A newborn who fails to establish regular breathing and appears blue and/or pale is likely to have asphyxia. Anticipate asphyxia in all high risk pregnancies or if there is irregular foetal heart, foetal bradycardia or tachycardia and meconium
stained liquor during labour. Occasionally asphyxia occurs unexpectedly.

  • All persons conducting deliveries should be able to resuscitate a baby at birth. Always be prepared to resuscitate.

Clinical Features

  • Assessment is best done following the ABC as in paediatric emergencies
  • APGAR scoring can also be used for assessing the degree of asphyxia.


  • Management is dependent on the APGAR of the baby. The management recommended at the various APGAR scores is indicated below:
    • APGAR score 7–10: None. Do not suction baby.
    • APGAR score 5–6: Give oxygen.
    • APGAR score 0–4: Initiate resuscitation with bag and mask.
  • If the mother had received pethidine: Give naloxone 0.01mg/kg/IV STAT.

APGAR Scoring

  • A: Appearance or colour
  • P: Pulse rate
  • G:Grimace or response to some stimulus
  • A: Activity (muscle tone)
  • R:Respiration

APGAR scoring

Clinical features Score
0 1 2
Heart rate (per minute) Absent Less than 100 Over 100
Respiration effort Absent Irregular, slow Regular
Muscle tone Limp (floppy) Some flexion of arms, legs Well flexed,
active motion
Reflex irritability (nasal catheter) No response Some motion, grimace Cries
Colour Blue, pale Pink body, blue extremities Completely pink

Harmful practices in a baby who is not breathing include slapping the baby, holding baby upside down, and pouring cold water. These should not be practiced. The act of drying the baby is enough stimulation.

After resuscitation refer the baby to a facility that can deal with complications.
Keep the baby warm throughout the journey by using Kangaroo Mother Care.


The following complications are known to occur:

  • Convulsions
  • Apnoea or irregular breathing
  • Respiratory distress
  • Poor feeding
  • Floppiness
  • Cerebral palsy if still neurologically abnormal at 1 week of age.
  • Admit all babies with complications.


  • Convulsions:
    • These tend to be atypical and therefore easily missed. They may involve the face (e.g., chewing movements, facial twitches), or twitching of the limbs. They can partial or generalized. Most often they appear within 24 hours of birth.
    • Treatment: Give IV phenobarbitone. Loading dose 20mg/kg/dose. Maximum for 24 hours 30mg/kg. Always give maximum dose before giving another anticonvulsant if the convulsions are not controlled. Addition of phenytoin
      may sometimes be necessary given in the same doses as phenobarbitone.
  • Breathing problems:
    • Give oxygen as needed.
  • Feeding:
    • Use NG tube if needed and baby is able to tolerate enteral feeds. Otherwise give IV fluids.
  • Floppiness and neurological damage:
    • Start physical therapy as soon as baby stabilizes. Mother to be shown how to feed the baby, how to and stimulate and do passive movements. This may need to be continued after discharge (see cerebral palsy). Counsel the mother all the time. She needs a lot of support and understanding.