Birth asphyxia represents a major global concern in neonatal health, occurring when the fetus is subjected to inadequate oxygen supply (hypoxia) and/or diminished blood flow (ischemia) to vital organs during labor (peripartum) and birth (intrapartum) (1). This lack of nutrients as well as oxygen causes tissue hypoxia, anaerobic metabolism, lactic acidosis, and a buildup for carbon dioxide (hypercapnia), which results in cell damage and eventually organ damage. (2). The brain is particularly susceptible to hypoxic-ischemic injury because of its significant oxygen requirements and restricted anaerobic capacity. Consequently, birth asphyxia is a principal factor in neonatal cerebral injury as well as enduring neurological impairments throughout the first year of life, affecting both term and preterm infants(3). Hypoxic-ischemic encephalopathy (HIE) is a major neurological disorder caused by severe or extended shortage of oxygen throughout birth. It involves multiple organ failure, in which oxygen deprivation damages the brain and is responsible for systemic problems that distress the heart, kidneys, liver, and lungs(4). In infants affected by HIE, cerebral injury is frequently linked with coronary insufficiency, hepatic dysfunction, renal impairment, and pulmonary distress. The severity of neurological impairment is influenced by the duration and intensity of oxygen deprivation, as well as the efficacy of resuscitation efforts initiated postnatally. These newborns often need intensive care, neuroprotective interventions along with extended measures to alleviate developmental and psychological consequences (5). Globally, birth asphyxia is recognized as one of the most significant causes of neonatal morbidity and mortality. It is the second- most common reason for death in newborns, after neonatal septicemia. Approximately 23% of all neonatal deaths worldwide are attributed to perinatal asphyxia (6). The World Health Organization (WHO) reports that four to nine million newborns experience birth asphyxia annually, with nearly 1.2 million fatalities each year. An equal number of affected infants survive but often with serious and irreversible neurological sequelae such as cerebral palsy, epilepsy, intellectual disabilities, developmental delay, learning disorders, and behavioral abnormalities. This makes perinatal asphyxia a major problem for newborns and a major cause of lifetime disabilities and financial trouble (7). In nations that are developing, where it impacts 1 to 6 per 1,000 live births, the incidence of birth asphyxia is notably elevated. It happens more often in low- and middle-income countries because they don't have enough resources, don't monitor the baby well enough during labor, don't do obstetric procedures quickly enough, and don't have enough places to resuscitate newborns. Upto one-fourth of survivors experience long-term neurodevelopmental impairments like cerebral palsy, epilepsy, or cognitive deficits, and the mortality rate among asphyxiated neonates is still a startling 20% to 50%. In order to prevent asphyxia-related illness and death, these findings highlight the significance of early problem detection and treatment, as well as better care for expectant mothers and newborns (8,9). In hospitals, diverse devices and metrics are utilized to assess fetal and newborn health and to predict or detect asphyxia. The Apgar score, umbilical cord arterial blood gas evaluation, base excess, fetal scalp pH measurement, as well as examination of meconium-stained amniotic fluid constitute a few of those most well-known tests. However, none of these parameters independently provides a fully reliable prediction or early diagnosis of perinatal asphyxia. The precision they achieve in diagnosing varies according on timing, clinical context, and the expertise of the medical professionals involved. Thus, Healthcare practitioners often rely on many indications to appropriately assess newborn distress and the need for intervention(10). In 1952, Dr. Virginia Apgar developed the Apgar scoring system. It remains one of the most popular and reliable methods for promptly assessing a newborn's health. It checks five important bodily functions: skin color, muscle tone, breathing effort, heart rate, and reflex irritability. Each parameter receives a score of 0, 1, or 2, for a total score ranging from 0 to 10. The normal range is 7 to 10, mild difficulties with breathing are indicated by a score of 5 to 6, moderate asphyxia is indicated by a score of 3 to 4, and serious asphyxia is indicated by a score of 0 to 2. One, five-, and ten-minutes following birth is when the evaluation is typically conducted. This enables medical professionals to assess the infant's adaptation and response to resuscitation (11). Despite improvements in perinatal care, asphyxia during birth is still one of the main causes of death and illness in babies around the world. It comes from a lack of oxygen, blood flow, and acidity in the metabolism, which can damage many organs, especially the brain (1). Instruments like the Apgar score as well as cord blood gas analysis make it easier to find problems early, but there is no one feature that guarantees accurate prediction or diagnosis. Persistent efforts to improve newborn shadowing, ensure instant obstetric handling, and strengthen neonatal revival practices have vigorous for averting related to asphyxia death as well as lasting neurological sequelae, eventually attractive survival and excellence of life in pretentious neonates by means of inclusive preventative as well as therapeutic interferences (12). The study sought to evaluate the relationship among umbilical cord arterial blood gas testing as well as Apgar scores at one minute and five minutes in determining the severity of delivery asphyxia. Additionally, it aimed to analyze neonatal outcomes of hypoxic-ischemic encephalopathy, encompassing resuscitation specifics, HIE staging, the necessity for inotropes and antibiotics, as well as feeding challenges, to furnish a thorough comprehension of clinical severity as well as therapeutic necessities in affected newborns.

