Secondary asphyxia of newborns. Neonatal asphyxia: a life-threatening condition

Asphyxia of newborns - what is it? First of all, it should be said that this concept is not clearly defined. In the most general sense, they denote one or another degree of respiratory depression while maintaining other signs of life (heartbeat, movement of arms and legs, contraction of other muscles, etc.).

In most cases, neonatal asphyxia is a consequence of oxygen starvation during fetal development. Therefore, in relation to newborns, the terms and hypoxia are used interchangeably.

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Asphyxia in a newborn child (fetus)

According to world statistics, about 20% of those born with asphyxia die after childbirth. Another 20% subsequently suffer from certain functional disorders associated with the functioning of the nervous system.

Complete absence of breathing in newly born children is diagnosed in 1% of children. Breathing with insufficiently effective gas exchange is observed in 15% of newborns. Thus, about 16% of children are born with varying degrees of hypoxia. More often premature babies are born with respiratory failure.

Classification of asphyxia of newborns

The state of suffocation in newborns is classified according to the time of occurrence and duration of oxygen deficiency. According to this principle, 2 types of asphyxia are distinguished:

• Arising from prolonged hypoxia in the womb;
• resulting from the course of childbirth.

This division is important in understanding what asphyxia is in newborns.

Asphyxia against the background of chronic antenatal fetal hypoxia

Insufficient supply of oxygen to the fetus leads to stable hypoxia and increases the likelihood of a child being born with asphyxia.
Causes of antenatal fetal asphyxia:

• The presence of chronic, infectious, endocrine diseases in a woman;
• low hemoglobin;
• unbalanced diet during pregnancy;
• lack of vitamins and minerals (in particular, iron);
• exposure to toxins during pregnancy;
• anomalies in the development of the placenta or umbilical cord.

Acute asphyxia on the background of intranatal hypoxia

The birth process is a great stress for both the woman and the child. At this stage, risk factors include:

• Abnormal position of the fetus;
• deviations during pregnancy and childbirth - premature, rapid, belated;
• maternal hypoxia during childbirth;
• fetal aspiration of amniotic fluid;
• trauma to the brain or spinal cord;
• the use of painkillers during childbirth;
• C-section.

It would be wrong to assume that any hypoxia will inevitably lead to postnatal asphyxia. For example, caesarean section is being used more and more frequently. In most cases, healthy children are born.

Degrees of asphyxia in newborns

For a more detailed understanding of what asphyxia is in a child, a special scale developed by an anesthesiologist from the United States, Virginia Apgar, is used.

In accordance with the ICD, two forms of suffocation are distinguished:

• moderate;
• heavy.

Table. Characteristics of mild (moderate) and severe asphyxia in newborns.

Causes of asphyxia in newborns

There are two groups of reasons:

• intrauterine hypoxia;
• inability of the newborn to adapt to postnatal circulation and respiration.

Intrauterine hypoxia can occur for numerous reasons, among which the main ones include:

• Violation of the blood supply to the fetus through the umbilical cord (presence of nodes, mechanical compression);
• placental disorders (insufficient gas exchange, low or high blood pressure, edema, heart attacks, inflammation, premature detachment);
• pathologies in a pregnant woman (cardiac, hematopoietic, pulmonary, endocrine diseases);
• smoking, alcohol abuse or systemic exposure to other toxic substances during pregnancy.

The inability of the child to go to postnatal breathing is based on the following reasons:

• Systemic developmental disorders, including as a result of intrauterine hypoxia;
• congenital stenosis (narrowing) of the airways;
• birth trauma of the brain;
• disorders of the thyroid gland;
• prematurity.

Treatment of asphyxia in newborns

newborns

First aid for asphyxia in a newborn involves the following steps:

• The child is placed under a heat source;
• dry the skin;
• conduct tactile stimulation on the back, sole of the foot;
• put the child on his back, throw his head back a little;
• clean the mouth and nasopharynx from the contents;
• amniotic fluid is sucked out of the respiratory tract using an endotracheal tube;
• in case of insufficient breathing or its complete absence, hardware ventilation of the lungs is started;
• with prolonged ventilation of the lungs, a probe is inserted into the stomach, through which the gas accumulating in it is sucked off.

All the above steps are carried out quickly for 2-3 minutes, periodically fixing vital signs. If, after the manipulations, the heart rate reached 100 beats per minute, spontaneous breathing appeared, and the skin became pinkish, artificial ventilation was stopped. If the child's condition has not improved, continue further resuscitation.

Resuscitation of newborns with asphyxia

Resuscitation is continued with an indirect heart massage, which is carried out for 30 s. If heart contractions remain at the level of 60-80 beats / min. or absent altogether resort to medication.

1. Adrenalin

A solution of adrenaline is administered intravenously at a dosage of up to 0.3 ml / kg. It enhances heart contractions, increases its blood supply, increases blood pressure, and has a bronchodilatory effect.

If, within 30 seconds after the administration of adrenaline, the heartbeat does not accelerate above 80 beats / min, repeat again.

1. infusion therapy.

In cases where there is no effect from the measures taken, blood volume replenishers are used - solutions of albumin, sodium chloride - at the rate of 10 ml / kg intravenously for 5 minutes.

Together with other resuscitation measures, the introduction of blood replenishing drugs improves blood circulation, increases blood pressure and heart rate.

If the measures taken are ineffective, intravenous administration of a 4% solution of sodium bicarbonate at a dosage of 4 ml / kg is indicated.

If necessary, pulmonary ventilation and fluid therapy continue as part of post-resuscitation intensive care.

Prevention of asphyxia in newborns

Prevention includes:

• Right way of life;
• timely preparation for pregnancy, including treatment of chronic somatic and endocrine diseases;
• intensive and effective treatment of infectious diseases during pregnancy;
• observation by a gynecologist during pregnancy.

Effective measures should include:

• Quit smoking and alcohol;
• compliance with the daily routine;
• daily walks several times a day;
• a balanced diet rich in vegetables, proteins, amino acids, vitamins and trace elements;
• additional vitamin support;
• positive emotions and a calm balanced state.

Caring for a child after suffering asphyxia

A child who has undergone asphyxia has a high probability of developing disorders of the nervous system. After discharge from the hospital, such a child should be under the supervision of a neurologist. No special home care is required.

