 2-3 days of life include irritability or coma, hypotonia or hypertonia, convulsions, apnea, poor suck and feeding difficulty. The diagnosis in preterm infants is difficult, as they may be hypotonic because of prematurity.

Suspect birth asphyxia in a baby with some/ all of the following

Foetal bradycardia
Prolonged of second stage labour
Required bag and mask ventilation > 5 min
Required cardiac massage
APGAR scores <7
Irritable, hypotonic, seizures, poor suck, poor colour
High lactate on cord blood

Suspect asphyxia if a child has been given low APGAR scores at birth

Classification of Hypoxic Ischemic Encephalopathy (HIE)

Classify the degree of Hypoxic Ischaemic Encephalopathy (HIE) according to the table below. Babies with mild and moderate HIE generally have a good prognosis and generally do well. An infant who, within a week of birth, is still floppy or spastic, unresponsive and cannot suck has a severe brain injury and will do poorly.

FEATURE	Mild	Moderate	Severe
Consciousness	Irritability	Lethargy	Comatose
Tone	Hypotonia	Marked hypotonia	Severe hypotonia
Seizures	No	Yes	Prolonged
Sucking/ respiration	Poor suck	Unable to suck	Unable to sustain spontaneous respiration

Management of Birth Asphyxia

Key facts for provider’s - supportive management of birth asphyxia

Check for emergency signs ABC and provide emergency care

Place these babies under radiant warmer to maintain normal temperature but prevent hyperthermia

Check blood glucose and if hypoglycaemia is detected. Treat. If not hypoglycaemic check blood glucose every 12 hrs.

Fluids: In a baby with emergency signs (breathing difficulty, shock, coma or convulsions), provide maintenance intravenous fluids and according to age after initial stabilisation of emergency signs.

Feeding: If the baby has neither emergency signs nor abdominal distension, consider enteral feeding. If the baby is sucking well, initiate breastfeeding or initiate tube feeding with breast milk in those with poor/no sucking using wall charts to determine the volume.

Distinguishing between convulsions and jitteriness

Convulsions	Jitteriness
Have both fast and slow components Slow movements (1-3 jerks per second)	Fast movements (4-6 per second); tremors are of equal amplitude
Not provoked by stimulation	Provoked by stimulation
Does not stop with restraint	Stops with restraint
Neurological examination-often abnormal	Neurological examination-usually normal
Often associated with eye movements (tonic deviation)	Not associated with eye movements or autonomic changes

For manangement of coma and convulsions see:

Document in health passport and classify HIE as mild, moderate or severe.
If severe arrange follow up at six months - focus on head growth, general health and motor neurodevelopment. Assessments at 12 to 24 months focus on cognitive skills and language development.