Nanyuki Teaching & Referral
Hospital
NBU Management of
Perinatal Asphyxia
WHO has defined perinatal asphyxia as a “failure to initiate and sustain breathing at birth”
Moderate asphyxia = slow gasping breathing or an Apgar score of 4-6 at 1 minute of age
Severe asphyxia = no breathing or an Apgar score of 0-3 at 1 minute 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
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
March 2015
Variable
Nanyuki Teaching & Referral
Hospital
Management post resuscitation;
All babies of moderate or severe perinatal asphyxia should be monitored for minimum 48 hours

Temperature control - Avoid hypothermia or hyperthermia

Check vital signs -

Fluids - All babies with Apgar scores <4 at 1 minute or <7 at 5minutes of age should be
started on intravenous maintenance fluids.

Immediate clinical assessment, recording respiration, heart rate,
blood pressure, capillary refill time, temperature and oxygen
saturation.
-
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 Apgar scores <4 at 1 minute or <7 at 5minutes of age should be
kept nil by mouth for the first 24-48 hours
- If poor suck, feed by NG tube
Moderate ones…..
-

Investigations – Blood sugar at admission, then twice daily
-


If frequent seizures, apnoeas, respiratory distress, or evidence of NEC or GI bleeding,
keep nil by mouth.
FHG, UECs, LFTs at 24 hours (unless clinically indicated earlier eg pallor)
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
-
If convulsions are still uncontrolled, phenytoin sodium should be added (20mg/kg)
-
Maintenance therapy of both phenobarbitone and phenytoin is started 12 hours later
in 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
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)
Dr J. Le Geyt, Dr S.M. Kilonzo
March 2015
Nanyuki Teaching & Referral
Hospital
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 ; <2% have any long term neurological complications
HIE grade II ; 30-50% die or have long term neurological complications
HIE grade III ; 70-80% die or have severe long term neurological complications, 10% have
moderate long term neurological complications
Grade I HIE do not require routine 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.
Dr J. Le Geyt, Dr S.M. Kilonzo
March 2015