The consequences of asphyxia in a newborn during childbirth

The most vulnerable in oxygen deficiency is the nervous tissue. Long periods of hypoxia during the formation of the fetal nervous system, as well as as a result of an acute lack of oxygen during childbirth, significantly increase the likelihood of developing certain disorders.

The consequences of severe neonatal asphyxia are manifested primarily in a poor response to resuscitation. In the absence of positive dynamics in the state of the newborn at the 20th minute after birth, the probability of death increases and amounts to:

• up to 60% - in those born in a normal period;
• up to 100% - in prematurely born.

The consequences of severe birth trauma asphyxia are reflected in the brain. For example, a child's poor response to resuscitation within 15 minutes after birth results in the development of cerebral palsy in 10% of cases, and within 20 minutes - in 60%. But these are very difficult cases.

More common are cases of moderate suffocation during childbirth. The consequences of asphyxia of newborns at an older age manifest themselves in different ways, but all of them will be associated with the functioning of the nervous system.

Such children, for example, are too active or, conversely, too phlegmatic. Sometimes they may not do well at school, but, on the contrary, they show themselves well in creative activities, circles. A possible later appearance of speech was noted.

Similar variations in the development of the child can also occur for other reasons unrelated to birth asphyxia. All this is usually called in one word - individuality, and should not cause concern to parents.

Conclusion

Despite the fact that the complete absence of breathing at birth occurs only in 6% of cases of all hypoxic conditions, to one degree or another, birth asphyxia is a phenomenon that occurs much more often than many people think. The consequences of asphyxia in a newborn may be delayed in the later life of the child. Any expectant mother should be attentive to her health, keep a calm and positive mood during pregnancy.

In the video, the doctor gives advice on behavior during childbirth, which will reduce the risk of developing newborn asphyxia

The absence of gas exchange in the lungs, accompanied by hypoxemia, hypercapnia and pathological acidosis in the body of a child after birth is called asphyxia. Of practical importance are the consequences of asphyxia in the form of brain damage. In asphyxia of varying severity, according to some authors, from 6 to 15% of children are born.

Etiology and pathogenesis. Risk factors for antenatal fetal asphyxia are extragenital pathology in the mother (hypertension, diseases of the heart, lungs, kidneys, diabetes mellitus, etc.), multiple pregnancies, infectious diseases during pregnancy, placental pathology, pregnancy complications (primarily gestosis), uterine bleeding , isoimmunization of a pregnant woman, post-term pregnancy. Drug addiction, substance abuse and smoking also lead to fetal hypoxia.

The most important reasons for which intranatal asphyxia of a newborn occurs can be divided into the following groups: disorders of umbilical circulation (compression, umbilical cord nodes), impaired placental gas exchange (ablation, placenta previa, placental insufficiency); inadequate perfusion of the maternal part of the placenta (hypertension or hypotension in the mother, impaired contractile activity of the uterus), maternal oxygenation disorders (heart disease, lung disease, anemia); the inability of the fetus to make the transition from fetal to postnatal circulation (the effect of drug therapy in the mother, maternal drug addiction, congenital malformations of the lungs, brain, heart in the fetus, etc.).

Short-term moderate fetal hypoxia includes compensatory mechanisms aimed at maintaining adequate oxygenation. The volume of circulating blood increases, the release of glucocorticoids, tachycardia develops. Acidosis increases the affinity of fetal hemoglobin for oxygen. With a longer duration of hypokia, anaerobic glycolysis is activated. A decrease in oxygen leads to a redistribution of circulating blood with a predominant supply of the heart, brain, and adrenal glands. The progression of hypercapnia and hypoxemia stimulates cerebral vasodilation, which first causes an increase in cerebral blood flow followed by a decrease. Over time, cerebral autoregulation of blood flow is lost, a decrease in cardiac output occurs and, as a result, arterial hypotension, which worsens tissue metabolism, and this, in turn, increases lactic acidosis. Reducing the intensity of metabolic processes allows the fetus to endure a long period of asphyxia. Adenosine, gamma-aminobutyric acid, opiates are released to help reduce oxygen consumption.

Prolonged hypoxia leads to inhibition of compensation mechanisms, an increase in the permeability of capillaries and cell membranes, as a result of which hemoconcentration develops, intravascular thrombi form, and hypovolemia occurs. Hemorheological and tissue disorders lead to cardiac hypoperfusion, hypoxic-ischemic encephalopathy, and pulmonary hypertension. Due to energy deficiency and acidosis, the level of free radicals increases, which, in turn, can cause brain hypoperfusion through stimulation of leukotriene production and the formation of leukocyte thrombi, damage to cell membranes and cell disintegration.

A possible consequence of asphyxia is the development of hypoxic-ischemic encephalopathy with partial loss of neurons, secondary deterioration against the background of the court, edema and cerebral infarction, activation of microglia with subsequent production of "excited" glutamate, hydrogen peroxide, glial toxins, which cause brain damage.

Apgar score

Classification. Assessment of the condition of the newborn 1 and 5 minutes after birth is performed according to the V. Apgar scale (1950). The Apgar score of 8, 9, 10 points at the 1st and 5th minutes is normal. A score of 4, 5, 6 points in the first minute of life is a sign of moderate asphyxia, if by the fifth minute it reaches 7-10 points. Severe asphyxia is diagnosed in a child who has an Apgar score of 0-3 points after 1 min or less than 7 points 5 min after birth. Now, according to many researchers, the assessment of the state of the newborn on the Apgar scale is not decisive. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in 1992 proposed the following definition of severe birth asphyxia: profound metabolic or mixed acidosis (pH<7,00) в крови из пуповинной артерии; низкая оценка по Апгар (0-3 балла) после 5 мин реанимации; неврологическая симптоматика сразу после рождения ребенка (судороги, мышечная гипотония, кома) или признаки гипоксически-ишемической энцефалопатии (отсутствие дыхательных движений или их периодический характер; нестабильность температуры тела, отсутствие нейромышечных и нейросенсорных реакций, судороги течение первой суток жизни, развитие моторных нарушений конце первых 7 дн жизни). По нашему мнению, для определения степени тяжести интранатальной асфиксии большое значение имеет реакция новорожденного ребенка на реанимационные мероприятия. Степень тяжести асфиксии целесообразно уточнять после проведения полного объема реанимационной помощи.

