Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Print this page Email this page Users Online: 106

 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 245-248

Birth asyphxia: Looking at trends of risk factors leading to birth asphyxia in a peripheral hospital

Department of Neonatal Intensive Care Unit, Venkata Padma Hospital, Vizianagaram, Andhra Pradesh, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Anantsagar Motepalli
Department of Neonatal Intensive Care Unit, Venkata Padma Hospital, Vizianagaram - 535 002, Andhra Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and Permissions

Objectives: To look at the trends of risk factors leading to birth asphyxia, in newborns admitted to a peripheral hospital giving tertiary care.
Methodology: Descriptive longitudinal study conducted over a period of 6 months (March 2016–August 2016) in babies fulfilling the criteria for birth asphyxia. Variables studied included antenatal care (ANC), period of gestation, place of delivery, mode of delivery, birth weight, pregnancy complication, and time of arrival to hospital.
Results: The total number of admission in neonatal unit during the study period was 540, of which 58 babies fulfilled the inclusion criteria for birth asphyxia. The majority of admissions were referred from government hospital (68.91%), and all the mothers were booked and had ANC visits. Similarly, all were full terms except one preterm baby. Caesarean section was performed in 25.8%, and 74.2% had normal vaginal delivery. All were institutional/hospital delivery. The majority (65%) of babies were referred within 6 h, and 79.3% of babies weighed more than 2.5 kg.
Conclusion: Birth asphyxia occurring in such a high number of booked cases with institutional/hospital delivery indicates inadequate perinatal services. It is advisable to have trained neonatal resuscitation personnel with all necessary equipments and medications at the time of delivery.

Keywords: Birth asphyxia, neonatal mortality, risk factors

How to cite this article:
Motepalli A, Patel MR, Rao V. Birth asyphxia: Looking at trends of risk factors leading to birth asphyxia in a peripheral hospital. J NTR Univ Health Sci 2018;7:245-8

How to cite this URL:
Motepalli A, Patel MR, Rao V. Birth asyphxia: Looking at trends of risk factors leading to birth asphyxia in a peripheral hospital. J NTR Univ Health Sci [serial online] 2018 [cited 2023 Feb 4];7:245-8. Available from: https://www.jdrntruhs.org/text.asp?2018/7/4/245/249818

  Introduction Top

Asphyxia is an insult to the fetus or newborn due to lack of oxygen or lack of perfusion to various organs.[1] National Neonatology Forum of India has defined asphyxia as gasping or ineffective breathing or lack of breathing at 1 min of life.[2]

Birth asphyxia is one of the most important causes of neonatal brain injury whose incidence ranges from 3.7 to 9/1000 deliveries in the west.[3] In addition to its contribution to mortality, birth asphyxia can result in cognitive impairment, epilepsy, cerebral palsy, and chronic disease in later life.[4],[5],[6],[7],[8] Birth asphyxia is the third largest (16%) reason for neonatal mortality and morbidity after prematurity (32%) and septicemia (19%).[9],[10],[11],[12]

About 0.75 million neonates die every year in India, the highest for any country in the world. The neonatal mortality rate (NMR) declined from 52/1000 live births in 1990 to 28/1000 live births in 2013, but the rate of decline has been slow.

Obviously, the “Committing to Child Survival: A Promise Renewed” goal of reducing under-five mortality to 20 or less per 1000 live births by 2035 will not be attained without specific efforts to reduce newborn mortality.[11] This study is an effort to study and analyze the risk factors leading to birth asphyxia in peripheral areas.

  Methodology Top

Prospective analysis of 58 babies admitted in neonatal intensive care unit of peripheral hospital giving tertiary care was carried out over a period of 6 months (March 2016–August 2016). The total admission during this period was 540, which included inborn and outborn. Of these, 58 patients fulfilled the inclusion criteria for birth asphyxia and thus were included in the analysis.

Inclusion criteria

  1. Babies referred with a history of not crying immediately following birth
  2. Requiring resuscitation at least with bag and mask
  3. Apgar score of less than 7 at 1 min
  4. Abnormal neurological signs (hypotonia, lethargy, poor sucking, seizures).

Newborns with severe congenital malformation, chromosomal anomalies such as Down's syndrome, TORCH [Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections] infections, septicemia, and RH incompatibility resulting in hemolysis were excluded.

  Results Top

Analysis of 58 patients with birth asphyxia showed that 38 were male and 20 were female. All were booked cases and had three antenatal visits and at least one visit was in the last trimester.

All had antenatal ultrasound done, and nine of them also underwent TIFFA (Targeted Imaging for Fetal Anomalies) scan. All of them were full term (except one preterm baby). None of the deliveries was conducted at home; 68.9% were born in government hospital and 31% were born in private hospital.

