VOL. 19, NO. 4, OCTOBER 2011 165 Pitsawong C. et al.

Risk Factors Associated with Birth Asphyxia in

Phramongkutklao Hospital
Thai Journal of Obstetrics and Gynaecology
October 2011, Vol. 19, pp. 165-171

OBSTETRICS
Ri sk Factors Associ ated wi th Bi rth Asphyxi a i n
Phramongkutklao Hospital
Chayasak Pitsawong MD*,
Prisana Panichkul MD**.
* Department of Obstetrics and Gynecology, Phramongkutklao Hospital, Bangkok, Thailand
**Maternal-Fetal Medicine Unit, Obstetrics and Gynecology, Phramongkutklao Hospital, Bangkok, Thailand
ABSTRACT
Objective: To determine the risk factors for birth asphyxia
Materials and Methods: After obtaining the approval from the Institutional Review Board, a
retrospective case-control study recruited 450 women who delivered at Phramongkutklao
Hospital between January 1, and December 31, 2009 were recruited by consecutive selection.
The study sample comprised 150 women who delivered newborns with an APGAR score at 1
minute of 7 or less, while the control comprised 300 women who delivered newborns with an
APGAR score at 1 minute more than 7. The risk factors for birth asphyxia were determined.
Result: The risk factors associated with birth asphyxia included moderate to thick meconium
(OR 5.51, 95% CI 2.58-11.77), breech presentation (OR 4.53, 95% CI 1.72-11.92), birth weight
< 2,500 grams (OR 2.46, 95% CI 1.4-4.29), sedation with morphine or pethidine (OR 2.29, 95%
CI 1.37-3.84) and preterm delivery (OR 2.08, 95% CI 1.24-3.51).
Conclusion: Most risk factors associated with birth asphyxia can be prevented. Therefore the
correct, quick and accurate diagnosis and proper management can reduce severe birth asphyxia.
Keywords: birth asphyxia, risk factor
Introduction
Asphyxia is a condition that occurs when there
is an impairment of blood-gas exchange, resulting in
hypoxemi a (l ack of oxygen) and hypercapni a
(accumulation of carbon dioxide). The combination of
the decrease in oxygen supply (hypoxia) and blood
supply (ischemia) results in a cascade of biochemical
changes inside the body, whose events lead to neuronal
cell death and brain damage. Continuous asphyxia will
also lead to multiple organ systems dysfunction. Thus,
birth asphyxia is a serious clinical problem worldwide
and contributes greatly to neonatal mortality and
morbidity
(1)
The World Health Organization (WHO)
estimates that globally, between four and nine million
newborns suffer birth asphyxia each year. Birth
asphyxia leads to an estimated 1.2 million deaths and
about the same number of infants who develop severe
consequences, such as epilepsy, cerebral palsy, and
developmental delay. WHO estimates for global
neonatal deaths caused by birth asphyxia are 29%
(2)
.
VOL. 19, NO. 4, OCTOBER 2011 166 Thai J Obstet Gynaecol
Birth asphyxia can be caused by events that have their
roots in either the antepartum or intrapartum and involve
fetal factors or combinations thereof.
The WHOs classifcation of diseases according
to ICD 10 (The International Classifcation of Disease
10) defnes birth asphyxia where the APGAR score at
1 minute is less than or equal to 7 by the two levels.
Severe birth asphyxia is defned where the APGAR
score at 1 minute is 0-3 and slight or moderate (mild or
moderate birth asphyxia) is defned where the APGAR
score at 1 minute is 4-7
(3)
. Other risk factors associated
with birth asphyxia were moderate to thick meconium-
stained amniotic fuid, breech presentation, birthweight
<2,500 g, intrapartum sedation with morphine or
pethidine and preterm delivery.
According to the Tenth Thai National Health
Development Plan, birth asphyxia should be reduced
to less than 30 per 1,000 live births. However, the
incidence of birth asphyxia in Phramongkutklao
Hospital is higher. In 2008 and 2009, the incidence of
birth asphyxia was 100.76 and 90.20 per 1,000 live
births, respectively.