Clinic. A child with moderate asphyxia after birth looks like this: there is no normal breathing during the first minute after birth, but the heart rate is 100 or more per minute; muscle tone is insignificant, the reaction to irritation is weak. Apgar score 1 min after birth - 4-6 points. "Blue asphyxia".

The condition of the child after birth is usually moderate. The child is often lethargic, physiological reflexes are suppressed. The cry is short, of little emotion. The skin is cyanotic, but quickly turn pink against the background of additional oxygenation. In the first hours of life, symptoms of hyperexcitability appear: hand tremor, irritated cry, frequent regurgitation, sleep disturbances, hyperesthesia.

Severe primary asphyxia after birth has the following manifestations: pulse less than 100 beats / min, breathing is absent or labored, skin is pale, muscles are atonic. Apgar score - 0-3 points. "White asphyxia".

If muscle tone, spontaneous motor activity, reaction to examination and pain irritation are reduced or absent, then the child's condition after birth is regarded as severe or very severe. Physiological reflexes of newborns in the first hours of life are not called. The color of the skin is pale or bludocyanotic and is restored to pink with active oxygenation (often mechanical ventilation) slowly. Heart sounds are muffled, systolic murmur may appear. Physical findings over the lungs are variable. Meconium, of course, passes before or during childbirth.

Children born in severe asphyxia constitute a high risk group for the development of hypoxic-ischemic encephalopathy or intracranial hemorrhages of hypoxic genesis - intraductal or subarachnoid.

Diagnostics. The antenatal diagnosis algorithm includes the following activities:

A) monitoring of the fetal heart rate - bradycardia and periodic deceleration of the fetal heart rate indicate hypoxia and impaired myocardial function;
b) ultrasonography - a decrease in motor activity, muscle tone and respiratory movements of the fetus is detected, i.e. the biophysical profile of the fetus changes;
c) biochemical testing - its data indicate antenatal problems.

Intranatal diagnosis algorithm:

Heart rate monitoring;
the presence of meconium in the amniotic fluid;
determination of pH and pO2 in blood taken from the skin of the head of the fetus;
d) determination of pH and pCO2 in arterial and venous blood from umbilical vessels.

Postnatal diagnosis: immediately after the birth of the child, respiratory activity, heart rate, skin color should be immediately assessed. If, after separation from the mother and carrying out the usual measures (drying, placed under radiant heat, drainage position, suction of secretions from the oropharynx), the child remains in a state of apnea, tactile stimulation should be performed. If there is no response, immediately start artificial lung ventilation with 100% oxygen for 15-30 seconds. If after this spontaneous breathing is not restored or the heart rate is less than 100 beats / min, it should be considered that the child was born in an asphyxial state.

Treatment. The only method of effective treatment that significantly improves the child's condition and reduces the consequences of hypoxic-ischemic encephalopathy is adequate cardiopulmonary resuscitation.

The following materials are needed:

Sources of radiant heat and oxygen;
suction with manometer;
breathing bag, children's face masks of different sizes;
laryngoscope with blades No. 0, 1; endotracheal tubes No. No. 2.5; 3; 3.5; four;
umbilical catheters No. 8, 10;
medicines: adrenaline hydrochloride, sodium bicarbonate, plasma expansion (5% albumin solution, isotonic sodium chloride solution, Ringeralactate solution), nalorfin.

Technique for primary resuscitation of newborns:

1. After the birth of a child, to prevent hypothermia, it is necessary to place her under a source of radiant heat and dry her skin from amniotic fluid. Remove wet diapers.
2. The child's head should be slightly lowered, the neck slightly extended. The resuscitator is behind the child. Turn the baby's head to the side.
3. To ensure the patency of the respiratory tract, suck the mucus from the mouth, then from the nose (during the suction of the electric-smoktuvachem, the negative pressure should be no more than 100 mm Hg. St.), Do not allow deep insertion of the catheter. Suction duration - no more than 5-10 s. During the procedure, bring an oxygen source closer to the child's face and monitor the heart rate (HR).
4. In case of severe asphyxia and deep meconium aspiration, suck out the contents of the oropharynx immediately after the birth of the head. After separation of the child from the mother, examine the larynx and trachea using direct laryngoscopy. In the presence of meconium, intubate the trachea with an endotracheal tube, suck out the contents. Start WL.
5. Immediately after the birth of the baby, immediately assess her respiratory activity; Heart rate (calculate for 6 s and multiply by 10); skin coloration.

If the heart rate is less than 60 bpm, there is no breathing, and the skin color is cyanotic, resuscitation should be started immediately. Wipe the newborn, aspirate mucus from the upper respiratory tract and begin mask ventilation of the lungs using a counterlung. If these measures are not effective, repeat suctioning of mucus from the upper respiratory tract and perform endotracheal intubation, followed by chest compressions.

At a heart rate of 60-100 beats / min, if breathing is ineffective, the skin color is cyanotic, you should wipe the newborn, suck out mucus from the upper respiratory tract, at the same time bring an oxygen source closer to the child’s face, if the condition does not improve, start mask ventilation of the lungs using a breathing bag after 1 min or even earlier if bradycardia persists. Start tactile stimulation (applying light blows to the soles and rubbing the back), refraining from more vigorous activities. If heart rate is less than 80 bpm, start chest compressions.

If the heart rate is above 100 beats / min, you need to wipe the child, if there is cyanosis of the skin - bring the oxygen source closer to the face, if there is no effect - conduct tactile stimulation for 2-3 seconds; if the heart rate drops to less than 100 beats / min - mask ventilation using a breathing bag.

When performing mask ventilation, the mask should cover the nose and mouth of the newborn. The initial positive pressure on inspiration is 30-40 cm of water. Art. Pressure control is carried out by a manometer (when a breathing bag with a volume of up to 750 ml is compressed with one hand, the pressure created does not exceed 30 cm of water. Art.). The initial breaths should be long (0.5-1 s), the respiratory rate gradually increases to 40-60 / min.

If, due to adequate ventilation, the child's condition stabilizes and the heart rate is more than 100 beats / min, artificial ventilation can be stopped, if, despite vigorous efforts, bradycardia persists, orotracheal intubation should be started.