This prospective observational study was conducted over a period of 12 months in the Neonatal Intensive Care Unit (NICU) of a tertiary care hospital in western Uttar Pradesh. The institute conducts approximately 400–450 deliveries per month (an average of 12–15 births per day), Of these, an estimated 5–7% of newborns require resuscitative measures or NICU admission for perinatal complications such as asphyxia, respiratory distress, or sepsis., with a Level III NICU facility catering to both inborn and referred neonates. The study comprised 135 term babies (≥37 weeks) delivered at the institution, all of whom had an Apgar score <7 at one minute as well as necessitated resuscitation at birth. Study Population and Setting: All eligible term neonates born within the study period, fulfilling the inclusion and exclusion criteria, were consecutively enrolled. Inclusion criteria comprised neonates with acidosis (cord arterial pH <7.2 and base deficit >12 mmol/L). Exclusion criteria included preterm infants (<37 weeks), neonates with major congenital anomalies, and those whose mothers had received sedatives or analgesics during delivery. Sample Size Estimation: The sample size was established by the correlation between umbilical cord blood pH as well as Apgar score alongside the degree of birth asphyxia from a prior study by Meena et al (r = 0.624 and r = 0.66, respectively) (13). At 95% confidence level and 20% allowable error, the minimum required sample size was 118. Considering a 10% dropout or nonresponse rate, the final sample size was rounded to 135 neonates. Sampling Technique: Consecutive sampling was applied in this study for enrollment of study neonates. All eligible neonates who satisfied the study's criteria were included one after the other until the anticipated total number of samples had been attained. Participant Enrolment Process: Immediately after the birth, the delivery room staff decided the eligibility of the neonate. Trained pediatric professionals performed the Apgar scoring at one and five minutes. Arterial blood was collected from the umbilical cord after it had been stabilized, before the placenta separated. After the study's details were explained, parents gave their written consent, which guaranteed their voluntary participation and privacy. Tool and Data Collection: Data collection was performed using a structured proforma. It included information about the mother's age, race, and other factors influencing the baby during pregnancy. It also recorded the baby's Apgar scores and cord arterial blood gas levels, such as pH, HCO₃, PCO₂, PO₂, base excess, and lactate. The Sarnat staging technique for Hypoxic-Ischemic Encephalopathy (HIE) was used to neurologically evaluate the severity of birth asphyxia (14). Trained residents gathered information, and the investigator looked at it every day to make sure that it was correct as well as complete. Data Analysis: Microsoft Excel was used to enter the data, and SPSS version 28.0 (Chicago, Illinois) was used for analysis. The mean ± standard deviation (SD) was used to represent continuous variables, along with frequencies and percentages were used to represent variables that are categorical. ANOVA as well as post-hoc Tukey HSD tests were used to compare HIE grades with biochemical variables. When necessary, the Mann-Whitney U as well Chi-square tests were used. Statistical significance was defined as a p-value <0.05. Ethical Considerations: The study protocol was approved by the Institutional Ethics Committee (Reference No. 2023/43). Written informed consent was obtained from parents prior to enrolment, with assurance of confidentiality and no additional cost to participants.

