According to medical statistics, about 10% of children need the active help of medical personnel from the very first minute of birth in order to actively scream, breathe regularly and effectively, restore the heart rate and adapt to new unusual living conditions. The percentage of premature babies who need such help is even higher. The biggest problem is asphyxiation.
What is newborn asphyxia?
Asphyxia of newborns is suffocation, manifested by impaired breathing, or lack of spontaneous breathing in the presence of a heartbeat and other signs of life. In other words, the baby is incapable, cannot breathe on its own immediately after birth, or he breathes, but his breathing is ineffective.
40% of premature babies and 10% of full-term babies need medical attention due to impaired spontaneous breathing. Newborn asphyxia is more common in premature babies. Among all newborns, children born in asphyxia account for 1 - 1.5% of the total.
A baby born with asphyxiation is a serious problem for doctors who provide care in the delivery room. Every year around the world, about a million children die from asphyxia, and about the same number of children develop serious complications later.
Asphyxia of the fetus and newborn occurs with hypoxia (a decrease in the concentration of oxygen in the tissues and blood) and hypercapnia (an increase in the content of carbon dioxide in the body), which is manifested by severe respiratory, circulatory and nervous system disorders of the child.
Causes of newborn asphyxia
Factors contributing to the development of asphyxia
Distinguish between antenatal and intrapartum factors.
Antenatal ones affect the developing fetus in utero and are a consequence of the lifestyle of a pregnant woman. Antenatal factors include:
- diseases of the mother (diabetes mellitus, hypertension, diseases and defects of the heart and blood vessels, kidneys, lungs, anemia);
- problems of previous pregnancies (miscarriages, stillbirths);
- complications during this pregnancy (threat of miscarriage and bleeding, polyhydramnios, oligohydramnios, undermaturity or overmaturity, multiple pregnancies);
- the mother is taking certain medications;
- social factors (taking drugs, lack of medical supervision during pregnancy, pregnant women under the age of 16 and over 35).
Intranatal factors act on the baby during childbirth.
Intranatal factors include various complications that occur immediately at the time of birth (rapid or protracted labor, presentation or premature placental abruption, abnormalities of labor).
All of them lead to fetal hypoxia - a decrease in oxygen supply to the tissues and oxygen starvation, which significantly increases the risk of having a baby with asphyxiation.
Causes of asphyxia
Among the numerous reasons, there are five main mechanisms that lead to asphyxia.
- Insufficient clearance of toxins from the maternal part of the placenta as a result of low or high pressure in the mother, overly active contractions, or for other reasons.
- A decrease in the concentration of oxygen in the blood and organs of the mother, which can be caused by severe anemia, insufficiency of the respiratory or cardiovascular system.
- Various pathologies on the part of the placenta, as a result of which gas exchange through it is disrupted. These include calcifications, previa or premature placental abruption, placental inflammation and hemorrhage.
- Interruption or disruption of blood flow to the fetus through the umbilical cord. This occurs when the umbilical cord tightly wraps around the baby's neck, when the umbilical cord is squeezed during the baby's passage through the birth canal, when the umbilical cord falls out.
- Insufficient respiratory efforts of a newborn due to the depressing effect of drugs on the nervous system (a consequence of the mother's treatment with various drugs), as a result of severe malformations, with prematurity, due to immaturity of the respiratory system, due to a violation of the flow of air into the respiratory tract (blockage or compression from the outside), as a result of birth trauma and severe intrauterine infections.
A special risk group for the development of asphyxia is made up of premature babies whose birth weight is extremely low, post-term and children who have intrauterine growth retardation. These children are at the highest risk of developing asphyxia.
Most children who are born with asphyxia have a combined effect of ante- and intranatal factors.
Today, among the reasons that cause chronic intrauterine hypoxia, drug addiction, substance abuse and alcoholism of the mother are not the last. The number of pregnant women who smoke is increasing progressively.
Smoking during pregnancy causes:
- narrowing of the uterine vessels, which continues for another half hour after a smoked cigarette;
- suppression of the respiratory activity of the fetus;
- an increase in the concentration of carbon dioxide in the blood of the fetus and the appearance of toxins, which increases the risk of prematurity and premature birth;
- hyperexcitability syndrome after birth;
- lung damage and delayed physical and mental development of the fetus.
The mechanism of development of asphyxia
With short-term and moderate hypoxia (a decrease in the level of oxygen in the blood), the fetus's body tries to compensate for the lack of oxygen. This is manifested by an increase in blood volume, increased heart rate, increased respiration, and increased fetal motor activity. The lack of oxygen is compensated by such adaptive reactions.
With prolonged and severe hypoxia, the fetal body cannot compensate for the lack of oxygen, tissues and organs suffer from oxygen starvation, because oxygen is delivered, first of all, to the brain and heart. The motor activity of the fetus decreases, the heart rate decreases, breathing becomes less frequent, and its depth increases.