An indirect heart massage is performed with both hands, placing the thumbs on the sternum just below the line connecting the nipples, clasping the chest with the rest of the fingers. When performing an indirect heart massage, avoid compression of the xiphoid process, the sternum should descend to a depth of 1.5-2 cm at a frequency of 90/min. If, despite ventilation of the lungs with 100% oxygen and chest compressions, bradycardia of less than 80 bpm persists, it is necessary to catheterize the umbilical vein and start medical resuscitation in the following sequence:

1) if the condition does not improve - intravenously quickly inject epinephrine hydrochloride 1:10,000 at a dose of 0.1 ml / kg (0.1% solution of the drug is diluted in isotonic sodium chloride solution). An alternative may be the endotracheal administration of epinephrine hydrochloride 1:10,000 at a dose of 0.1-0.3 ml / kg, additionally diluted in a syringe with isotonic sodium chloride solution in a ratio of 1:1;
2) if the bradycardia is less than 80 beats / min, a 5% solution of albumin (plasma, Ringeralactate solution) is used at a dose of up to 10 ml / kg intravenously slowly over 10 minutes;
3) sodium bicarbonate 4.2% solution at a dose of 4 ml / kg intravenously slowly at a rate of 2 ml / (kgmin), against the background of effective ventilation;
4) if the condition does not improve, repeat the administration of epinephrine hydrochloride 1:10,000 at a dose of 0.1-0.2 ml/kg. When conducting medical resuscitation, it is necessary to control the adequacy of heart massage, the position of the endotracheal tube in the trachea, the flow of 100% oxygen into the respiratory bag, the reliability of the connection of oxygen hoses, and the adequacy of pressure during ventilation of the lungs.

The newborn may be in a state of narcotic depression, then prolonged ventilation of the lungs is necessary; the introduction of a 0.05% solution of narorphine at a dose of 0.2-0.5 ml intravenously. The drug can be administered repeatedly at two-minute intervals, but the total dose should not exceed 1.6 ml.

If resuscitation does not lead to the appearance of spontaneous sustained breathing within 30 minutes, the prognosis is always poor for severe neurological damage. Therefore, it is justified to stop resuscitation after 30 minutes if there is no spontaneous breathing (provided that the child was given the opportunity to demonstrate it) and bradycardia persists.

Newborns who have undergone asphyxia need supervision and post-resuscitation stabilization in the intensive care unit for at least 24 hours.

The main principles of treatment in the post-resuscitation period are: fluid restriction by 30-40% of the physiological need; maintaining adequate perfusion and blood pressure, treatment with a court, ensuring adequate oxygenation (against the background of monitoring the level of blood gases and acid-base status); correction of hypoglycemia (monitoring of blood sugar levels); prevention and treatment of hemorrhagic complications.

Possible complications of asphyxia:

1) CNS: hypoxic-ischemic encephalopathy, cerebral edema, neonatal convulsions, intracranial hemorrhage (intraventricular, subarachnoid), which is most typical for premature babies, syndrome of impaired secretion of antidiuretic hormone;
2) respiratory system: pulmonary hypertension, damage to the surfactant system, meconium aspiration, pulmonary hemorrhage;
3) excretory system: proteinuria, hematuria, oliguria, acute renal failure;
4) cardiovascular system: tricuspid valve insufficiency, myocardial necrosis, hypotension, left ventricular dysfunction, sinus bradycardia, rigid heart rhythm, shock;
5) metabolic disorders: metabolic acidosis, hypoglycemia, hypocalcemia, hyponatremia, hyperkalemia;
6) digestive system: necrotizing enterocolitis, hepatic dysfunction, gastric or intestinal bleeding, reduced tolerance to enteral loading;
7) blood system: thrombocytopenia, DIC, polycythemia.

Prevention. To prevent intranatal asphyxia, you should:

Timely determine the risk factors for the development of asphyxia;
adequately manage high-risk pregnant women;
timely diagnose and treat intrauterine fetal hypoxia;
to monitor the condition of the fetus during childbirth, to carry out adequate management of labor

Forecast. Mortality in severe asphyxia, according to a follow-up study, reaches 10-20%, the frequency of remote neuropsychiatric complications is also high. Therefore, resuscitation measures are stopped after 15-20 minutes in the absence of spontaneous breathing and the presence of persistent bradycardia. The long-term prognosis for acute intrapartum asphyxia is better than for neonatal asphyxia that developed against the background of chronic intrauterine hypoxia.

The pathological condition of the newborn, due to respiratory failure and resulting oxygen deficiency.

There are primary (at birth) and secondary (in the first hours and days of life) asphyxia of the newborn.

Etiology.

The causes of primary A. N. are acute and chronic intrauterine oxygen deficiency - fetal hypoxia, intracranial trauma, immunological incompatibility of the blood of the mother and fetus, intrauterine infection, complete or partial blockage of the respiratory tract of the fetus or newborn with mucus, amniotic fluid (aspiration asphyxia), defects fetal development.

The occurrence is facilitated by extragenital diseases of a pregnant woman (cardiovascular, especially in the stage of decompensation, severe lung diseases, severe anemia, diabetes mellitus, thyrotoxicosis, infectious diseases, etc.), late toxicosis of pregnant women, post-pregnancy, premature detachment of the placenta, pathology of the umbilical cord, fetal membranes and placenta, complications in childbirth (untimely rupture of amniotic fluid, anomalies of labor activity, discrepancy between the size of the pelvis of the woman in labor and the fetal head, incorrect insertion of the fetal head, etc.).

Secondary may be associated with impaired cerebral circulation in a newborn, pneumopathy, etc.

Pathogenesis.

Regardless of the causes of oxygen deficiency in the body of a newborn, there is a restructuring of metabolic processes, hemodynamics and microcirculation. Their severity depends on the intensity and duration of hypoxia.

Metabolic or respiratory-metabolic acidosis develops, accompanied by hypoglycemia, azotemia and hyperkalemia, followed by potassium deficiency. Electrolyte imbalance and metabolic acidosis lead to cellular overhydration.