Therefore, we conducted this study to determine
the risk factors associated with birth asphyxia in
Phramongkutklao Hospital, to be used as basic
information for preventing birth asphyxia in the future.
Materials and Methods
After approved by the Institutional Review Board
of the Royal Thai Army Medical Department, a
retrospective case-control study was conducted. All
parturients with a gestational age of 28 weeks or more
or fetal birth weight of 1,000 g or more were recruited.
However, those who delivered fetuses with a major
congenital anomaly or women with intrauterine fetal
death or a stillbirth were excluded. The data were
collected from January 1, to December 31, 2009 at
Phramongkutklao Hospital. A total of 2,306 deliveries
occurred during the study period. All pregnant women
who delivered newborns with an APGAR score at 1
minute of 7 or less were included in the study group
and the control group comprised pregnant women who
delivered newborns with an APGAR score at 1 minute
> 7. The sample size calculation was determined by
two proportion mean formula
(4)
. Method for selecting
the population in each group was consecutive selection
with the ratio of 1 to 2 between study and control groups,
i.e., 150 cases 300 cases were required in the study
and control group, respectively.
The collected data were divided into three groups;
maternal, intrapartum and neonatal factors. Maternal
or antepartum factors included maternal age, gestational
age, hypertension, diabetes mellitus and antenatal clinic
(ANC) follow-up less than 4 visits. Intrapartum factors
comprised breech presentation, chorioamnionitis,
oligohydramnios, meconium in amniotic fuid, premature
rupture of membranes more than 18 hours, sedation
with morphine or pethidine and route of delivery. In
addition, fetal factors consisted of intrauterine growth
restriction (IUGR), twin pregnancy, birthweight less than
2,500 grams, preterm delivery and fetal distress.
The demographic data was determined by mean
and percentage. Student t-test was used to compare
the significant contributing factors as appropriate.
Association between birth asphyxia and risk factors
was determined by logistic regression. The potential
risk factors were determined by multiple logistic
regression. The signifcant level was defned as a
p-value < 0.05. The percentage of risk factors
associated with birth asphyxia at different intensity
levels was estimated with odds ratio and 95%
confdence interval (CI).
Result
The demographic data of the recruited women
are shown (Table 1). The average age in the study
group and control group was 28.29 and 28.39 years,
respectively. The gestational age of the study group
was 38.07 weeks and of the control group was 37.35
weeks. The primigravidarum in the study group
comprised 80 cases and 132 cases in the control group
whereas multigravidarum comprised 70 cases and
168 cases, respectively. Maternal or antepartum factors,
of the study group compared with those of the control
group are shown (Table 2).
Breech presentation moderate to thick meconium-
VOL. 19, NO. 4, OCTOBER 2011 167 Pitsawong C. et al. Risk Factors Associated with Birth Asphyxia in
Phramongkutklao Hospital
stained amniotic fuid, as well as intrapartum sedation
with morphine or pethidine were signifcantly associated
with birth asphyxia as shown (Table 3).
Regarding fetal factors, fetal birth weight less
than 2,500 grams (OR 2.40, 95% CI 1.42-4.04) and
preterm delivery (OR 2.08, 95% CI 1.24-3.51) were
signifcantly related to birth asphyxia as demonstrated
in Table 4. However, intrauterine growth restriction, twin
pregnancy and diagnosis of fetal distress were not
signifcantly related to birth asphyxia.
Signifcant risk factors for birth asphyxia were
further analyzed by multiple logistic regression model.
Factors that were independently associated with birth
asphyxia included moderate to thick meconium-stained
amniotic fuid (OR 5.51, 95% CI 2.58-11.77), breech
presentation (OR 4.53, 95% CI 1.72-11.92), birthweight
less than 2,500 grams (OR 2.46, 95% CI 1.40-4.29),
sedation with morphine or pethidine (OR 2.29, 95% CI
1.37-3.84) and preterm delivery (OR 2.08, 95% CI 1.24-
3.51) (Table 5).
