Asphyxia at birth continues to be a significant contributor to neonatal morbidity and mortality, especially in low- and middle-income countries where access to skilled obstetric care, timely neonatal resuscitation, and advanced intensive care units may be limited [1]. It is caused by the inability of the newborn to ventilate and/or oxygenate at birth, causing an accumulation of CO₂, metabolic acidosis, and cellular damage. The clinical effects depend on the degree and length of hypoxia and can range from mild respiratory depression to life-threatening multi-organ failure and death. It is noted that the perinatal period is a time when the central nervous system is especially susceptible to hypoxic-ischemic injury [2]. Hypoxic-ischemic encephalopathy is one of the most serious complications of birth asphyxia and can manifest as impaired consciousness, feeding problems, abnormal muscle tone, poor neonatal reflexes, respiratory dysfunction, and convulsions. In severe cases, it can lead to coma and respiratory failure and cause death [3]. Apart from neurological damage, an asphyxic birth can damage the cardiovascular, renal, respiratory, hepatic, gastrointestinal and haematological systems, due to the systemic effects of prolonged lack of oxygen [4]. Several maternal, obstetric and neonatal factors have been linked with birth asphyxia. Maternal-related factors may be hypertension during pregnancy, anemia, diabetes, infection, and poor ante-natal care. Obstetric factors such as prolonged or obstructed labor, premature rupture of membranes, meconium-stained amniotic fluid, placental abruption, abnormal fetal presentation, cord prolapse, and emergency operative delivery may compromise fetal oxygenation [5]. Neonatal factors such as being premature, low birth weight, intrauterine growth restriction, congenital abnormalities, and difficulty transitioning to the outside world may further increase the risk for resuscitation and intensive care after birth [6]. Birth asphyxia is usually diagnosed by a combination of clinical and biochemical features, rather than on any single parameter. Supporting the diagnosis may be Apgar scores, need for extended resuscitation, evidence of metabolic acidosis, neurological abnormalities, or dysfunction of one or more organ systems [7]. It is important to identify the affected neonates early, as resuscitation and post-resuscitation care can minimise secondary injury if done in time. Therapeutic hypothermia is an important neuroprotective intervention in moderate-to-severe HIE neonates, which is initiated within the recommended therapeutic window [8]. Asphyxial injury may involve any organ system, but hypoxic ischemic encephalopathy (HIE) is the most serious sequelae clinically. Sarnat and Sarnat suggested a useful tool to evaluate the severity of suspected HIE in neonates [9]. The longterm effects of birth asphyxia are permanent neurodevelopmental abnormalities such as cerebral palsy, epilepsy, and intellectual disability. Neonates with birth asphyxia often end up being admitted to the neonatal intensive care unit for the therapy of breathing issues, seizures, metabolic derangements, cardiovascular instability, nutritional support, and rigorous neurological follow-up [10]. The severity of initial hypoxia, gestational age, birth weight, hypoxic-ischemic encephalopathy, multiorgan involvement, availability of trained personnel, and timing of resuscitative and supportive interventions influence outcomes. Many babies born with severe asphyxia may have long-term problems with their brain development, such as cerebral palsy, epilepsy, intellectual disability, hearing loss and developmental delay [11]. Objective To calculate the proportion of neonates admitted to the NICU with birth asphyxia and to characterise the neonatal features, mortality trends, length of stay and short-term outcomes following birth asphyxia.

