Perinatal asphyxia is the leading cause of neonatal morbidity and mortality. In institutional delivery incidence is 5% and accounts for 24.3% of neonatal deaths [1]. It is the greatest burden and fifth leading cause of death in under 5years of age [2]. Cerebral palsy is one of the most costly neurologic disabilities occurred due to hypoxic-ischemic event because of its frequency (2/1000 births) and lifelong disability, huge burden to society [3,4].

The term “asphyxia” is derived from the Greek language which means “stopping of the pulse”.According to World Health Organization, birth asphyxia is “inability to start and manage breathing during childbirth” and depends on Apgar score, an Apgar score of <7 at one moment of life is suggestive of birth asphyxia [5]. Apgar scores are a valuable tool for future events in babies with perinatal asphyxia [6,7].

According to ACOG and AAP Criteria for diagnosis for asphyxia before birth are [8,9]:

• Delayed metabolic or blended acidemia (pH <7.0 on line blood vessel blood test).
• Determination of an Apgar score of <3 for 5 min or more.
• Clinical neurologic appearance as seizures, hypotonia, trance state or HIE in the prompt neonatal period.
• Proof of multi-organ framework brokenness in the quick neonatal period.

According to the World Health Organization (WHO) report,four million develop birth asphyxia, and newborn asphyxia condition depends on the severity and its consequences, such as epilepsy, cerebral palsy and developmental delay [4,5]. This is the reason, mortality and morbidity both are very significant and worrisome. Birth asphyxia related to events that are either the antepartum, the intrapartum, or the postpartum periods or combination thereof [10].

The current study was therefore planned to evaluate related factors and short term outcome of asphyxiated neonates born intramurally where standard management protocol was started immediately after birth and extramurally at home or another hospital from where the asphyxiated neonate was referred and transported to a facility equipped with NICU causing a delay in the start of standard management protocol

In the present study, 71% of extramural babies admitted to the neonatal ward after 6 hours (Table 1). This is showing delayed or inaccurate identification of the gravity of the situation, inaccurate diagnosis and in many cases delayed referral and transport to an appropriate referral centre.

All term neonates 242(58.3%) were HIE II followed by 121(29.1%) were HIE-III and rest 52 (12.5%) were HIE-I cases.HIE III was found in 81(66.6%) extramural neonates f/b 40(33.4%) intramural neonates with a statistical significance (P=0.001).Male babies were marginally higher than female (58.1% males versus 41.9% female.with a statistically insignificant (P=0.510535). The number of caesarean deliveries was higher in the intramural group (47.5%) as compared to extramural group (26.2%)(Table 1).

Table-1: Clinical profile of newborns with birth asphyxia.

The number of normal vaginal deliveries were higher in the extramural group(65.3%) as compared to intramural group(44.7%)remaining 7% of intramural and 8.4% of extramural delivered instrumentally with statistical significant(p=.0001)(Table 1).

Fig-1: Comparison of risk factors and perinatal events between the intramural and extramural group.

In the present study, various factors and event are associated with birth asphyxia.

75% extramural newborn who admitted after 6 hours and 60% who admitted within 6 hours of birth had neurological disability on discharge and statistically significant (P .0047)(Figure 3).

Table-2: Outcome in terms of survival of term neonates with birth asphyxia.

Table-3: Outcome in terms of survival of asphyxiated extramural neonates.

In the present study mortality rate in extramural babies were 35.67% and intramural babies were 13.47%(Table 2). 38.14% of babies who admitted after 6 hours of birth were died as compared to before 6 hours of birth 26% of babies died which is not statistically significant(0.0591)(Table 3).

Asphyxiated Extramural neonates delivered in Tertiary hospital (25%) and PHC (25%) followed by FRU (18%), Private hospital (10%) and home delivery (12.8%). Most of them arrived after 6 hours of birth (Figure 4).

Fig-4: Place of delivery of asphyxiated extramural neonates.

Asphyxiated extramural newborn mostly transported through ambulance (93%).but when they brought to our hospital condition of newborn deteriorated due to improper method of transportation, untrained staff for neonatal transportation (Table 4).

Table-4: Transportation of extramural term newborn with asphyxia.

2/3 of HIE III were extramural and 1/3 were intramural with a statistical significance (P=0.001). the percentage of HIE stage III was statistically higher in the Extramural group who admitted after 6 hours when compared to the extramural group who admitted within 6 hours (p<0.05).

Neonates with the feature of HIE III showing the severity of birth asphyxia, poor management,delay in diagnosis,delay in referral,a grave prognosis which was more seen in extramural neonates. Similar findings are seen in Kriti Mohan et al [7] in term neonates the maximum number of neonates had features of stage II (54%) while 31% and 14% had stage I and III features respectively [16].

In the present study number of caesarean deliveries were higher in the intramural group.The number of normal vaginal deliveries were higher in the extramural group (65.3%) with statisticalsignificant (p=.0001) This is similar to study done by Memon et al [14] while other studies have shown75% and 51%[ deliveries by caesarian section [17,18].

Since our centre is a tertiary referral centre and caters to a large percentage of complicated obstetrical cases, the number of modes of delivery other than vaginal delivery was much higher in the intramural group as compared to the extramural group. In general, the percentage of caesarean deliveries was higher in babies who were born asphyxiated.

This implies that much more early intervention was required in these cases. If the extramural neonates who were born asphyxiated by vaginal delivery, had a chance of an early intervention/termination of labour the n prognosis will be good.

In the present study, various factors and event are associated with birth asphyxia. Meconium stained liquor and prolonged labour are one of the most common factors or event associated with asphyxia in both groups. showing no statistical significance (p>.056). In Saranappa at al40% had a history of meconium-stained liquor, 11.66% had PROM, 13.33%hadPIH and 5% has cord prolapsed [18].

Extramural neonates especially who admitted after 6 hours of birth also have a higher requirement anticonvulsant,vasopressor,oxygenation,ventilator support in terms of both number and duration.

The neurological examination was abnormal in most of the neonates who survived at discharge in the group who were admitted after the first 6hours of life (n=19 out of 37 discharged neonates) in both

The study has shown the significant differences that account in the antenatal and perinatal profile, perinatal management and resuscitation, postnatal management, morbidity, mortality and neurodevelopment outcome of extramurally delivered neonates in a peripheral health centre or at home as compared to intramurally delivered neonates in a tertiary level institute. For improvement of their outcome infrastructure, skilled manpower, early referral with well-equipped transport unit, well equipped NICU appropriate guidelines is required. Still, there is large no. of home delivery in our state although the health care system through Janani Surakshayojana providing lots of facilities and incentives to institutional deliveries.

This study helps make Strict guidelines for early detection of risk factors, early referral of these high-riskpregnancies in-utero, the timely intervention of these high-risk pregnancies and advanced NICU care can help inreducing the occurrence of birth asphyxia and hence mortality and morbidity in neonates.

Dr. Yogita Rathiwrote the protocol, conceptualized, analysed data, prepared and finalized the manuscript.

Author acknowledges the supporting staff of the Department of Paediatrics and thePediatricsresident doctors who helped and support during the study period.