The result of severe hypoxia is insufficient oxygen supply to the brain and impaired development, which can aggravate respiratory failure at birth.
The lungs of a full-term fetus before childbirth secrete fluid, which enters the amniotic fluid. Fetal respiration is shallow and the glottis is closed, therefore, during normal development, amniotic fluid cannot enter the lungs.
However, pronounced and prolonged fetal hypoxia can irritate the respiratory center, as a result of which the depth of breathing increases, the glottis opens and the amniotic fluid enters the lungs. This is how aspiration occurs. The substances present in the amniotic fluid cause inflammation of the lung tissue, make it difficult for the lungs to expand on the first breath, which leads to respiratory failure. Thus, the result of aspiration by amniotic fluid is asphyxia.
Respiratory disorders in newborns can be caused not only by impaired gas exchange in the lungs, but also as a result of damage to the nervous system and other organs.
Non-lung related causes of breathing problems include:
- Nervous system disorders: abnormalities in the development of the brain and spinal cord, the effects of drugs and drugs, infection.
- Violation of the cardiovascular system. These include malformations of the heart and blood vessels, dropsy of the fetus.
- Malformations of the gastrointestinal tract: esophageal atresia (blindly ending esophagus), fistulas between the trachea and the esophagus.
- Metabolic disorders.
- Dysfunction of the adrenal and thyroid glands.
- Blood disorders such as anemia.
- Improper development of the airways.
- Congenital malformations of the skeletal system: malformations of the sternum and ribs, as well as rib injuries.
Types of newborn asphyxia
- Acute asphyxia caused by exposure only to intranatal factors, that is, arising during childbirth.
- Asphyxia, which developed against the background of prolonged intrauterine hypoxia. The child developed in conditions of lack of oxygen for a month or more.
The severity is distinguished:
- slight asphyxia;
- moderate asphyxia;
- severe asphyxia.
Neonatologists assess the condition of a newborn baby using the Apgar scale, which includes an assessment of breathing, heartbeat, muscle tone, skin color and reflexes of the newborn. The assessment of the condition of the newborn is carried out at the first and fifth minute of life. Healthy children gain 7-10 points on the Apgar scale.
A low score indicates that the child has problems with either breathing or heartbeat and requires immediate medical attention.
Manifestations of asphyxia
Light asphyxia
Manifested by cardiorespiratory depression. This is a depression of breathing or heartbeat as a result of stress that the child feels during the transition from intrauterine life to the outside world.
Childbirth is a tremendous stress for a baby, especially if there are any complications. At the same time, in the first minute of life, the baby receives an assessment of 4-6 points according to Apgar. As a rule, for such children, it is enough to create optimal conditions of the surrounding world, warmth and temporary support for breathing, and after five minutes the child recovers, he is given 7 points or higher.
Moderate asphyxia
The baby's condition at birth is assessed as moderate. The baby is lethargic, reacts poorly to examination and stimuli, but spontaneous movements of the arms and legs are observed. The child screams weakly, with little emotion and quickly becomes silent. The baby's skin is cyanotic, but quickly turns pink after inhaling oxygen through the mask. Rapid palpitations, reduced reflexes.
Breathing after its restoration is rhythmic, but weakened, intercostal spaces may sink. After medical assistance in the delivery room, children still need oxygen therapy for some time. With timely and adequate medical care, the condition of children improves quite quickly and they recover on the 4th - 5th day of life.
Severe asphyxia
The baby's condition at birth is severe or extremely difficult.
With severe asphyxia, the child reacts poorly to examination or does not react at all, while the muscle tone and movements of the child are weak or absent at all. Skin color is bluish-pale or just pale. It turns pink after breathing oxygen slowly, the skin regains its color for a long time. The heartbeat is muffled. Breathing is irregular, irregular.
In very severe asphyxia, the skin is pale or sallow. The pressure is low. The child does not breathe, does not respond to examination, eyes are closed, there is no movement, no reflexes.
How asphyxia of any severity will proceed directly depends on the knowledge and skills of medical personnel and good nursing, as well as on how the child developed in utero and on the existing concomitant diseases.
Asphyxia and hypoxia. Differences in manifestations in newborns
The picture of acute asphyxia and asphyxia in children who have undergone intrauterine hypoxia has some differences.
The characteristics of children born in asphyxia who have undergone prolonged intrauterine hypoxia are presented below.
- Significantly expressed and long-lasting metabolic and hemodynamic disorders (movement of blood in the vessels of the body).
- Often, various bleeding occurs as a result of inhibition of hematopoiesis and a decrease in the content of trace elements in the blood, which are responsible for stopping bleeding.
- More often, severe lung lesions develop as a result of aspiration, surfactant deficiency (this substance prevents the lungs from collapsing), and inflammation of the lung tissue.
- Metabolic disorders often occur, which is manifested by a decrease in blood sugar and important trace elements (calcium, magnesium).
- Characterized by neurological disorders resulting from hypoxia and due to cerebral edema, hydrocephalus (dropsy), hemorrhages.