Table 1. Demographic data (mean/percentage)
Demographic data Study group(n=150) Control group (n=300)
1. Maternal age (years) 28.29 28.33
2. Gestational age (weeks) 38.07 37.35
3. Primigravidarum 80 132
4. Multigravidarum 70 168
Table 2. Antepartum factors
Maternal factors
Study group
(n=150)
Control group
(n=300)
OR (95% CI) p-value*
n % n %
1. Maternal age 17 years 9 6.04 22 7.33 0.79 (0.35-1.77) 0.57
2. Maternal age 35 years 16 10.74 38 12.67 0.81 (0.43-1.51) 0.52
3. ANC < 4 visits 1 0.67 5 1.67 0.39 (0.04-3.44) 0.40
4. Primigravidarum 80 53.02 132 44.00 1.43 (0.96-2.13) 0.07
5. Multigravidarum 70 46.98 168 56.00 1.00 (0.96-2.13) 0.07
6. Hypertension 9 6.04 14 4.67 1.31 (0.55-3.10) 0.53
7. Diabetes mellitus 9 6.04 13 4.33 1.41 (0.59-3.39) 0.43
*Statistically signifcant if p <0.05
VOL. 19, NO. 4, OCTOBER 2011 168 Thai J Obstet Gynaecol
Table 3. Intrapartum factors
Intrapartum factor
Study group
(n=150)
Control group
(n=300)
OR (95% CI) p-value*
n % n %
1. Breech presentation 14 9.40 8 2.67 3.78
(1.55-9.23)
(0.28-14.53)
(0.33-6.88)
(0.13-1.18)
(2.12-9.08)
(0.05-4.51)
(1.14-2.97)
0.003
2. Chorioamnionitis 2 1.34 2 0.67 2.02 0.48
3. Oligohydramnios 3 2.01 4 1.33 1.52 0.58
4. Mild meconium 4 2.68 22 7.33 0.40 0.09
5. Moderate to thick meconium 24 16.11 12 4.00 4.39 0.001
6. PROM > 18 hours 1 0.67 4 1.33 0.50 0.53
7. Sedation 68 45.64 106 35.33 1.84 0.01
8. Vacuum or forceps extraction 10 6.71 10 3.33 2.18 (0.87-5.42) 0.09
9. Cesarean section 46 30.87 87 29.00 1.15 (0.74-1.78) 0.51
*Statistically signifcant if p <0.05
Table 4. Fetal factors
Fetal factors
Study group
(n=150)
Control group
(n=300)
OR (95% CI) p-value*
n % n %
1. IUGR 1 0.67 3 1.00 0.66 (0.06-6.48) 0.72
2. Twin pregnancy 7 4.70 8 2.67 1.79 (0.63-5.06) 0.26
3. Birthweight < 2,500 grams 35 23.49 34 11.33 2.40 (1.42-4.04) 0.001
4. Preterm delivery 33 22.15 36 12.00 2.08 (1.24-3.51) 0.006
5. Fetal distress 12 8.05 11 3.69 2.28 (0.98-5.31) 0.055
*Statistically signifcant if p <0.05
Table 5. Multiple logistic regression analysis
Risk factors OR (95% C.I) p-value*
1. Moderate to thick meconium
5.51 (2.58-11.77) <0.001
2. Breech presentation
4.53 (1.72-11.92) 0.002
3. Birthweight < 2,500 grams
2.46 (1.40-4.29) 0.002
4. Sedation with morphine or pethidine
2.29 (1.37-3.84) 0.002
5. Preterm delivery 2.08 (1.24-3.51) 0.006
*Statistically signifcant if p <0.05
VOL. 19, NO. 4, OCTOBER 2011 169 Pitsawong C. et al. Risk Factors Associated with Birth Asphyxia in
Phramongkutklao Hospital
Discussion
Risk factors of birth asphyxia in this study
included preterm delivery, which was 2.08 times that
of the control group. Similar results were reported in
prior studies
(5-10)
. Preterm babies have a variety of
morbidities, largely due to organ system immaturity,
especially lung immaturation causing respiratory
distress syndrome (RDS) in infants after birth. In the
case of preterm labor, it is important to make a diagnosis
and fnd the cause to provide appropriate management
to prevent preterm delivery.
