Doldol Hospital
Perinatal Asphyxia Guideline
Management of
Perinatal Asphyxia
Perinatal asphyxia is defined as a “failure to initiate and sustain breathing at birth”
Moderate asphyxia = slow gasping breathing or an Apgar score of 4-6 at 5 minutes of age
Severe asphyxia
=
no breathing
or an Apgar score of 0-3 at 5 minutes of age.
Perinatal asphyxia can lead to multi-organ dysfunction. Virtually any organ can be effected. In term infants with
asphyxia, renal, CNS, cardiac and lung dysfunction occur in 50%, 28%, 25% and 25% cases, respectively.
The most serious effects are seen on the central nervous system, termed Hypoxic ischaemic encephalopathy.
Good supportive care is essential in the first 48 hours after asphyxia to prevent ongoing brain injury in the
penumbra region.
Possible impacts of perinatal asphyxia
CNS
Cardiac
Renal
Hypoxic ischemic encephalopathy, intracranial haemorrhage, seizures,
long-term neurological sequelae
Myocardial dysfunction, valvular dysfunction, rhythm abnormalities,
congestive cardiac failure
Haematuria, acute tubular necrosis, renal vein thrombosis
Gastro-intestinal Necrotizing enterocolitis, hepatic dysfunction
Haematological
Pulmonary
Metabolic
Thrombocytopenia, DIC/ coagulation abnormalities
respiratory failure, apnoeas, meconium aspiration, Surfactant
depletion, pulmonary hypertension
hypoglycaemia, acidosis, hypocalcaemia, hyponatremia (SIADH or
renal involvement)
Classification of Hypoxic Ischaemic Encephalopathy
Levene’s classification is a useful clinical tool for grading the severity of hypoxic ischaemic encephalopathy.
Feature
1
Consciousness
Mild
Grade I
Irritable
Moderate
Grade II
Lethargy
Severe
Grade III
Comatose
Tone
Normal
Hypotonia
Flaccid
Seizures
No
Yes
Prolonged
Sucking
Weak suck
Unable to suck
Heart rate
Tachycardia
Weak suck /Unable
to suck
Bradycardia
Dr J. Le Geyt, Dr S.M. Kilonzo
Variable
July 2015
Doldol Hospital
Perinatal Asphyxia Guideline
Management post resuscitation;
All babies of moderate or severe perinatal asphyxia should be transferred to a
newborn unit for minimum 48 hours.
If the clinical course is not typical of a hypoxic-ischaemic insult, consider other causes (possible other causes
include [but are not limited to] metabolic disease, infection, drug exposure, CNS malformation, or neonatal
stroke)

Temperature control - Avoid hypothermia or hyperthermia

Check vital signs -

Fluids - All babies with moderate or severe perinatal asphyxia should be started on intravenous
Immediate clinical assessment, recording respiration, heart rate,
blood pressure, capillary refill time, temperature and oxygen saturation.
maintenance fluids.

-
Urine output monitoring (consider catheterisation)
-
If low urine output, oedema, or significant renal impairment in the UECs, fluid restrict to 2/3rd
maintenance.
Feeding - All babies with severe perinatal asphyxia, or clinical signs of HIE grade II, should be kept
nil by mouth for the first 48 hours

-
All babies with moderate perinatal asphyxia, or clinical signs of HIE grade I, should be kept
nil by mouth for the first 24 hours
-
If inadequate suck, feed by NG tube
-
If frequent seizures, apnoeas, respiratory distress, or evidence of NEC or GI bleeding, remain
nil by mouth.
Investigations – Blood sugar at admission, then twice daily
-

FHG, UECs, LFTs at 24 hours (unless clinically indicated earlier eg pallor, jaundice)
Seizures – First line treatment is phenobarbitone (20 mg/kg) unless significant apnoeas or
respiratory depression is present. If there is no response, two additional
doses of 10 mg/kg can be given

2
-
If convulsions are still uncontrolled, phenytoin sodium should be added (20mg/kg)
-
Maintenance therapy of both phenobarbitone and phenytoin is started 12 hours later
at a dose of 5 mg/kg/day in a single dose.
-
Anticonvulsants can be stopped after 48 hours without seizures (unless the baby has been on
them for >7days, then wean over 3 days)
Neurological examination - Assessment twice daily
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015
Doldol Hospital
Perinatal Asphyxia Guideline
Prognosis
Neurodevelopmental outcome correlates closely with the severity of HIE (it does not correlate well to Apgar
scores).
The baby’s diagnosis should be its worst HIE grade during admission.
HIE grade I
HIE grade II
HIE grade III
; <2% have any long term neurological complications
; 30-50% die or have long term neurological complications
; 70-80% die or have severe long term neurological complications, 10% have
moderate long term neurological complications
Grade I HIE do not require routine neuro-developmental follow-up.
Grade II and III should have neuro-developmental assessments (and intervention if needed) at follow-up clinics
for at least the first 18 months of life.
References
3

“The Apgar Score”. American Committee on Obstetrics Practice Fetus and Newborn / American
Academy of Pediatrics, Committee Opinion. 2010.

“Post-resuscitation management of asphyxiated neonates”. R. Agarwal, et al. Division of Neonatology,
All India Institute of Medical Sciences, New Delhi, India. WHO Collaboration Centre. 2007
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015