In acute hypoxia, the volume of circulating blood increases mainly due to an increase in the volume of circulating erythrocytes. A. n., which developed against the background of chronic fetal hypoxia, is accompanied by hypovolemia. There is a thickening of the blood, its viscosity increases, the aggregation ability of erythrocytes and platelets increases. In the brain, heart, kidneys, adrenal glands and liver of newborns, as a result of microcirculatory disorders, edema, hemorrhages and areas of ischemia occur, and tissue hypoxia develops. Central and peripheral hemodynamics are disturbed, which is manifested by a decrease in stroke and minute volume of the heart and a drop in blood pressure. Disorders of metabolism, hemodynamics and microcirculation disrupt the urinary function of the kidneys.

clinical picture.

The leading symptom of A. n. is a violation of breathing, leading to a change in cardiac activity and hemodynamics, a violation of neuromuscular conduction and reflexes. Severity A. n. determined by the Apgar scale (see Apgar method). Allocate A. n. moderate and severe (Apgar score in the first minute after birth, respectively, 7-4 and 3-0 points). In clinical practice, it is customary to distinguish three degrees of severity of asphyxia:

• mild (Apgar score in the first minute after birth 7-6 points),
• moderate (5-4 points)
• severe (3-1 points).

A total score of 0 points indicates clinical death. With mild asphyxia, the newborn takes the first breath within the first minute after birth, but his breathing is weakened, acrocyanosis and cyanosis of the nasolabial triangle are noted, and some decrease in muscle tone. With asphyxia of moderate severity, the child takes the first breath within the first minute after birth, breathing is weakened (regular or irregular), the cry is weak, as a rule, bradycardia is noted, but there may also be tachycardia, muscle tone and reflexes are reduced, the skin is cyanotic, sometimes mainly in areas of the face, hands and feet, the umbilical cord pulsates. In severe asphyxia, breathing is irregular (separate breaths) or absent, the child does not scream, sometimes groans, the heartbeat is slow, in some cases it is replaced by single irregular heartbeats, muscle hypotension or atony is observed, reflexes are absent, the skin is pale as a result of peripheral vascular spasm, the umbilical cord is not pulsating; adrenal insufficiency often develops.

In the first hours and days of life, newborns who have undergone asphyxia develop a posthypoxic syndrome, the main manifestation of which is the defeat of the central nervous system. At the same time, every third child born in a state of moderate asphyxia has a violation of cerebral circulation of the I-II degree, in all children who have undergone severe asphyxia, the phenomena of impaired liquorodynamics and cerebral circulation of the II-III degree develop. Oxygen deficiency and disorders of the function of external respiration disrupt the formation of hemodynamics and microcirculation, in connection with which fetal communications are preserved: the arterial (botallian) duct remains open; as a result of a spasm of the pulmonary capillaries, leading to an increase in pressure in the pulmonary circulation and an overload of the right half of the heart, the foramen ovale does not close. In the lungs, atelectasis and often hyaline membranes are found. There are violations of cardiac activity: deafness of tones, extrasystole, arterial hypotension. Against the background of hypoxia and reduced immune defense, microbial colonization of the intestine is often disrupted, which leads to the development of dysbacteriosis. During the first 5-7 days of life, metabolic disorders persist, manifested by the accumulation of acidic metabolic products, urea, hypoglycemia, electrolyte imbalance and true potassium deficiency in the child's body. Due to impaired renal function and a sharp decrease in diuresis, edematous syndrome develops in newborns after the 2-3rd day of life.

The diagnosis of asphyxia and its severity is established on the basis of determining the degree of respiratory failure, changes in heart rate, muscle tone, reflexes, and skin color in the first minute after birth. The degree of severity of the transferred asphyxia is also indicated by indicators of the acid-base state (see Acid-base balance). So, if in healthy newborns the pH of the blood taken from the vein of the umbilical cord is 7.22-7.36, BE (base deficiency) is from - 9 to - 12 mmol / l, then with mild asphyxia and moderate asphyxia, these indicators are respectively equal 7.19-7.11 and from - 13 to - 18 mmol / l, with severe asphyxia pH less than 7.1 BE from - 19 mmol / l and more. A thorough neurological examination of the newborn, ultrasound examination of the brain allow us to differentiate between hypoxic and traumatic lesions of the central nervous system. In the case of a predominantly hypoxic lesion of the c.n.s. focal neurological symptoms are not detected in most children, a syndrome of increased neuro-reflex excitability develops, in more severe cases - a syndrome of depression of the central nervous system. In children with a predominance of the traumatic component (extensive subdural, subarachnoid and intraventricular hemorrhages, etc.), hypoxemic vascular shock with spasm of peripheral vessels and severe pallor of the skin, hyperexcitability are often observed at birth, focal neurological symptoms and convulsive syndrome that occurs a few hours after birth .

Treatment.

Children born in asphyxia need resuscitation assistance. Its effectiveness largely depends on how early treatment is started. Resuscitation measures are carried out in the delivery room under the control of the main parameters of the body's vital activity: respiratory rate and its conduction to the lower parts of the lungs, heart rate, blood pressure, hematocrit and acid-base state.

At the time of the birth of the fetal head and immediately after the birth of the child, the contents of the upper respiratory tract are carefully removed with a soft catheter using an electric suction (in this case, tees are used to create intermittent air rarefaction); immediately cut the umbilical cord and place the child on the resuscitation table under a source of radiant heat. Here, the contents of the nasal passages, oropharynx, and also the contents of the stomach are re-aspirated. With mild asphyxia, the child is given a drainage (knee-elbow) position, inhalation of a 60% oxygen-air mixture is prescribed, cocarboxylase (8 mg / kg) is injected into the vein of the umbilical cord in 10-15 ml of 10% glucose solution. In the case of moderate asphyxia, to normalize breathing, artificial lung ventilation (ALV) is indicated with a mask until regular breathing is restored and a pink color of the skin appears (usually within 2-3 minutes), then oxygen therapy is continued by inhalation. Oxygen must be supplied humidified and heated in any type of oxygen therapy. Cocarboxylase is injected into the vein of the umbilical cord in the same dose as in mild asphyxia. In case of severe asphyxia, immediately after crossing the umbilical cord and suctioning the contents of the upper respiratory tract and stomach, tracheal intubation is performed under the control of direct laryngoscopy and mechanical ventilation until regular breathing is restored (if the child has not taken a single breath within 15-20 minutes, resuscitation is stopped even if heartbeat). Simultaneously with mechanical ventilation, cocarboxylase is injected into the vein of the umbilical cord (8-10 mg / kg in 10-15 ml of 10% glucose solution), 5% sodium bicarbonate solution (only after creating adequate ventilation of the lungs, an average of 5 ml / kg), 10% solution calcium gluconate (0.5-1 ml/kg), prednisolonehemisuccinate (1 mg/kg) or hydrocortisone (5 mg/kg) to restore vascular tone. In the event of bradycardia, 0.1 ml of a 0.1% solution of atropine sulfate is injected into the vein of the umbilical cord. At a heart rate of less than 50 beats per 1 min or during cardiac arrest, an indirect heart massage is performed, 0.5-1 ml of a 0.01% (1: 10,000) solution of adrenaline hydrochloride is injected into the umbilical cord vein or intracardiac.