Figure 1. Flowchart showing the selection and progression of study participants. Figure 1 depicts the enrollment and analysis process of study participants in a prospective observational study conducted in the Neonatal Intensive Care Unit (NICU) and Labor Room of a tertiary care teaching hospital with an average of 12–15 deliveries per day (approximately 400–450 per month). Out of 150 neonates initially approached, 15 were excluded due to prematurity (<37 weeks, n=6), congenital anomalies (n=4), maternal sedative/analgesic exposure (n=3), or parental refusal of consent (n=2). A total of 135 term neonates meeting the inclusion criteria—Apgar score <7 at 1 minute and/or requiring resuscitation with umbilical cord arterial pH <7.2—were enrolled. All participants underwent Apgar assessment at 1 and 5 minutes, cord arterial blood gas (ABG) analysis (pH, HCO₃⁻, PCO₂, PO₂, base excess, and lactate), and hypoxic-ischemic encephalopathy (HIE) staging using Sarnat and Sarnat criteria. All 135 neonates completed follow-up and were included in the final statistical analysis correlating Apgar scores, ABG parameters, and HIE severity. Table 1. Basic Socio-Demographic Profile of Study Participants (n = 135) Variable Category / Unit Frequency (n) Percentage (%) / Mean ± SD Maternal Age (years) Mean ± SD – 25.8 ± 4.1 Parity Primipara 79 58.5 Multipara 56 41.5 Mode of Delivery Normal vaginal delivery 82 60.7 Cesarean section 53 39.3 Gestational Age (weeks) Mean ± SD – 38.4 ± 1.1 Birth Weight (kg) Mean ± SD – 2.74 ± 0.4 Birth Weight Category < 2.5 kg 30 22.2 2.5 – 2.99 kg 60 44.4 ≥ 3.0 kg 45 33.4 Sex of Neonate Male 77 57.0 Female 58 43.0 The table 1 summarizes the maternal and neonatal demographic characteristics of the study population (n = 135). The average age of the mothers was 25.8 ± 4.1 years, which means that most of the people who took part were young adults. A majority of mothers were primiparous (58.5%), while 41.5% were multiparous. Regarding the mode of delivery, normal vaginal delivery was more frequent (60.7%) compared to cesarean section (39.3%). The average gestational age of the newborns was 38.4 ± 1.1 weeks, which shows that most of them were born at full term. The average weight of a newborn was 2.74 ± 0.4 kg. Almost half (44.4%) weighed between 2.5 as well as 2.99 kg, 22.2% were low birth weight (<2.5 kg), and 33.4% weighed 3.0 kg or more. There were more male babies (57.0%) than female babies (43.0%) in terms of where they lived. The data show that the obstetric profile shows balanced distribution overall. Most commonly recorded data were term births, vaginal delivery, and to young first-time mothers, leading to babies with normal median birth weights. Table 2: APGAR scores of the study participants (n=135): APGAR score Mean ± SD (APGAR score) Minimum APGAR score Maximum APGAR score At 1 minute 4.49±0.9 2 6 At 5 minutes 6.18±0.9 4 7 Table 2 describes that most infants demonstrated moderate birth depressive disorders and needed assistance to recover, showing an average APGAR score of 4.49 ± 0.9 at one minute. After five minutes, the average score increased to 6.18 ± 0.9, suggesting successful neonatal resuscitation and recovery of the vital body functions like breathing and muscle tone. The range of scores (2–6 at 30 seconds and 4–7 at 5 minutes) points to the significant variation in both the initial distress and the subsequent response. This highlights the significance of prompt and appropriate response when a newborn is choking. Figure 2: Classification of perinatal hypoxia by using Apgar score Figure 2 shows that at 1 minute, 21% of neonates had severe hypoxia (1–3), 14% had only mild distress (6–7), and 65% had moderate hypoxia (Apgar 4–5). Ninety-one percent had Apgar scores above five minutes, indicating that they had been successfully revived and were on the mend. The remaining 9% continued to experience perinatal asphyxia, as indicated by scores below 5. These findings highlight how effective early neonatal intervention is at addressing hypoxic conditions. Table 3: Arterial blood gas investigation of cord blood (n=135) ABG variables Mean ± SD Minimum Maximum pH 7.09±0.1 6.700 7.20 HCO3 15.08±5.0 4.4 46.1 PCO2 40.66±11.7 16.7 80.6 PO2 71.86±23.6 11.1 228.0 BE 13.05±7.0 -26.4 25.8 Lactate 5.81±4.1 .2 22.0 Table 3 shows the metabolic acidosis was evident from ABG profile of the neonates, exhibiting