On t he cont rar y, ot her factors such as
chorioamnionitis, oligohydramnios, route of delivery,
PROM longer than 18 hours, IUGR, fetal distress and
twins were found to be the risk factors of birth asphyxia
in previous studies
(5,7)
but did not affect the incidence
of birth asphyxia in the present study. Possible
explanations included the small sample size contributed
to the observed negative correlation of this factor and
also because of the different studied population.
Maternal age and parity were not associated
with birth asphyxia in this study, similar to those in
the study of Praditsathawong S, et al
(11)
. The present
study reaffirms that most birth asphyxia results are
strongly associated with pregnancy factors such as
moderate to thick meconium-stained amniotic fuid,
breech presentation, fetal birth weight < 2,500 grams,
intrapartum sedation with morphine or pethidine and
preterm delivery.
The strongest risk factor associated with asphyxia
in this study was moderate to thick meconium-stained
amniotic fuid. This factor was associated with asphyxia
was 5.51 times higher than clear amniotic fuid which
was the same as in previous studies
(1,5-7,12)
. Those with
mild or thin meconium-stained amniotic fuid were not
found to relate to birth asphyxia in this study. In healthy,
well-oxygenated fetuses, this diluted meconium is
readily cleared from the lungs by normal physiological
mechanisms. In some cases, however, the inhaled
meconium is not cleared, and meconium aspiration
syndrome results. It can occur after normal labor, but
is more likely when the meconium is thick
(13)
. If the
meconium-stained amniotic fluid was presented,
immediate endotracheal meconium suction after
delivery could reduce meconium aspiration syndrome.
Breech presentation exhibited a 4.53 times higher
risk of birth asphyxia than other presentations similar to
previous studies
(5,8,9,12)
. The assumption is that breech
presentation has a high rate of umbilical cord prolapse,
head entrapment, birth trauma and also increased
perinatal mortality. This result was supported by the
study of Hannah ME and colleagues
(14)
comparing the
planned caesarean section to the planned vaginal birth
for breech presentation at term revealing that perinatal
mortality, neonatal mortality, or serious neonatal
morbidity was significantly lower for the planned
caesarean section group than for the planned vaginal
birth group. Also, the meta-analysis study of infant
outcomes after breech delivery by Gifford DS et al
(15)

and Su M et al
(16)
suggests an increased risk of injury
and injury or death after a trial of labor.
Risk of asphyxia in fetal birth weight less than
2,500 grams was 2.46 times more at risk compared
with fetal birth weight more than 2,500 grams similar
to previous reports
(12,17-19)
. Low birthweight (LBW)
infants are often related to maternal complications such
as anemia, hypertension, and diabetes that present
preconception or antepartum. To decrease the risk
of LBW, in the case of previously described maternal
conditions, these pregnant women should be advised to
take care of themselves or try to cease or decrease their
risky activities that cause LBW fetuses (e.g., smoking,
alcohol consumption, etc.).
Intrapartum sedation with morphine or pethidine
also had signifcant association with birth asphyxia,
as demonstrated in previous studies
(5-7,9,10)
. These
opioids readily cross the placenta and for pethidine -
its half-life in the newborn is approximately 13 hours
or longer
(20)
. Narcotics used during labor may cause
newborn respiratory depression with the depressant
effect in the fetus that follows closely behind the peak
maternal analgesic effect. However, parental use of
these narcotics during labor is optional for pain relief.
The appropriate drug selection and appropriate time of
administration with early recognition of problems and
concerns after use is important.
VOL. 19, NO. 4, OCTOBER 2011 170 Thai J Obstet Gynaecol
Conclusion
Most risk factors associated with birth asphyxia
can be prevented. Therefore, the timely and accurate
diagnosis and proper management can reduce severe
birth asphyxia.
Acknowledgments
We woul d l i ke to t hank t he Di rector of
the Department of Obstetrics and Gynecology,
Phramongkutklao Hospital for the wholehearted
support of this study. We also appreciate all the helpful
recommendations and valuable information of all the
staff of our department. Finally, We are very grateful
for all of the patients and the nurse staffs for their
cooperation.