This was a cross-sectional study conducted in the Neonatal Intensive Care Unit (NICU) in Koppal Institute of Medical Sciences (KIMS), Koppal, Karnataka, India from 1st January 2026 to 31st January 2026. A total of 270 neonates who were admitted to the NICU were enrolled during the study period using non-probability consecutive sampling. To participate in the study, all neonates (0-28 days old) admitted to the NICU were eligible regardless of sex, gestational age, or mode of delivery. All neonates admitted to the NICU who had the full clinical record of the mother, obstetric, delivery, and neonatal records were included for the study period. Neonates who had major congenital malformations, chromosomal abnormalities, congenital infections, or who had incomplete clinical and obstetric records were excluded. Birth asphyxia was determined based on the documented clinical diagnosis of failure to establish or sustain good respiration at birth, which included low Apgar scores, need for neonatal resuscitation, respiratory depression and/or neurologic signs suggestive of hypoxic-ischemic injury. Data Collection A structured proforma was used to collect data from the NICU records, maternal obstetric records, delivery notes, and the neonatal case files. All neonates signed up for the study period had information recorded. History of the baby was recorded as sex, gestational age, birth weight, place of delivery, mode of delivery, Apgar scores at 1 and 5 minutes, need for resuscitation, type of resuscitation, age at admission to the NICU and need for respiratory support. According to clinical information, neonates were classified as preterm, term, or post term, and as low birth weight or not, based on birth weight. Maternal and obstetric factors were maternal age, parity, adequacy of antenatal care, hypertension, maternal anemia, diabetes mellitus, prolonged or obstructed labor, preterm rupture of membranes, meconium-stained amniotic fluid, placental complications, abnormal fetal presentation, fetal distress, and mode of delivery. These factors were evaluated for their association with birth asphyxia. Clinical symptoms of neonates with birth asphyxia were respiratory distress, poor feeding, altered level of consciousness, abnormal muscle tone, depressed neonatal reflexes, seizures and need for respiratory or cardiovascular support. Complications reported at admission to the NICU were hypoxic-ischemic encephalopathy, respiratory failure, seizures, acute kidney injury, shock, metabolic disturbances, and multiorgan dysfunction. The main outcome was the incidence of birth asphyxia in the neonates admitted to NICU during the study period. Secondary outcomes consisted of associated maternal, obstetric and neonatal risk factors, clinical manifestations, complications, need for respiratory support, length of NICU stay and short term neonatal outcome. Outcomes included discharged/recovered, referred to another healthcare facility, left against medical advice, and died during admission. Statistical Analysis The data was entered into Microsoft Excel then analyzed using SPSS statistical software. Gestational age, birth weight, Apgar score and the duration of the NICU stay were quantitative variables and were presented as mean ± standard deviation or as median with interquartile range depending on the distribution of data. Categorical variables were displayed as frequencies and percentages. The Chi-square test or Fisher's exact test was used to determine the association between birth asphyxia and maternal, obstetric, and neonatal factors depending on the data. Independent-samples t-test was used to compare continuous variables. The p value was considered statistically significant when < 0.05

A total of 270 neonates were managed in the Neonatal Intensive Care Unit during the study period. Of these, 237 (87.8%) were discharged, 26 (9.6%) expired, 4 (1.5%) were referred to another facility, and 3 (1.1%) left against medical advice. The subsequent demographic and admission-profile analysis included 244 neonates with non-fatal outcomes. Among 244 neonates, 139 (56.97%) were male and 105 (43.03%) were female. Most were inborn, 151 (61.9%), while 93 (38.1%) were outborn. Full-term neonates constituted the majority, 146 (59.8%), followed by preterm neonates, 90 (36.9%), and post-term neonates, 8 (3.3%). Gestational age was 37 to <42 weeks in 146 (59.8%) neonates, while 49 (20.1%) were between 34 and <37 weeks. Regarding admission weight, 115 (47.1%) weighed ≥2500 g and 107 (43.9%) weighed 1500–2499 g, whereas only 8 (3.3%) weighed <1000 g. Most neonates, 160 (65.6%), were admitted within the first day of life, followed by 59 (24.2%) between 1 and 3 days. Table I. Demographic and admission characteristics of neonates (n=244) Variable n (%) Sex Male 139 (56.97) Female 105 (43.03) Admission source Inborn 151 (61.9) Outborn 93 (38.1) Maturity Preterm 90 (36.9) Full term 146 (59.8) Post-term 8 (3.3) Gestational age <28 weeks 5 (2.0) 28 to <32 weeks 18 (7.4) 