After restoring breathing and cardiac activity and stabilizing the child’s condition, he is transferred to the intensive care unit of the neonatal unit, where measures are taken to prevent and eliminate cerebral edema, restore hemodynamic and microcirculation disorders, normalize metabolism and kidney function. Craniocerebral hypothermia is carried out - local cooling of the head of the newborn (see Artificial hypothermia) and infusion-dehydration therapy. Premedication is required before craniocerebral hypothermia (infusion of 20% sodium hydroxybutyrate solution 100 mg/kg and 0.25% droperidol solution 0.5 mg/kg). The volume of therapeutic measures is determined by the state of the child, they are carried out under the control of hemodynamic parameters, blood coagulation, acid-base status, protein, glucose, potassium, sodium, calcium, chloride, magnesium in the blood serum. To eliminate metabolic disorders, restore hemodynamics and kidney function, 10% glucose solution, rheopolyglucin is injected intravenously, from the second or third day - hemodez. The total volume of fluid administered (including feeding) on ​​the first or second day should be 40-60 ml / kg, on the third day - 60-70 ml / kg, on the fourth - 70-80 ml / kg, on the fifth - 80-90 ml / kg, for the sixth-seventh - 100 ml / kg. From the second or third day, a 7.5% potassium chloride solution (1 ml / kg per day) is added to the dropper. Cocarboxylase (8-10 mg / kg per day), 5% solution of ascorbic acid (1-2 ml per day), 20% solution of calcium pantothenate (1-2 mg / kg per day), 1% solution of riboflavin- mononucleotide (0.2-0.4 ml / kg per day), pyridoxal phosphate (0.5-1 mg per day), cytochrome C (1-2 ml of a 0.25% solution per day for severe asphyxia), intramuscularly administered 0 5% solution of lipoic acid (0.2-0.4 ml / kg per day). Tocopherol acetate is also used 5-10 mg / kg per day intramuscularly or 3-5 drops of a 5-10% solution per 1 kg of body weight inside, glutamic acid 0.1 g 3 times a day inside. In order to prevent hemorrhagic syndrome in the first hours of life, a 1% solution of vikasol (0.1 ml / kg) is injected intramuscularly once, rutin is prescribed orally (0.005 g 2 times a day). In severe asphyxia, a 12.5% ​​solution of etamsylate (dicynone) is indicated at 0.5 ml / kg intravenously or intramuscularly. In the syndrome of increased neuro-reflex excitability, sedative and dehydration therapy is prescribed: 25% magnesium sulfate solution 0.2-0.4 ml / kg per day intramuscularly, seduxen (Relanium) 0.2-0.5 mg / kg per day intramuscularly or intravenously, sodium hydroxybutyrate 150-200 mg / kg per day intravenously, lasix 2-4 mg / kg per day intramuscularly or intravenously, mannitol 0.5-1 g of dry matter per 1 kg of body weight intraveinally 10% glucose solution, phenobarbital 5-10 mg / kg per day orally. In the case of the development of cardiovascular insufficiency, accompanied by tachycardia, 0.1 ml of a 0.06% solution of corglycone, digoxin is administered intravenously (the saturation dose on the first day is 0.05-0.07 mg / kg, on the next day 1/5 part of this dose), 2.4% solution of aminophylline (0.1-0.2 ml / kg per day). For the prevention of dysbacteriosis, bifidumbacterin is included in the complex of therapy, 2 doses 2 times a day.

Care is essential. The child should be provided with peace, the head is given an elevated position. Children who have suffered mild asphyxia are placed in an oxygen tent; children who have undergone moderate and severe asphyxia - in an incubator. Oxygen is supplied at a rate of 4-5 l / min, which creates a concentration of 30-40%. In the absence of the necessary equipment, oxygen can be supplied through a mask or nasal cannula. Often shown repeated suction of mucus from the upper respiratory tract and stomach. It is necessary to monitor body temperature, diuresis, bowel function. The first feeding with mild asphyxia and moderate asphyxia is prescribed 12-18 hours after birth (with expressed breast milk). Those born in severe asphyxia begin to be fed through a tube 24 hours after birth. The timing of breastfeeding is determined by the condition of the child. Due to the possibility of complications from the c.n.s. for children born in asphyxia, after discharge from the maternity hospital, a dispensary observation of a pediatrician and a neuropathologist is established.

The prognosis depends on the severity of asphyxia, the completeness and timeliness of therapeutic measures. In case of primary asphyxia, to determine the prognosis, the condition of the newborn is reassessed on the Apgar scale 5 minutes after birth. If the score increases, the prognosis for life is favorable. During the first year of life, children who have had asphyxia may experience hypo- and hyperexcitability syndromes, hypertensive-hydrocephalic, convulsive, diencephalic disorders, etc.

Prevention includes timely detection and treatment of extragenital diseases in pregnant women, pathologies of pregnancy and childbirth, prevention of intrauterine fetal hypoxia, especially at the end of the second stage of labor, suction of mucus from the upper respiratory tract immediately after the birth of a child.

Throughout pregnancy, parents look forward to the birth of a little treasure. At the same time, parents can experience a variety of emotions: fear, joy, excitement, and so on. Of course, the birth of a child is the happiest moment in the life of any family, and only the news that the baby has some health problems can overshadow this joy. Recently, quite often you can meet cases with the occurrence of asphyxia in a newborn. Of course, in such a situation, parents become very nervous, but in most cases this is not necessary, because modern medicine allows you to cure this complication very quickly and in the future the development of the child is no different from other children.

