Explore New Ways to Predict and Prevent Birth Asphyxia
Burden, Causes and Consequences
Birth of a new born is the most amazing phenomena of nature, and childhood being the most valuable period of life. However, World Health Organization (WHO) had reported that 5.9 million deaths occur among children below 5 years of age. Of these, 2.7 million (45%) died during the neonatal period (within the first month of their life) and approximately similar number are stillborn. Overwhelming majority of the new born deaths are accounted by the developing countries of the world. India alone resulting in one million neonatal deaths, contribute 25% of the neonatal death burden globally.
The vast majority of deaths among neonates are driven by preterm birth, intrapartum-related complications (birth asphyxia or impaired breathing at birth), and infections. Birth asphyxia also known as hypoxic-ischaemia is a serious and common problem, contributing almost 23% of the neonatal and 8.5% of children under-five deaths globally. Recent estimates indicate that ~ 20 of 1000 deliveries have clinical and biochemical evidence of perinatal asphyxia. In India birth asphyxia results in 0.5-1.0 million cases/year and 20% of neonatal deaths.
Neonatal or perinatal asphyxia is a medical condition that results from deprivation of oxygen due to cessation or interruption of blood flow or gas exchange during the time of birth. According to WHO birth asphyxia is defined as “Failure to initiate or sustain respiration following birth”. The known perinatal insults that results in high suspicion of hypoxic-ischemic injury includes placental abruptions or cord accidents or typical clinical signs, biochemical evidence of metabolic acidosis or depressed APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score. Other maternal risk factors that may lead to asphyxia are pre-eclampsia, eclampsia, anaemia, and maternal diabetes. Severe cardiopulmonary abnormalities or prematurity may also engender asphyxia in the newborns.
The majority of infants exposed to hypoxic-ischaemia during perinatal period may recovers completely. Nevertheless, in significant number of cases it lasts long enough to cause death or trigger a cascade of neuronal injury leading to neonatal encephalopathy (NE) also termed as hypoxic-ischemic encephalopathy (HIE), resulting in long term damage. As per recent approximations 50%-80% of NE are attributed to hypoxia-ischaemia. The complications of HIE/NE are wide-ranging that may modify the motor, sensory, cognitive and behavioural outcomes in a child. Nevertheless, the brain damage is of most concern and perhaps least likely to compensate.
Challenges and Knowledge Gaps
The existence of wide knowledge gap is a major hurdle in guiding the clinical management, development of therapeutic interventions and effective implementation of the best strategies for tackling asphyxia. The delivery process and 48 hours immediately following birth is the most risky period for new born survival. This is when the mother and child should receive appropriate care. However, practically half of all mothers and new-borns in developing countries of the world do not receive the required care during this period. This is even more challenging in Indian rural setting where most pregnant women and new-borns do not readily access available care and support. Babies who survive birth asphyxia have an increased risk of disability, which exacts a heavy load on families and health systems.
Difficulty in distinguishing the warning signs of birth asphyxia, instantly following birth is a major hurdle in managing perinatal asphyxia. There is a shortcoming of skilled manpower, capable of identifying asphyxia and providing neonatal resuscitation. Inadequate antenatal, postnatal and obstetric care guidelines are also a source of concern. Furthermore, lack of continuity between, existing mother and child care programs that goes hand in hand also makes management of neonatal asphyxia difficult.
Absence of low-cost imaging modalities/tools for prognosis of fetal distress and biomarkers to predict asphyxia among new born. There is also a lack of low cost ventilators, infant warmers and continuous positive airway pressure (CPAP) to deal with potential problems of initiating cooling upon transport, as well as cooling in low-resource settings. Development of an acceptable, non-invasive point of care test for accurate prediction of birth asphyxia has considerable potential to reduce infant deaths in low-resource settings through improvements in antenatal and postnatal care uptake and or by referral of high risk women to higher level health facilities with experience in care of vulnerable infants.
There has been incomplete awareness about the exact magnitude of the asphyxia burden and its long term consequences owing to unrecorded burden of neonatal deaths accounted by low-income countries. Difference in behaviour or reduced care-seeking approach for baby girl as compared to boys is also a common observation in South Asia region.
What should we look for?
- Overseeing the potential harm, it is also necessary to strive for a reliable early marker to predict asphyxia and its sequelae.
- Interventions are needed to prevent fetal asphyxia during labour.
- Considering the plausible benefit of early treatment, it is increasingly important to identify infants with hypoxic-ischaemic induced encephalopathy. Markers of intrapartum fetal asphyxia and neonatal blood biomarkers are needed.
- Tools to accurately predict/prognosticate individual predispositions to or a progression of secondary complications in asphyxia affected newborns.
- Need of low cost kits and laryngeal mask for neonatal resuscitation.
- Information, education and communication material including video films for resuscitation skills to grass root level workers, doctors, nurses, midwives etc.
- Although, several currently available neuroimaging modalities such as electroencephalography (EEG), amplitude-integrated electroencephalography (aEEG) and magnetic resonance imaging (MRIs) have acquired significant role in the process of prognostication. However, it is important to explore novel low cost interventions /logical algorithms/techniques/devices to monitor labour progress which are of use to peripheral health workers.
- To reduce the consequence of asphyxia low cost cooling techniques are needed. Development and evaluation of low cost ventilators, infant warmers, CPAP and pulse oximetry equipment.
- Study the effect of induced labour and augmentation techniques on fetal oxygenation.
- Role of Caesarean section in alleviating the effects of intrapartum fetal asphyxia?
- Stimulated by the ramification there is considerable need to initiate surveillance programs for birth asphyxia cases/ mortality and determine the risk factors for the same.
- Besides developing antenatal and obstetric care guidelines, birth asphyxia management guidelines are also needed.
- Potential problems regarding initiating cooling upon transport, as well as cooling in low-resource setting needs to be reviewed. Therapeutic hypothermia is safe and effective only with strict adherence to standard protocols that needs to be developed.
- Provision of newer modes of therapy.