References
1. Adcock LM, Stark AR. Systemic effects of perinatal
asphyxia. Up-To-Date version 18.3. [Internet] 2010
[updated 2010 August 23; cited 2010 Dec 15]. Available
from: URL: http://www.uptodate.com.
2. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths:
When? Where? Why? Lancet 2005;365:891-900.
3. The International Classifcation of Disease 10 Revision
Thai Modifcation Volume 2. Ministry of public health
Bureau of policy and strategy office of the permanent
secretary, second ed 2006; 265.
4. Lertsakornsiri M. Risk factors associated with birth
asphyxia in Lampang Hospital. Lampang Med 2003; 28:
1-11.
5. Wongsang N. Risk factors associated with birth asphyxia
in Samutprakarn Hospital. Bull Dept Med Serv 2000; 25:
78-86.
6. Taweethammasathit T. Risk factors associated with
APGAR score 7 at birth in Mukdahan Hospital. Medical
J of Ubon Hospital 2004; 25: 273-82.
7. 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:
1381-90.
8. Chandra S, Ramji S, Thirupuram S. Perinatal asphyxia:
multivariate analysis of risk factors in hospital births.
Indian Pediatr 1997; 34: 206-12.
9. Kerdarunsree A. Prevalence and factors associated with
birth asphyxia in Ratchapiphat Hospital. Vajira Med J
2004; 48: 79-86.
10. Milsom I, Ladfors L, Thiringer K, Niklasson A, Odeback
A, back A, Thornberg E. Infuence of maternal, obstetric
and fetal risk factors on the prevalence of birth asphyxia
at term in a Swedish urban population. Acta Obstet
Gynecol Scand 2002;81:90917.
11. Praditsathawong S, Nimitsurachat S. Risk factor
associated with low APGAR score of new born at 1
minute. Thai J Obstet Gynaecol 2000; 12: 277-82.
12. Chen ZL, He RZ, Peng Q, Guo KY, Zhang YQ, Yuan HH,
et al. Prenatal risk factors for neonatal asphyxia: how risk
for each? Zhongguo Dang Dai Er Ke Za Zhi 2009; 11:
161-5.
13. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC,
Rouse DJ, Spong CY, editors. Williams Obstetrics.
23rded. New York: McGraw-Hill; 2005. p. 605-45.
14. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED,
Saigal S, Willan AR. Planned caesarean section versus
planned vaginal birth for breech presentation at term:
a randomised multicentre trial. Term Breech Trial
Collaborative Group. Lancet 2000 ; 21; 356(9239):1375-
83.
15. Gifford DS, Morton SC, Fiske M, Kahn K. A meta-analysis
of infant outcomes after breech delivery. Obstet Gynecol
1995; 85:1047-54.
16. Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E,
et al. Factors associated with adverse perinatal outcome
in the Term Breech Trial. Am J Obstet Gynecol 2003 ;189:
740-5.
17. Panichwattana C, Thammadee S, Khemkhang T. Factors
infuenced birth asphyxia at Uttaradit Hospital. Region 8
Med J 2000; 8: 53-66.
18. Pajjokkhuppati L. Obstetric risk factors influenced
APGAR score 7 at 1 minutes after birth and the effect to
fetus in Suratthanee Hospital. Region 11 Med J 2002;16:
21-33.
19. Jittawarhodome T. Birth asphyxia in Satul Hospital.
Region 12 Med J 2545;13: 43-54.
20. American College of Obstetricians and Gynecologists:
Obstetric analgesia and anesthesia. Int J Gynaecol
Obstet 2002;78:321-35.
VOL. 19, NO. 4, OCTOBER 2011 171 Pitsawong C. et al. Risk Factors Associated with Birth Asphyxia in
Phramongkutklao Hospital

,
:
:
450
consecutive selection 1 2552 31 2552 450
2 (APGAR < 7) 150 (APGAR > 7) 300
: (OR 5.51,
95% CI 2.58-11.77), (OR 4.53, 95% CI 1.72-11.92), < 2,500 (OR 2.46, 95%
CI 1.4-4.29), morphine pethidine (OR 2.29, 95% CI 1.37-3.84) 37
(OR 2.08, 95% CI1.24-3.51)
: