Fetal distress

Definition
Fetal distress is defined as depletion of oxygen and accumulation of carbon dioxide,leading to a state of hypoxia and acidosis during intra-uterine life.

Etiology
Maternal factors
1) 2)

3)
4)

5)

Microvascular ischaemia(PIH) Low oxygen carried by RBC(severe anemia) Acute bleeding(placenta previa, placental abruption) Shock and acute infection obstructed of Utero-placental blood flow

Etiology
Placentaumbilical factors
1) 2) 3) 4) 5)

Obstructed of umbilical blood flow Dysfunction of placenta Fetal factors Malformations of cardiovascular system Intrauterine infection

Pathogenesis
Acute fetal distress Hypoxiaaccumulation of carbon dioxide Respiratory Acidosis FHR FHR FHR Intestinal peristalsis Relaxation of the anal sphincter Meconium aspiration Fetal or neonatal pneumonia

Pathogenesis
Chronic Fetal distress IUGR
(intrauterine growth retardation)

Clinical manifestation
Acute fetal distress
(1)FHR FHR>180 beats/min (tachycardia) <100 beats/min (bradycardia) (LD) Repeated Late deceleration Placenta dysfunction (VD) Variable deceleration Umbilical factors

Clinical manifestation
Acute fetal distress
(2) Meconium staining of the amniotic fluid grade IIIIII (3) Fetal movement Frequentlydecrease and weaken (4) Acidosis FBS (fetal blood sample) pH<7.20 pO2<10mmHg (15~30mmHg) CO2>60mmHg (35~55mmHg)

Clinical manifestation
Chronic fetal distress
(1) Placental function (24h E3<10mg or E/C<10) (2) FHR (3) BPS (4) Fetal movement (5) Amnioscopy

Management
Remove the induced factors actively
Correct the acidosis:
5%NaHCO3 250ML

Terminate the pregnancy

(1) FHR>160 or <120 bpm

meconium staining (II~III) (2) Meconium staining grade III amniotic fluid volume<2cm (3) FHR<100 bpm continually

Management
Terminate the pregnancy
(4) Repeated LD and severe VD (5) Baseline variability disappear with LD

(6) FBS pH<7.20

Forceps delivery Caesarean section

Neonatal Asphyxia

Aim & Claim

Understand the assessment & care of normal birth Familiar with the pathogenesis of birth asphyxia Hold of Apgar score & ABCDE resuscitation

Familiar with the complication of severe asphyxia

Definition
Birth asphyxia is defined as a

reduction of oxygen delivery and an

accumulation of carbon dioxide owing

to cessation of blood supply to the

fetus around the time of birth.

This is pathologic condition referred to neonate who have no spontaneous breathing or represented irregular breathing movement after birth. Usually caused by perinatal hypoxia. It is emergency condition and need quickly treatment (resuscitation).

Etiology
Pathologically, any factors which
interfere with the circulation between

maternal and fetal blood exchange

could result in the happens of perinatal

asphyxia. These factors can be

maternal factor, delivery factor and fetal factor.

EtiologyHigh Risk Factors

Maternal factor:
hypoxia, anemia, diabetes, hypertension, smoking, nephritis, heart disease, too old or too young,etc

Delivery condition:
Abruption of placenta, placenta previa, prolapsed cord, premature rupture of membranes,etc

Fetal factor:
Multiple birth, congenital or malformed fetus,etc

Pathophysiology
When fetal asphyxia happens, the body will show a self-defended mechanism which redistribute blood flow to different organs called interorgans shunt in order to prevent some important organs including brain, heart and adrenal from hypoxic damage.

Pathophysiology(I)

Hypoxic cellular damages:

a. Reversible damage(early stage):

Hypoxia may decrease the

production of ATP, and result in the cellular functions . But these change can be reversible if hypoxia is reversed in short time.

b. Unreversible damage:

If hypoxia exist in long time enough, the cellular damage will become unreversible that means even if hypoxia disappear but the cellular damages are not recovers. In other words, the complications will happen.

Pathophysiology(II)
Asphyxia development:
a. Primary apnea

breathing stop but normal muscular tone or hypertonia, tachycardia (quick heart rate), and hypertension

Happens early and shortly, self-defended mechanismcould not be damage to organ functions if corrected quickly

b. Secondary apnea

Features of severe asphyxia or unsuccessful resuscitation, usually

result in damage of organs function.

Pathophysiology(III)

Other damages:
a. Persistent pulmonary hypertension (PPHN) b. Hyper/hypoglycemia c. Hyperbilirubinemia

Clinic manifestations
Fetal asphyxia
fetal heart rate: tachycardia fetal movement: increase bradycardia decrease

amniotic fluid: meconium-stained

Clinic manifestations Apgar score:

A: appearance(skin color) P: pulse(heart rate) G: grimace(reactive ability) A: activity(muscular tension)

R: respiration

APGAR score
Score Heart rate
Respiration Muscle tone Response to stimulation Color of trunk

0
none none limp none
white

1
<100 irregular reduced grimaced
blue

2
> 100 regular normal cough
pink

Degree of asphyxia:
Apgar score 8~10: no asphyxia Apgar score 4~8: mild/cyanosis asphyxia Apgar score 0~3: severe/pale asphyxia

Clinic manifestations

Complications:
CNS: HIE, ICH RS: MAS, RDS, pulmonary hemorrhage CVS: heart failure, cardiac shock GIS: NEC, stress gastric ulcer

Others: hypoglycemia, hypocalcemia,

hyponatremia

Diagnosis
1/ Evidence of fetal distress 2/ Fetal metabolic acidosis 3/ Abnormal neurological state

4/ Multiorgan involvement

Management
ABCDE resuscitation
A (air way) B (breathing) C (circulation) D (drug) E (evaluation)

Airway
1/ open by placing the head in the neutral
position 2/ clean up completely amniotic fluid from the airway by suction with syringe as soon as possible

3/ if meconium-stained, tracheal
cathetershould be placed to ensure meconium to be removed

Breathing
1/ ensure face mask covers nose &

mouth connect to oxygen bag

2/ establish respiration of 30-40/min

with chest wall movement

3/ if no response, intubation &

mechanic ventilation is necessary

Circulation 1/ if heart rate <60/bpm, start external cardiac compression with fingers 2/ ratio 3:1 ( 90 compressions to 30 bpm)

Drugs
1/ if profound bradycardia, give adrenaline (1:10000, 0.1-0.3ml/kg) by endotracheal tube or umbilical vein 2/ if no response, intravenous fluid (saline, albumin, plasma, blood) with 10ml/kg 3/ if acidosis, give 5% sodium bicarbonate (SB) with 3-5ml/kg

4/ if bradypnea, consider using naloxone (0.1mg/kg)

Evaluation

Evaluate the result of

resuscitation to determine if

more rescue necessary:

If not good, repeat the resuscitation If good, transmit baby to NICU

Remember

In the whole resuscitation, the most important step is

A --- clean up completely the

airway