32 to <34 weeks 18 (7.4) 34 to <37 weeks 49 (20.1) 37 to <42 weeks 146 (59.8) ≥42 weeks 8 (3.3) Weight on admission <1000 g 8 (3.3) 1000–1499 g 14 (5.7) 1500–2499 g 107 (43.9) ≥2500 g 115 (47.1) Age on admission <1 day 160 (65.6) 1–3 days 59 (24.2) 4–7 days 14 (5.7) 8–14 days 8 (3.3) ≥15 days 3 (1.2) Perinatal asphyxia was the leading specific indication, present in 44 (18.0%), followed by low birth weight <1800 g in 38 (15.6%) and respiratory distress in 35 (14.3%). Table II. Treatment outcomes and duration of NICU stay (n=270) Variable n (%) / Value Treatment outcome Discharged 237 (87.8) Expired 26 (9.6) Referred 4 (1.5) LAMA 3 (1.1) Duration of NICU stay <1 day 7 (2.6) 1–3 days 93 (34.4) 4–7 days 112 (41.5) >7 days 58 (21.5) Mean duration of stay, days 5.97 Mortality was higher among males than females, 17 (12.2%) versus 9 (8.6%), and among facility-referred outborn neonates compared with inborn neonates, 15 (16.3%) versus 11 (7.3%). Preterm neonates had markedly higher mortality than full-term neonates, 18 (20.0%) versus 8 (5.5%). Mortality increased substantially with decreasing gestational age, reaching 4 (80.0%) among neonates born before 28 weeks and 10 (55.6%) among those born at 28 to <32 weeks, compared with 8 (5.5%) among term neonates. Table III. Mortality according to neonatal characteristics Variable Admissions, n Mortality, n (%) Overall 244 26 (10.7) Sex Male 139 17 (12.2) Female 105 9 (8.6) Admission source Inborn 151 11 (7.3) Outborn, facility referral 92 15 (16.3) Outborn, community referral 1 0 (0.0) Maturity Preterm 90 18 (20.0) Full term 146 8 (5.5) Post-term 8 0 (0.0) Gestational age <28 weeks 5 4 (80.0) 28 to <32 weeks 18 10 (55.6) 32 to <34 weeks 18 2 (11.1) 34 to <37 weeks 49 2 (4.1) 37 to <42 weeks 146 8 (5.5) ≥42 weeks 8 0 (0.0) Weight on admission <1000 g 8 9 (11.2) 1000–1499 g 14 5 (35.7) 1500–2499 g 107 8 (7.5) ≥2500 g 115 4 (3.5) Age on admission <1 day 160 19 (11.9) 1–3 days 59 4 (6.8) 4–7 days 14 2 (14.3) 8–14 days 8 1 (12.5) ≥15 days 3 0 (0.0) Among the 26 neonatal deaths, 11 occurred in inborn and 15 in outborn neonates. Extremely low birth weight was the leading cause among inborn deaths, accounting for 5 (45.5%), followed by respiratory distress syndrome in 3 (27.3%) and HIE/moderate-to-severe birth asphyxia in 2 (18.2%). Table IV. Cause-of-death profile and documented referral diagnoses Variable Inborn, n (%) Outborn, n (%) / Overall Cause of death (n=26) n=11 n=15 Extremely low birth weight (<1000 g) 5 (45.5) 4 (26.7) HIE/moderate-to-severe birth asphyxia 2 (18.2) 4 (26.7) Respiratory distress syndrome 3 (27.3) 2 (13.3) Sepsis 0 (0.0) 4 (26.7) Major congenital malformation 1 (9.1) 0 (0.0) Prematurity <28 weeks 0 (0.0) 1 (6.7) Documented referral diagnoses n (%) Hirschsprung disease 3 (50.0) Necrotizing enterocolitis with pneumoperitoneum 1 (16.7) Bilateral septic arthritis 1 (16.7) Congenital diaphragmatic hernia 1 (16.7) Total documented referral cases 6 (100.0)

In the present study, the pattern of admission and outcome of 270 neonates admitted to Koppal Institute of Medical Sciences in January, 2026, in the NICU, was analysed, with a focus on birth asphyxia. Perinatal asphyxia was reported in 18.0% (44/244) of neonates in the admission-profile data and was one of the most common specific causes of admission to the NICU. A total of 237 (87.8%) of the neonates were discharged on the other hand, 26 (9.6%) died, this represents neonatal mortality in the short term, which remained clinically significant despite the good outcome of most neonates admitted. Birth asphyxia was another significant cause of death, accounting for 6 (23.1%) of 26 deaths, which included hypoxic-ischemic encephalopathy and moderate-to-severe birth asphyxia. In the present study, the frequency of perinatal asphyxia underlines its ongoing significance as a reason for admission of neonates to NICU. Birth asphyxia has also been found to be one of the leading causes of admission to neonatal units in low- and middle-income countries (LMICs), and early neonatal death (ENND), by previous studies in neonatal units in LMICs [13]. The high prevalence of asphyxia in these environments may be related to intrapartum complications, delayed recognition of fetal distress, prolonged or obstructed labor, meconium-stained liquor, limited availability and suboptimal quality of neonatal resuscitation, or all of these. The findings highlight the importance of prevention of birth asphyxia, in addition to quality newborn care post-birth, in ensuring quality intrapartum monitoring and antenatal surveillance. In the present study, the number of male neonates (139) was more than that of females (105), showing the majority of male neonates (56.97%). Male neonates had a higher number of reported deaths compared to females (12.2% vs. 8.6%). Male neonates have been shown, in previous studies, to be more susceptible to adverse perinatal events which has been attributed to differences in pulmonary maturation, adaptation to hypoxic stress