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 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 1-4

Impact of early referral on immediate outcome of asphyxiated newborns

1 Department of Pediatrics, Gandhi Medical College, Bhopal, Madhya Pradesh, India
2 Consultant Pediatrician, Paras Hospital, Gurgaon, Haryana, India
3 Department of Pediatrics, LN Medical College, Bhopal, Madhya Pradesh, India

Date of Submission18-Feb-2020
Date of Decision24-Sep-2020
Date of Acceptance22-Dec-2020
Date of Web Publication08-Feb-2021

Correspondence Address:
Dr. Poorva Gohiya
Gandhi Medical College, Bhopal, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.JCN_18_20

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Introduction: Perinatal asphyxia is a significant cause of neonatal morbidity and mortality. Early recognition of perinatal asphyxia and timely referral to centers well equipped in postresuscitation management helps to minimize unfavorable consequences. We did this observational study with the aim of finding out the impact of referral timings on early (72 h) outcome of asphyxiated newborns. Materials and Methods: This is a prospective observational study conducted in the sick newborn care unit, of a teaching institute in central India, over a period of 12 months. We enrolled 150 full-term neonates admitted with perinatal asphyxia. Their early outcome was recorded and analyzed. Results: The short-term outcome of asphyxiated neonates at 72 h of admission was significantly better when they were admitted within 6 h of birth. Conclusion: Early recognition of birth asphyxia and timely referral helps in reducing morbidity and mortality in neonates.

Keywords: Mortality, postresuscitation care, transport

How to cite this article:
Gohiya P, Ubriani N, Dwivedi R. Impact of early referral on immediate outcome of asphyxiated newborns. J Clin Neonatol 2021;10:1-4

How to cite this URL:
Gohiya P, Ubriani N, Dwivedi R. Impact of early referral on immediate outcome of asphyxiated newborns. J Clin Neonatol [serial online] 2021 [cited 2021 Aug 1];10:1-4. Available from: https://www.jcnonweb.com/text.asp?2021/10/1/1/308843

  Introduction Top

The WHO describes birth asphyxia as failure to initiate or sustain spontaneous and effective breathing at birth.[1] The American Academy of Pediatrics and American College of Obstetrics and Gynecology define the following four criteria to diagnose asphyxia:[1] (1) prolonged metabolic or mixed acidosis (pH < 7) in an umbilical cord arterial blood sample;[2] (2) persistence of an Apgar score of 0–3 for longer than 5 min;[3] (3) unexplained neurological manifestations, for example, seizures, hypotonia, coma, and encephalopathy in the immediate neonatal period;[4] and (4) evidence of multiorgan system dysfunction, that is, gastrointestinal, renal, cardiovascular, and respiratory.[2] Perinatal asphyxia is a major cause of neonatal deaths in India, both in hospitals and in the community. It accounts for 23% of neonatal deaths and 8% of all deaths in children <5 years of age.[3] Decreasing neonatal mortality is a critical component of achieving the third Sustainable Development Goal, that is, the target of achieving neonatal mortality rate as low as 12/1000 live births by 2030.[3] There is enough evidence in literature that emphasizes early and adequate management of perinatal asphyxia in order to prevent neonatal mortality. Neonates born in peripheral hospitals which do not have adequate neonatal stabilization services are referred to tertiary centers. The time to reach the hospital can be long due to the distance between the referral between two facilities or delayed referral. The proportion of outborn admissions at our center is almost 60% of the total admissions in a year. Babies are referred from various districts all over the state. They are referred by state-provided vehicles as well as private vehicles, which may or may not be equipped with basic equipment for transport. On reviewing our hospital data of previous few years, we hypothesized that the time of referral impacted the outcome of babies with hypoxic-ischemic encephalopathy (HIE). Thus, this study was planned with the objective of studying the impact of time of referral and certain other factors such as parity of mother and mode of delivery on the early outcome of asphyxiated newborns at our center.

  Materials and Methods Top

This study was carried out in the sick newborn care unit of the department of pediatrics of a tertiary care institute over a period of 12 months after clearance from the ethical committee. A total of 150 full-term neonates admitted with perinatal asphyxia who fulfilled the inclusion criteria were studied. The study was approved by the institutional ethical committee.

Inclusion criteria

  1. Clinical history consistent with perinatal asphyxia
  2. 5-min Apgar score <7
  3. History of delayed cry or not breathing
  4. Need of resuscitation for >5 min (minimum – any two of the above).

Exclusion criteria

  1. Preterm newborns
  2. Birth weight <1500 g
  3. Opium- or anesthesia-related low Apgar Scores
  4. Congenital malformations
  5. Congenital infections.

  Methods Top

Maternal information including maternal age, parity, antenatal checkups, any relevant medical history, or any significant antepartum or intrapartum events was recorded. Neonatal data included name, gender, place of delivery, age on admission, gestational age, body weight, Apgar score, and need for resuscitation after birth. The correlation of antepartum and intrapartum events such as maternal parity, type of delivery, and prolonged labor, with birth asphyxia, was evaluated.

Thorough clinical examination of all asphyxiated neonates was done at admission and at 6, 12, 24, 36, 48, and 72 h of admission with a special emphasis on the signs of encephalopathy, and HIE was graded as per the Sarnat and Sarnat staging.[4],[5]

The early outcome was recorded after 72 h of admission in terms of:

  1. Clinical improvement
  2. No improvement or deterioration (progression to higher stages of HIE)
  3. Death.

Statistical analysis

The data were analyzed using SPSS version 20 (IBM, USA). Quantitative data were expressed as mean and standard deviation. Categorical data were expressed as percentage. Chi-square test was used to compare the percentage. Pearson's correlation coefficient was used to find out the correlation between variables.

  Results Top

All the neonates were divided into three groups on the basis of their birth weight. A total of 105 out of 150 neonates were >2500 g [Table 1].
Table 1: Demographic characteristics of neonates with perinatal asphyxia

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Out of the 150 asphyxiated neonates studied, 91 (60.66%) were admitted within 6 h of birth. Antepartum and intrapartum risk factors were present in 98 (65.3%) mothers. The important identified risk factors were meconium-stained liquor in 37 (24.67%); preeclampsia/eclampsia in 24 (18%); and other factors were obstructed labor, premature rupture of membranes antepartum hemorrhage malpresentation and multiple pregnancy. A significant negative correlation was found between the increasing parity of mother and HIE Stages II and III (Pearson's correlation coefficient = −0.42).[6] Out of 64.7% asphyxiated neonates born to primiparous mothers, 14% had no signs of encephalopathy; 11.3% developed HIE-I; 56.7% developed seizures and progressed to HIE-II; and 17.5% neonates developed HIE-III. A significant negative correlation was found between the increasing parity of mother and higher stages of perinatal asphyxia (Pearson's correlation coefficient = −0.42), implying a strong correlation between primiparity and HIE Stages II and III.

Out of 63 neonates with HIE Stage I, 56 (88%) improved and 7 (14.2%) either did not show any improvement or deteriorated. Among 64 neonates under HIE Stage II, only 39 (61%) neonates improved, 16 (25%) neonates either did not improve or deteriorated with time, and 9 (14%) expired. None of the neonates in HIE Stage III (23) were found to improve after 72 h of observation. Out of these 23 neonates, 7 (31.4%) survived but did not improve, and majority of them (16 [69.6%]) expired. Out of 92 neonates admitted within 6 h of birth, 66 (71.7%) improved within 72 h, 18 (19.6%) either did not improve or deteriorated, and 8 (8.7%) expired. Out of 58 neonates admitted after 6 h of birth, 29 (50%) improved, 12 (20.7%) either showed no improvement or deteriorated, and 17 (29.3%) expired. When the early outcome of neonates with asphyxia was measured in relation to age of the neonate at the time of admission, statistically significant difference was noted in the outcome of two groups with more deaths among neonates who were admitted later than 6 h of birth (P = 0.021) [Table 2].
Table 2: Short-term outcome of asphyxiated neonates at 72 h of admission in relation to age at admission

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  Discussion Top

At our center, the rate of admission of neonates with birth asphyxia/HIE was estimated to be about 23.5% of the total neonatal admissions. On reviewing our hospital data of previous few years, we hypothesized that the time of referral impacted the outcome of babies with HIE. Thus, this study was planned with the objective of finding the impact of early referral on immediate outcome of asphyxiated newborns, that is, within 72 h. The clinical characteristics of neonates are described in [Table 3]. Memon et al.[7] in their study noted a statistically significant difference between neonates who were received within 6 h and those who were received after 6 h of birth, when they correlated the outcome in terms of disability to death with more adverse outcome in those neonates who were received after 6 h of birth (P < 0.0001). In our study, the early outcome of neonates was assessed in relation to age at the time of admission; it was significantly better for neonates who were admitted within 6 h of birth. Significantly adverse early outcome (after 72 h of admission) in terms of death was observed in those asphyxiated neonates who were admitted after 6 h of birth (P = 0.021). Thus, our study provides enough evidence to say that, referral within 6 h of birth is life saving in the cases of birth asphyxia or HIE. In this setting, newborns are referred from long distances to tertiary care centers and care during transport varies, therefore uniform transport guidelines in terms of distances to be covered and en route management protocol should be standardized in order to decrease deaths due to asphyxia.
Table 3: Clinical characteristics of neonates with perinatal asphyxia

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We also observed that greater number of mothers with asphyxiated neonates had received very poor antenatal care with no or <4 antenatal checkups during their entire period of conception. This might have led to failure in detecting, treating, and preventing many risk factors associated with perinatal asphyxia.

In our study, a negative correlation was observed between vaginal mode of delivery and higher stages of asphyxia (Pearson's correlation coefficient = −0.161). Similar results regarding the modes of delivery were observed in other studies also.[8],[9],[10] They concluded an inverse relationship between elective cesarean section and encephalopathy. The limitation of the study is we have not taken into consideration the management during transport of babies who traveled long distances. We do not have therapeutic hypothermia equipment at our center, therefore the study was based on conventional management of HIE. The asphyxiated babies are managed as per standard protocol except therapeutic hypothermia with policy of do no harm. In our study, primiparity was associated with poor outcome of asphyxiated neonates in terms of higher stages of encephalopathy. There are certain other studies[11],[12],[13] which have also found a negative correlation of primiparity with higher stages of HIE. Primiparous mothers do have more chances of cephalopelvic disproportion, which remains undiagnosed till labor. There are factors such as young age, anemia, and inadequate nutrition, which make primiparous women vulnerable and thus peripartum asphyxia can occur.

  Conclusion Top

All asphyxiated babies should be transferred to a tertiary care neonatal intensive care unit as early as possible and preferably within 6 h of birth. Early referral will improve immediate outcome of severely asphyxiated babies. Maternal factors should be managed antenatally and perinatally so as to decrease perinatal asphyxia. The limitation of our study is that we have no control population so as to establish a definitive causal relationship among various factors. We had limited data regarding APGAR scores and resuscitation, therefore these factors could not be assessed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Perinatal mortality: A listing of available information. WHO/FRH/MSM/96.7. Geneva: WHO; 1996.  Back to cited text no. 1
Paul VK. Neonatal morbidity and mortality: Report of the national neonatal and perinatal database. Indian Pediatr 1999;36:167-9.  Back to cited text no. 2
Fadel SA, Rasaily R, Awasthi S, Begum R, Black RE, Gelband H, et al. Changes in cause-specific neonatal and 1–59-month child mortality in India from 2000 to 2015: A nationally representative survey. Lancet 2017;390:1972-80.  Back to cited text no. 3
Health in 2015: From MDGs to SDGs WHO2015. ISBN 978 92 4 156511 0 (NLM classification: WA 530).  Back to cited text no. 4
Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol 1976;33:696-705.  Back to cited text no. 5
Mukaka MM. Statistics corner: A guide to appropriate use of correlation coefficient in medical research. Malawi Med J 2012;24:69-71.  Back to cited text no. 6
Memon S, Shaikh S, Bibi S. To compare the outcome (early) of neonates with birth asphyxia in-relation to place of delivery and age at time of admission. J Pak Med Assoc 2012;62:1277-81.  Back to cited text no. 7
Majeed R, Menon Y, Majeed F, Shaikh NP, Rajar UD. Risk factors for birth asphyxia. J Ayub Med College Abbottabad: JAMC 2007;19:67-71.  Back to cited text no. 8
Padachayee N, Ballot DE. Outcome of neonates with perinatal asphyxia at a tertiary academic hospital in Johannesburg, South Africa. SAJCH 2013;7:89-94.  Back to cited text no. 9
Üzel H, Kelekçi S, Devecioğlu C, Güneş A, Yolbaş İ, Şen V. Neonatal asphyxia: A study of 210 cases. J Clin Exp Invest 2012;3:1948.  Back to cited text no. 10
Aslam HM, Saleem S, Afzal R, Iqbal U, Saleem SM, Shaikh MW, et al. Risk factors of birth asphyxia. Ital J Pediatr 2014;40:94.  Back to cited text no. 11
Rani S, Chawla D, Huria A, Jain S. Risk factors for perinatal mortality due to asphyxia among emergency obstetric referrals in a tertiary hospital. Indian Pediatr 2012;49:191-4.  Back to cited text no. 12
Tasew H, Zemicheal M, Teklay G, Mariye T, Ayele E. Risk factors of birth asphyxia among newborns in public hospitals of Central Zone, Tigray, Ethiopia 2018. BMC Res Notes 2018;11:496. https://doi.org/10.1186/s13104-018-3611-3.  Back to cited text no. 13


  [Table 1], [Table 2], [Table 3]


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