None of the inborn babies had birth asphyxia during the study period. Almost 74% had a normal vaginal delivery, of which 36.2% required induction. Out of the admitted babies with birth asphyxia, 55 improved and were discharged; 5 of them required ventilation, of which 2 survived.

Among the 58 patients included in this study, 38 patients (65.5%) came within 6 h of life with almost 98% patients (38 + 19 = 57) arriving to the hospital in 24 h.

  Discussion Top

The frequency of birth asphyxia was 10.7% in our study, while it varies from 9%[13] to 13%[14] in different studies. Hence, it was consistent with national data.

The risk factors for birth asphyxia include increasing or decreasing maternal age, prolonged rupture of membranes, meconium-stained fluid, multiple births, nonattendance for antenatal care (ANC), low birth weight (LBW) infants, malpresentation, augmentation of labor with oxytocin, antepartum hemorrhage, severe eclampsia and preeclampsia, and antepartum and intrapartum anemia.[15],[16]

Birth asphyxia can be caused by events that have their roots in the antepartum, intrapartum, postpartum periods, or combinations thereof. A recent review suggests that asphyxia is probably primarily antepartum in origin in 50% of cases, intrapartum in 40%, and postpartum in the remaining 10% of cases.[17]

The results in this study were contrary to our expectations. We found that the majority of the mothers were booked cases, had ANC including antenatal ultrasonography (USG), and delivered at government hospital or private maternity homes with deliveries attended by doctors/with trained personnel; in spite of this, the babies still suffered from birth asphyxia.

Previously published data proved that there is a huge difference in the neonatal deaths among those mothers who had regular antenatal visits when compared with unbooked cases. In a study conducted by Shaheen, the perinatal mortality rate was 111/1000 live births in nonbooked cases when compared with 17/1000 in booked cases.[18]

From this study, it was evident that the antenatal services have improved drastically as all the expectant mothers were booked, had ANC visits, USGs, and also all were delivered in hospital/maternity home, but the unexpected high rates of birth asphyxia are attributable to intrapartum causes and lack of trained neonatal resuscitation at the time of delivery.

Some of the promising points noted were that all the mothers had ANC visit, with at least one visit in the last trimester, and all were delivered in hospital and referred to tertiary hospital within 6 h of life [Figure 1].
Figure 1: Among the 58 patients included in the present study, 38 patients (65.5%) came within 6 hours of life with almost 98% patients (38+19=57) arrived to the hospital in 24 hrs

Click here to view

It is estimated that the risks of neonatal mortality and LBW are increased by almost 50% if the maternal age at childbirth is <20 years [Figure 2]. It is also estimated that shifting age at childbirth to above 20 years would reduce the overall NMR by 9.4%.[19],[20],[21] The majority of them (56%) were above 20 years in our study [Figure 3].
Figure 2: Maternal Age : The above figure shows that 10 patients(17.2%) were less than 20 years and majority were between 20-25 yrs (56.8%) of age

Click here to view
Figure 3: Weight of newborn at the time of admission: the pie chart shows that 46 patients (79.3%) were of good birth weight, that is, 2.5–4 kg and only 10 patients (17%) weighed <2.5 kg

Click here to view

In spite of this, there were babies with Sarnat stage II [Figure 4] from a majority of peripheral government hospital (74.1%) indicating unawareness and lack of skills regarding neonatal resuscitation. None of the inborn babies admitted during the period had birth asphyxia. The art of neonatal resuscitation of asphyxiated babies has now become an important part of neonatal care. The slogan “give a breath and save a life” conveys the essence of the art.
Figure 4: Sarnat staging : The above figure shows that the maximum number (74.1%) had sarnat staging II and out of 20.6% of sarnat stage III, 5% required ventilator support

Click here to view

Meconium-stained amniotic fluid was found to be present as one of the risk factors [Figure 5], and findings were comparable to previous study also.[22] Preeclampsia was found to be associated significantly with increased risk of birth asphyxia.[23]
Figure 5: Pregnancy complication: 30% of the pregnancies were complicated and thick meconium/maternal infection/pre-eclampsia formed the majority

Click here to view

It is important to recognize that birth asphyxia is one of the major determinants of infant mortality and morbidity and is preventable to a large extent. We have overcome many risk factors of birth asphyxia in recent years, and hence a trained personnel in labor room after giving basic care to the newborn baby, initiating resuscitation if necessary, and summon for help if needed. A properly trained person in neonatal resuscitation preferably a pediatrician should be present at every delivery especially the high-risk cases. The same has been recommended by the International Liaison Committee on Resuscitation (ILCOR), Neonatal Resuscitation Program (NRP), of the American Heart Association.[24]

The presence of working resuscitation equipments is another important requirement. Hospital paramedics should be trained regularly in basic newborn care and certified regularly for preliminary resuscitative measures. Prior stabilization and appropriate transport would be important determinants in further reducing mortality and morbidity of birth asphyxia.

  Conclusion Top

Birth asphyxia occurring in such a high number of booked cases with institutional/hospital delivery indicates inadequate perinatal services. It is advisable to have trained neonatal resuscitation personnel with all necessary equipments and medications at the time of delivery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Leviton A, Nelson KB. Problems with definitions and classifications of newborn encephalopathy. Pediatr Neurol 1992;8:85-90.  Back to cited text no. 1
Snyder EY, Cloherty JP. Perinatal asphyxia. In: Cloherty JP, Stark AR, editors. Manual of Neonatal Care. 4th ed. Philadelphia: Lippincott-Williams & Wilkins; 1998. p. 515-32  Back to cited text no. 2
Mcintosh N. Hypoxic ischaemic encephalopathy (HIE). In Forfar and Arneil's Textbook of Paediatrics. New York: Churchill Living Stone; 1998. p. 126.  Back to cited text no. 3
Leviton A, Nelson KB. Problems with definitions and classifications of newborn encephalopathy. Pediatr Neurol 1992;8:85-90.  Back to cited text no. 4
Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 2001;344:467-71.  Back to cited text no. 5
Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability Form Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Cambridge: Harvard University Press; 1996. p. 429-53.  Back to cited text no. 6
Lawn JE, Manandhar A, Haws RA, Darmstadt GL. Reducing one million child deaths from birth asphyxia – A survey of health systems gaps and priorities. Health Res PolicySyst 2007;5:4.  Back to cited text no. 7
World Health Organization. World Health Report. Geneva: WHO; 2005.  Back to cited text no. 8
National Neonatal and Perinatal Database Report. 2002-2003:1-58.  Back to cited text no. 9
Lopez AD, Methers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: Systematic analysis of population health data. Lancet 2006;367:1747-57.  Back to cited text no. 10
Committing to Child Survival: A Promise Renewed; 2013.  Back to cited text no. 11
Lopez AD, Mathers CD. Measuring the global burden of disease and epidemiological transitions: 2002-2030. Ann Trop Med Parasitol 2006;100:481-99.  Back to cited text no. 12
Kaye D. Antenatal and intrapartum risk factors for birth asphyxia among emergency obstetric referrals in Mulago Hospital, Kampala, Uganda. East Afr Med J 2003;80:140-3.  Back to cited text no. 13
Majeed R, Memon Y, Majeed F, Shaikh NP, Rajar UD. Risk factors of birth asphyxia. J Ayub Med Coll Abbottabad 2007;19:67-71.  Back to cited text no. 14
Shrestha M, Shrestha L, Shrestha PS. Profile of asphyxiated babies at Tribhuvan University Teaching Hospital. J Nepal Pediatr Soc 2009;29:3-5.  Back to cited text no. 15
Thornberg E, Thiringer K, Odeback A, Milsom I. Birth asphyxia: Incidence, clinical course and outcome in a Swedish population. Acta Paediatr 1995;84:927-32.  Back to cited text no. 16
Dilenge ME, Majnemer A, Shevell MI. Long-term developmental outcome of asphyxiated term neonates. J Child Neurol 2001;16:781-92.  Back to cited text no. 17
Shaheen F. Clinical audit of perinatal mortality in a teaching Hospital. Pak J Obstet Gynaecol 1997;10:27-30.  Back to cited text no. 18
Paul VK, Sachdev HS, Mavalankar D, Ramachandran P, Sankar MJ, Bhandari N, et al. Reproductive health, and child health and nutrition in India: Meeting the challenge. Lancet 2011;377:332-49.  Back to cited text no. 19
Conde-Agudelo A, Belizán JM, Lammers C. Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. Am J Obset Gynecol 2005;192:342-9.  Back to cited text no. 20
United Nations Children Fund (UNICEF) Early Marriage: Child Spouses. Florence, Italy: Innocenti Digest Innocenti Research Centre, UNICEF; 2001.  Back to cited text no. 21
Pitsawong C, Panichkul P. Risk factors associated with birth asphyxia in Phramongkutklao Hospital. Thai J Obstet Gynaecol 2012;19:165-71.  Back to cited text no. 22
Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC, et al. Risk factors for neonatal mortality due to birth asphyxia in southern Nepal: A prospective, community-based cohort study. Pediatrics 2008;121:e1381-90.  Back to cited text no. 23
Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, et al. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010;126:e1400-413.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures

 Article Access Statistics
    PDF Downloaded379    
    Comments [Add]    

Recommend this journal