- Often combined with intrauterine infections, bacterial complications often join.
- After the postponed asphyxia, there are long-term consequences.
Complications of newborn asphyxia
Among the complications, there are early complications, the development of which occurs in the first hours and days of a baby's life, and late ones, which arise after the first week of life.
Early complications include the following conditions:
- Damage to the brain, which is manifested by edema, intracranial hemorrhage, death of brain areas due to lack of oxygen.
- Violation of blood flow through the vessels of the body, which is manifested by shock, pulmonary and heart failure.
- Kidney damage, resulting in renal failure.
- Pulmonary involvement manifested by pulmonary edema, pulmonary hemorrhage, aspiration, and pneumonia.
- The defeat of the digestive system. The intestine suffers most, its motility is disturbed, as a result of insufficient blood supply, some parts of the intestine die off, and inflammation develops.
- Damage to the blood system, which is manifested by anemia, a decrease in the number of platelets and bleeding from various organs.
Late complications include the following conditions:
- Accession of infections, meningitis (inflammation of the brain), pneumonia (inflammation of the lungs), enterocolitis (inflammation of the intestines) develops.
- Neurological disorders (hydrocephalus, encephalopathy). The most serious neurological complication is leukomalacia - damage (melting) and death of areas of the brain.
- Consequences of excessive oxygen therapy: bronchopulmonary dysplasia, retinal vascular damage.
Resuscitation of newborns with asphyxia
The condition of children born with asphyxiation requires resuscitation assistance. Resuscitation is a complex of medical measures aimed at revitalizing, resuming breathing and heart contractions.
Resuscitation is carried out according to the ABC system, developed back in 1980:
- "A" means providing and maintaining an airway;
- "B" stands for breath. It is necessary to restore breathing with the help of artificial or assisted ventilation;
- "C" means to restore and support the contractions of the heart and blood flow through the vessels.
Resuscitation measures for newborns have their own characteristics, their success largely depends on the readiness of medical personnel and a correct assessment of the child's condition.
The principles of resuscitation of newborns with asphyxia
- The readiness of the medical staff. Ideally, care should be provided by two people who are skilled and familiar with the pregnancy and childbirth. Before labor begins, nursing staff should check if equipment and medication are ready to provide care.
- The readiness of the place where the child will be helped. It should be specially equipped and located directly in the delivery room or in the immediate vicinity of it.
- Providing resuscitation in the first minute of life.
- Stages of resuscitation according to the "ABC" -system with an assessment of the effectiveness of each stage.
- Caution in infusion therapy.
- Observation after relief of asphyxia.
Respiration recovery begins as soon as the head appears from the birth canal, with the suction of mucus from the nose and mouth. Once the baby is fully born, it needs to be rewarmed. To do this, it is wiped off, wrapped in heated diapers and placed under radiant heat.In the delivery room there should be no leakage, the air temperature should not drop below 25 ºС.
Both hypothermia and overheating depress breathing, so they should not be allowed.
If the child screamed, they put him on his mother's belly. If the baby is not breathing, breathing is stimulated by wiping the back and patting the baby's soles. With moderate and severe asphyxia, breathing stimulation is ineffective, so the child is quickly transferred to radiant heat and artificial ventilation (ALV) is started. After 20 - 25 seconds, they look to see if breathing has appeared. If the baby's breathing is restored and the heart rate is above 100 per minute, resuscitation is stopped and the baby's condition is monitored, trying to feed the baby with mother's milk as soon as possible.
If there is no effect from mechanical ventilation, the contents of the oral cavity are aspirated again and mechanical ventilation is resumed. In the absence of breathing on the background of mechanical ventilation for two minutes, tracheal intubation is performed. A hollow tube is inserted into the trachea, which provides air to the lungs, the child is connected to an artificial respiration apparatus.
In the absence of a heartbeat or a decrease in the frequency of contractions of less than 60 per minute, chest compressions are started, continuing mechanical ventilation. The massage is stopped if the heart begins to beat on its own. If there is no heartbeat for more than 30 seconds, the heart is stimulated with drugs.
Prevention of asphyxia in newborns
All measures for the prevention of asphyxia are reduced to the timely identification and elimination of the causes of fetal hypoxia in a pregnant woman.
Every pregnant woman should be monitored by a gynecologist throughout her pregnancy. It is necessary to register on time, take tests, undergo medical consultations and treatment, which is prescribed if necessary.
The mother's lifestyle has a significant impact on the development of the fetus.
Conclusion
Treatment of children who have undergone asphyxiation, until complete recovery, is quite long.
After the events held in the delivery room, children are transferred to the children's intensive care unit or to the neonatal pathology department. In the future, if required, prescribe rehabilitation therapy in specialized departments.
The prognosis largely depends on the severity of brain damage caused by hypoxia. The more the brain suffers, the greater the likelihood of death, the risk of complications and the longer the period of complete recovery. Premature babies have a worse prognosis than babies born on time.
