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August 1988, Volume 38, Issue 8

Original Article


Sajid Maqbool  ( Department of Paediatrics, Shaikh Zayed Hospital, Lahore. )
M. Saeed  ( Department of Paediatrics,King Edward Medical College, Lahore. )
Shaukat Raza Khan  ( Department of Paediatrics,King Edward Medical College, Lahore. )


Apgar scores recorded at 5 minutes after birth for 807 newborns delivered during 1985, revealed that 3.3% had Apgar scores of 0-3 (severe asphyxia). Asphyxiated infants were more commonly of low birth weight (less than 2500 G) belonging to the poor income groups and those delivered by Caesarian Section (JPMA 38:217, 1988).


Birth asphyxia is probably the commonest cause of perinatal brain injury associated with high mortality and morbidity. In the evaluation of the newborn for evidence of asphyxia, the Apgar scoring system is utilized.1,2 A five-minute Apgar score of 7-10 is considered “normal”. Scores of 4,5 and 6 are not markers of high levels of risk of later neurologic dysfunction. An Apgar score of 0—3 at 5 minutes is associated with a 3-fold increased risk of cerebral palsy and indicates the possibffity of hypoxia3,4. Factors that may influence the Apgar score include pre­maturity, maternal sedation or analgesia, muscle disease, cerebral malformations and cardiores­piratory conditions, and therefore the validity of the Apgar score has been questioned in the diag­nosis of asphyxia in the premature infants5-8.
Utilizing the Apgar scoring system evalua­tion of the frequency of asphyxia was carried out in this study.


An independent observer, well-versed in the criteria used for the Apgar scoring systera and familiar with neonatal resuscitative techniques, was stationed in the delivery room of King Edward Medical College, hospital during 1985. Apgar score was carried out with special emphasis on the 5 minute score using stopwatch and pre-printed Apgar score cards (Table 1).

This was supplemen­ted with historical information about the mother (age, socioeconomic status, parity, level of ante­partum care). Information was also gathered on the newborn (height, weight, head circumference gestational age and congenital maiforalong with mations).


Of the 1000 consecutive deliveries moni­tored, complete information was available in 807 cases. Of these, a total of 27 (33%) had Apgar scores of 3 or less at 5 minutes and were thus termed severely asphyxiated.
Comparison of 27 asphyxiated newborns with the rest is given in Table- II.

Of the asphy­xiated group, 51% were delivered by Caesarian Section, as compared to 25% of the healthy group. Similarly, 95% of the healthy newborns were born at full term, compared to 70% in the asphyxiated group, and 30% of the infants in the asphyxiated group were of low birth weight in contrast to only in the healthy group. The difference in the two groups was statistically significant.
The possible etiological factors are given Table III.

Prolonged rupture of membranes (more than 24 hours) was the cause in 33% cases followed by cephalopelvic disproportion and ante­partum hemorrhage.
Of 27 asphyxiated newborns 19 could be followed to a maximum of 1 month age. Of these 47% cases died, 26% had neurological deficit and only 26% were apparently normal.


The present study utilized the Apgar scoring system to delineate cases of asphyxia.
This was not correlated with fetal scalp lactate level monitoring or cord blood pH because of lack of availability of these facilities9,10. The fre­quency of birth asphyxia in the present study was 3.3% which is much higher than in developed countries. In the USA11 it varies between 1.5-6/ 1000 live births while in Finland12 it was 2.2/ Multipara 21(78%) 685 (88%) 1000 live births in 1968-72, dropping to 0.3/1000
Primigravida6 (22%) 95 (12%) live births in 1978 — 1982. Birth asphyxia is one 10 (37%) 550 (71% )of the commonest cause of perinatal brain injury14 (51 %) 195 (25%)* associated with high mortality, and in survivors, 2 (7%)  35 (4%)  long-term neurological handicap6. It has been 10 shown that with persistently low Apgars (i.e. less than 3 at 20 mins) the mortality rises to 87% and the rate of cerebral palsy is as high as 57%3. 15 (56%) 558 (72%) Although postnatal causes are included in the etiology of asphyxia, it has been found that in most instances, oxygen deprivation of the fetus 12 (44%) 205 (26%)* occurs before delivery4. Of the 19 cases that could be followed to one month of age 9 (47%) died, and 5 (26%) showed some degree of neuro (Rs 1000/ month) Gestation F.T. L.B.W. <2500G PREM logical deficit.
It would seem appropriate, therefore, that _maximal attention be focussed on provision of a network of centers for antenatal care, with early and efficient utilization of referral of high risk pregnancies to designated tertiary care centers. These centers, with appropriate monitoring and intervention facilities can then help in lowering the high frequency of asphyxia and therefore the ensuing morbidity and mortality.


1. Apgar, V. A proposal for a new method of’ evaluation of the newborn infant. Curr. Res. Anesth. Analg., 1953; 32:260.
2. Apgar, V., Holaday, DA., James, L.S., Weisbrot, l.M. and Berrien, C. Evaluation of the newborn infant — second report. JAMA., 1985; 158 : 168.
3. Nelson, K.B. and Ellenberg, J.H. Apgar scores as predictors of chronic neurologic disability. Pediatrics, 198 1;68 : 36.
4. Myers, RE. and Adamson, K. Obstetric consi­derations of perinatal brain injury, in reviews in perinatal medicine. Edited by Scapelli, E.M. and Cosmi, E.V. New York, Raven Press, 1981, p. 222.
5. Catlin, E.A., Carpenter, M.W., Bran, B.S., Mayfield. S.R., Shaul, P.W., Goldsteir, M. and Oh, W. The Apgar score revisited ; influence of gestational age. J. Pediatr., 1986;5 :865.
6. Goldenberg, R.L., Huddleston, J.F. and Nelson, K.G. Apgar scores and umbilical arterial pH in preterm newborn infants. Am. J. Obstet. Gynecol., 1984; 149:651.
7. Desousa, S,W., John, R.W., Richards. B. and Milner. R.D.G. Fetal distress and birth scores in newborn infants. Arch. Dis. Child., 1975; 507 : 920.
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9. Smith, N.C., Soutter, W.P., Sharp, F., McColl, J. and Ford, 1. Fetal scalp blood lactate as an indicator of intrapartum hypoxia. Br. Obstet. GynaecoL, 1983; 90:821.
10. Vintzileos, A.M., Gaffney, S., Salinger, L.M., Kontopoulos, V.G., Campbell, WA. and Nochimson, DJ. The relationship among the fetal biophysical profile, umbilical cord pH, and Apgar scores. Am. J. Obstet. Gynecol., 1987; 157:627.
11. Volpe, JJ. Neurology of the newborn. Philadelphia, Saunders, 1981.
12. Tenovuo, A., Kero, P., Piekkala, P., Sillanpaa, M. and Erkkola, R. Advances in perinatal care and declining regional neonatal mortality in Finland 1968 1982. Acta Pediatr. Scand., 1986; 75 : 362.

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