Asphyxia- this is a pathology with which a child is born and at the same time the baby's breathing is disturbed and there is a lack of oxygen.

Causes of asphyxia in a newborn baby

• intracranial injury in a child, which he received directly during childbirth;
• congenital abnormalities that affect breathing or cause difficulty in breathing;
• immunological incompatibility of a woman with her child;
• the presence of mucus or amniotic fluid in the child's respiratory tract.

Secondary asphyxia in a newborn child may appear only a few hours or even days after his birth. The causes of secondary asphyxia are:

• heart defects;
• problems with cerebral circulation in a child;
• serious problems with the central nervous system.

What changes occur in the body of a child after asphyxia

It is possible to understand that a newborn has asphyxia just a few seconds after his birth. To do this, you need to assess the frequency and adequacy of the child's breathing, the color of his skin, all indicators of muscle tone and heartbeat, as well as the presence of certain reflexes. The main signs by which one can understand the presence of asphyxia are breathing problems, which can cause serious complications in the body of a newborn baby. Therefore, doctors immediately after the birth of the baby very carefully examine him and give an approximate assessment on the Apgar scale. There are four forms of asphyxia:

1. Light;
2. Medium;
3. heavy;
4. clinical death.

The average form of asphyxia can get a slightly lower score - 45 points. Just as in the previous case, the child takes the first breath for a minute, but his breathing is very weak and irregular. In addition, the child can observe tachycardia and a low level of muscle tone. The skin of the face, feet and hands will acquire a clear bluish tint.

In the presence of a severe form of asphyxia, the child is given an Apgar score of no higher than 1-3 points. The child's breathing may be very irregular, or it may not be at all. The child cannot fully scream and only moans slightly or makes barely audible sounds. The heartbeat is almost inaudible, and the reflexes are completely absent. Atony or hypotension may also be noted. The skin will be unnaturally pale. There will be no pulse in the umbilical cord. In most cases, with a severe form of asphyxia, the baby also has acute adrenal insufficiency.

In the most severe form of asphyxia, namely with clinical death, the child is given the lowest score - 0 points. In this case, doctors must immediately take all necessary measures to save the life of the child.

It can be added to the above that it is possible to determine the presence of asphyxia not only with the help of an external primary examination of the child. Also, experts determine this pathology during ultrasound of the brain and spinal cord. Since asphyxia primarily affects the central nervous system, it will not be difficult to understand its presence. You can also examine the acid-base state of the child's blood. This method can be used to confirm a previously diagnosed diagnosis.

How to treat acute asphyxia in a newborn

• heartbeat;
• breathing;
• hematocrit.

What do doctors do when a child is born with asphyxia

After the baby's breathing is restored, he will be transferred to a special intensive care unit.

Measures for the prevention of asphyxia in newborns

As has been mentioned several times: intrauterine hypoxia can become the cause of asphyxia. This complication can be avoided very simply: it is enough to visit a doctor regularly. Also during pregnancy, you should try to remove all possible risks of asphyxia in the future in the child. For this you need to do:

• avoid any infectious or somatic diseases during pregnancy;
• it is worth considering the age of the expectant mother, if it is too out of bounds, then follow-up with a doctor should be strengthened;
• remove all possible disturbances in the work of the endocrine system;
• try to avoid stress and anxiety;
• get rid of all bad habits;
• monitor changes in the hormonal background of a woman.

Everything that was mentioned a little above is a confirmation that you need to regularly go to the doctor so that in the future you can avoid the appearance of such a dangerous condition in a child.

A very important role in the prevention of asphyxia is played by the lifestyle of the expectant mother. That is why she needs to follow simple rules and then pregnancy, childbirth will proceed without complications, and the child will be born healthy and strong.

1. Walk more outdoors. Thus, the woman’s blood will be maximally saturated with oxygen, which will be transmitted to the child. It should be borne in mind that the baby is in great need of this element. You should not believe those women who say that walking is useful only outside the city. Go to parks or squares that are in your city and don't listen to anyone.
2. Compliance with the daily routine. It is worth forgetting about the frantic pace of life. A woman who is expecting a baby should sleep at least 9 hours. It is also desirable that a woman rested for several hours during the day.
3. Take vitamin complexes and eat right. A pregnant woman, like no other, needs a large amount of vitamins and nutrients that are needed not only for her, but also for her child. Of course, a woman cannot physically take everything the body needs from food, and therefore a good vitamin and mineral complex will be very useful. Of course, before you start taking such a drug, you need to consult a doctor, because it is he who should prescribe the desired complex.
4. Don't be nervous and don't worry. Pregnancy is the most beautiful period in a woman's life, and therefore you need to try to eliminate all possible stresses and experiences. To do this, try as much and as often as possible to be distracted from the hustle and bustle around you, walk more, chat with friends and just get positive emotions.

Asphyxia in a newborn is a pathology of the infant's respiratory function, with the concomitant development of oxygen deficiency. Such a problem can occur both during the birth process and during the first days after the baby is born. Asphyxia is a rather dangerous condition that requires the provision of competent and, importantly, timely professional assistance.

Varieties and degrees of asphyxia in newborns

Asphyxia in newborn babies is a fairly common problem. Depending on the causes of its occurrence, doctors distinguish 2 types of asphyxia:

1. Intrauterine- develops against the background of a long stay of the baby in the mother's womb.
2. Postpartum- is a complication of the birth process.

note: according to statistics, manifestations of asphyxia are diagnosed in 4% of newborn babies!

Depending on the severity of manifestations, asphyxia is divided into 3 degrees: mild, moderate, severe. The pathological process is accompanied by a disorder of the respiratory function and disturbances in the activity of the cardiovascular system. The reasons that can provoke the development of asphyxia in a newborn are numerous and varied. In many ways, provoking factors depend on the type of pathology and the time of its manifestation (primary or secondary).

What causes intrauterine asphyxia?

Primary intrauterine asphyxia, in most cases, develops against the background of prolonged, located in the mother's womb . To provoke this pathology, according to doctors, the following factors can:

Important! The presence of diseases of an infectious, cardiovascular and endocrine nature in a future mother, occurring in a chronic form, increases the risk of asphyxia in a baby. Therefore, a pregnant woman with such health problems should be under the constant supervision of the attending physician!