and susceptibility to neonatal complications. While sex is not a modifiable factor, it is important to identify groups at increased risk of adverse outcomes to monitor more closely during the early neonatal period [14]. Most neonates were inborn (151 (61.9%)) and the remainder were outborn (93 (38.1%)). Mortality, however, in the outborn neonates referred to the facilities was significantly higher than in the inborn neonates, 16.3% versus 7.3%. This difference in clinical significance, as outborn neonates can have a delay in recognition, stabilization, referral or transport to tertiary neonatal care. Poor outcomes have been reported for neonates that are referred for care to other practices, especially when they are transported for extended periods of time, or if they do not receive a standard level of thermal care, airway support, oxygenation, glucose maintenance and monitoring during transport. Improving neonatal referral pathways and pre-referral stabilization of neonates may thus make a significant contribution to the prevention of neonatal deaths [15]. Another significant poor outcome predictor was prematurity. The number of neonates represented in the admission profile was 90 (36.9%) preterm and 146 (59.8%) term. A significant difference in mortality rates was noted between term and preterm neonates (18 (20.0%) versus 8 (5.5%)). This relationship was even more marked at extreme gestations, with a mortality rate of 80.0% for neonates born <28 weeks and 55.6% for those born 28 to <32 weeks. These results are like those in previous studies where there was a strong negative correlation between gestational age and neonatal mortality. Extremely and very preterm neonates are at a high risk for respiratory distress syndrome, apnea, hypothermia, infection, intraventricular hemorrhage, feeding intolerance, and low birth weight-related complications. Most neonates were admitted very early, and 160 (65.6%) of neonates were admitted on the first day while 59 (24.2%) were admitted on the first 3 days [16,17]. The reported high proportion of admission in the immediate neonatal period indicates that the complications that occur during the process of labor, delivery and immediate transition to the postnatal period are significant. Common complications associated with asphyxia at birth, respiratory distress, aspiration of meconium, prematurity and low birth weight are all obvious acute complications of pregnancy almost from the time of delivery and often necessitate immediate intensive care. The high percentage of early admissions further emphasises the need for a high level of competent assistance at delivery, availability of neonatal resuscitation and prompt access to NICU care [18]. The treatment outcome was relatively good for most neonates, with 87.8% discharged from NICU. The mean duration of NICU stay was 5.97 days, with the largest proportion remaining admitted for 4-7 days (112 patients, 41.5%), followed by 112 patients (41.5%) who stayed for 1-3 days. The underlying diagnosis, gestational age, need for respiratory support, feeding establishment, and evolution of complications all have an impact on the duration of hospitalization. Moderate-to-severe birth asphyxia infants may need prolonged monitoring as neurological abnormalities, seizures, feeding problems, respiratory instability, and organ dysfunction can develop over the first few days after the hypoxic event [19]. Limitations There are some limitations in this study. It was carried out in a single tertiary care NICU over a brief one-month period and might not capture seasonal changes in neonatal admission and outcomes and may not be generalizable. The cross-sectional design also meant that long-term outcomes and causal relationships could not be assessed. Most of the material of the study was obtained from routinely documented hospital records, and some maternal, obstetric, resuscitation, laboratory, and neurological variables were not consistently available for all neonates. Clinical signs, Apgar score, resuscitation requirement, and evidence of hypoxic-ischemic encephalopathy were identified as the main sources of data used to diagnose birth asphyxia, and standardized methods of measuring metabolic acidosis were not consistently available. There was no evaluation of long-term neurodevelopmental outcomes.

Birth asphyxia remained an important cause of NICU admission and neonatal mortality in this study, accounting for 44 (18.0%) admissions and contributing substantially to deaths through hypoxic-ischemic encephalopathy and moderate-to-severe asphyxia. Prematurity, low birth weight, and outborn status were associated with poorer neonatal outcomes, while the highest mortality was observed among extremely preterm and very low birth weight neonates. Most admitted neonates were discharged successfully, indicating generally favorable short-term outcomes despite the significant burden of high-risk neonatal conditions

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