Causes of postpartum asphyxia

Primary postpartum asphyxia occurs mainly against the background of violations of the birth process and congenital diseases of the baby itself .

The causes of this pathology in a newborn may be the following factors:

Important! Most often, postpartum asphyxia is diagnosed in. Also, defects in the internal organs of the fetus can lead to this problem, so during pregnancy it is important to do control tests so that doctors are as prepared as possible to provide first aid to the baby.

What complications during childbirth can lead to asphyxia?

Quite often, asphyxia in an infant is recorded in case of difficult childbirth. According to obstetrician-gynecologists, the following complications of the birth process lead to the development of pathology:

What causes secondary asphyxia?

Problems with the respiratory system can occur in a baby a few days after he is born.

This type of pathology is called secondary asphyxia.

Possible causes include the following factors:

• narrowing of the airways (stenosis);
• hemorrhages in the lungs;
• not detected immediately after birth;
• violations of circulatory processes in the brain area;
• pneumopathy;
• manifestations of respiratory distress syndrome;
• hyaline membranes;
• the presence of atelectasis, localized in the lungs;
• insufficient sanitation of the gastric cavity after the birth of the baby;
• disorders in the activity of the central nervous system.

Important! The ingress of breast milk or mixture during feeding into the respiratory tract of the baby can also lead to the development of secondary asphyxia!

How does pathology manifest itself?

Clinical manifestations of asphyxia in newborn babies depend on the severity of the pathological process. In the case of mild asphyxia, the child may show signs such as weakened respiratory function, blue color of the skin in the area of ​​the lips and nose, reduced muscle tone.

For a moderate degree of asphyxia, the following signs are characteristic:

With a severe degree of asphyxia, the baby's breathing is either completely absent, or manifested by rare, superficial breaths.

In addition, the child has the following alarming symptoms:

• severe bradycardia;
• heart rhythm disturbances ();
• decreased muscle tone;
• pallor of the skin and mucous membranes;
• numerous hemorrhages in the area of ​​the skin.

Important! In the absence of any signs of life in a newborn, clinical death is recorded. In this case, the child needs urgent help from resuscitators!

Consequences of asphyxia of newborns

Asphyxia is an extremely serious and dangerous condition, which is fraught with numerous complications.

Among the early complications of this pathology, physicians distinguish the following:

• necrotic processes;
• swelling and hemorrhage in the brain area;

Important! In the absence of timely medical care, asphyxia can lead to blockage of the respiratory function and death of the baby!

However, even if the efforts of the doctors were successful, and the respiratory function of the infant was restored within a few months, the likelihood of the following complications belonging to the late category is high:

• blood poisoning;
• hydrocephalus;
• encephalopathy;
• increased excitability of the nervous system;
• slow reactions;
• convulsive syndrome;
• disturbances in the functioning of the gastrointestinal tract.

Note: a baby who has undergone asphyxia should be under the supervision of a qualified specialist during the first year of life!

First aid measures for asphyxia of the newborn

If signs characteristic of asphyxia appear, the infant needs urgent medical care.! Therapeutic measures begin with the fact that they dry the skin of the baby and place it under a heat source.

The newborn is placed on its back, slightly tilting its head, after which the area of ​​​​the nasopharynx and oral cavity, as well as the respiratory tract, are thoroughly cleaned from the remnants of amniotic fluid.

In case of weakening or complete absence of respiratory function, doctors resort to hardware ventilation of the lungs and cleansing the gastric cavity from accumulated gases, using a special probe for this purpose.

note: if the measures listed above do not bring proper results within 3 minutes, the doctors inject Adrenaline to the child, do indirect stimulation of the heart area (massage), and carry out infusion therapy!

Therapy after asphyxia

Therapy of young patients after asphyxia should be aimed at preventing the development of possible complications, especially hemorrhages in the brain area. In most cases, babies are recommended medications such as glutamic and nicotinic acid, Vikasol, Dicinon, etc. A course of oxygen therapy is mandatory.

Further treatment depends on the general condition of the child, the symptoms present and the general clinical picture, and therefore is chosen by a pediatrician on an individual basis. The average duration of the therapeutic course is about 2 weeks.

note: You can feed a child after suffering asphyxia no earlier than after 15-16 hours. Infants with severe asphyxia are usually fed by tube after 24 hours.

For the rehabilitation of a child after asphyxia for 3 years, physiotherapeutic procedures such as massage and therapeutic exercises are recommended.

Further care

After discharge from the maternity hospital, it is important to strictly follow all the recommendations issued by the specialist regarding further treatment and care of the baby! Pediatricians do not recommend starting complementary foods for children who have had asphyxia before the age of one. If there is such an opportunity, it is desirable that the baby eat mother's milk until one and a half years old.

Since babies with asphyxia are especially susceptible to viral and infectious diseases, pediatricians recommend a course of vitamin therapy for preventive purposes.

About prevention

The expectant mother will be able to prevent the development of asphyxia in a baby if she follows the following recommendations of specialists:

1. . Even before conception, undergo a comprehensive medical examination and treat all identified pathologies.
2. Eat healthy and nutritious meals while you're expecting a baby.
3. Take special vitamin and mineral complexes for expectant mothers.
4. Do gymnastics for pregnant women, regularly take walks in the fresh air and avoid psycho-emotional shocks.

Of great importance in the prevention of asphyxia in newborns is the regular visit by the expectant mother to a gynecologist, scheduled ultrasound and laboratory tests.. Timely diagnosis will allow to identify and treat possible complications during pregnancy, fraught with subsequent asphyxia (such as preeclampsia, hypoxia, placental insufficiency, etc.).

note: according to statistics, measures to prevent asphyxia in newborns give positive results in 40% of cases!

Asphyxia in newborns is a dangerous condition, fraught with complete inhibition of respiratory function and the development of severe complications. At the first signs characteristic of this pathology, the baby needs urgent help from resuscitators! Subsequent treatment is aimed at preventing possible complications and is established on an individual basis. The causes of asphyxia are very diverse, however, pregnancy planning and strict adherence by the expectant mother to the recommendations of a specialist will reduce possible risks to a minimum!

Betsik Julia, obstetrician-gynecologist