an average pH of 7.09 ± 0.1. The bicarbonate concentration (15.08 ± 5.0 mmol/L) and base excess (13.05 ± 7.0 mmol/L) values are substantially decreased. The averages of PCO₂ (40.66 ± 11.7 mmHg) and PO₂ (71.86 ± 23.6 mmHg) demonstrate that the air flow is satisfactory but the oxygenation remains stable. The elevated lactate level (5.81 ± 4.1 mmol/L) indicates that the oxygen shortage is still present. Table 4: Classification of acidosis through arterial blood pH Variable Classification of acidosis with arterial blood pH Frequency Percentage pH 7.10-7.2(Mild) 66 48.9 7.00-≤7.10(Moderate) 49 36.3 <7.00(Severe) 20 14.8 Total 135 100.0 Table 4 shows that about half of the newborns (48.9%) had mild acidosis (pH 7.10–7.20), 36.3% had moderately acidosis (pH 7.00–7.10), along with 14.8% had profound acidosis (pH <7.00). From this distribution it can be inferred that, majority of newborns had metabolic disturbances within a controllable range while only a small percentage of asphyxiated neonates developed critical acidemia. The results emphasize the central role of early identification of acidosis and its prompt treatment to minimize hypoxic-ischemic damage. Figure 3 presents that around 80% neonates needed stimulation or IPPV at birth, and half required intubation for respiratory stabilization. The order of presentation of hypoxic-ischemic encephalopathy phases indicated a predominance of Stage 1 cases, with a lesser frequency of Stage 3 and Stage 2 presentations. Almost half of the babies were given antibiotics, and one-third were given inotropes. Two-thirds of the babies had no trouble eating, which shows that they were recovering well after the first treatment. Table 5: HIE staging vs mean APGAR score at 1minute: HIE grading(I) HIE grading(J) Mean Difference (I-J) Std. Error Significance 95% Confidence Interval Lower bound Upper bound 1.0 2.0 .4539 .2414 .149 -.118 1.026 3.0 1.2488 .1924 .000 .793 1.705 2.0 1.0 -.4539 .2414 .149 -1.026 .118 3.0 .7949 .2816 .015 .127 1.462 3.0 1.0 -1.2488 .1924 .000 -1.705 -.793 2.0 -.7949 .2816 .015 -1.462 -.127 As presented in Table 5, Post-hoc evaluation employing the Tukey HSD test revealed significant disparities in mean scores for Apgar between HIE Stages 1 and 3 (p = 0.000) as well as among Stages 2 and 3 (p = 0.015), which suggests inferior initial adjustment in neonates using severe HIE. The non-significant disparity among Stages 1 and 2 (p = 0.149) indicates comparable levels of early depression in these groups. Overall, the findings highlight an inverse relationship between HIE stage and initial Apgar performance. Table 6: HIE staging vs mean APGAR score at 5 minutes: HIE grading(I) HIE grading(J) Mean Difference (I-J) Std. Error Significance 95% Confidence Interval Lower bound Upper bound 1.0 2.0 .3986 .2166 .161 -.115 .912 3.0 1.5704 .1726 .000 1.161 1.980 2.0 1.0 -.3986 .2166 .161 -.912 .115 3.0 1.1718 .2526 .000 .573 1.771 3.0 1.0 -1.5704 .1726 .000 -1.980 -1.161 2.0 -1.1718 .2526 .000 -1.771 -.573 According to Table 6, the post-hoc Tukey HSD test revealed highly significant differences in 5-minute Apgar scores between HIE Stages 1 and 3 (p = 0.000) and between Stages 2 and 3 (p = 0.000), confirming that neonates with severe HIE showed markedly lower recovery scores. The absence of a significant difference between Stages 1 and 2 (p = 0.161) suggests comparable post-resuscitative improvement among these groups. Overall, the analysis underscores a robust unfavorable correlation between HIE severity and recovery effectiveness. Figure 4: HIE staging vs mean pH (Post-hoc Tukey HSD Test) A post-hoc Tukey HSD study confirms a distinct downward drift in mean pH morals as HIE severity increases, as shown in Figure 4. Between Stages 1 and 3, portentous clear metabolic acidosis in simple HIE shows the most noticeable decline. Smaller inter-stage changes (Stage 1 vs. 2 in addition to Stage 2 vs. 3) suggest a generalized deterioration of acidemia commensurate with the severity of hypoxic-ischemic maltreatment. Table 7: HIE staging vs mean lactate: HIE grading(I) HIE grading(J) Mean Alteration (I-J) Std. Error Significance 95% Confidence Interval Lower bound Upper bound 1.0 2.0 -4.1813 1.0134 .000 -6.583 -1.779 3.0 -4.5097 .8076 .000 -6.424 -2.595 2.0 1.0 4.1813 1.0134 .000 1.779 6.583 3.0 -.3285 1.1818 .958 -3.130 2.473 3.0 1.0 4.5097 .8076 .000 2.595 6.424 2.0 .3285 1.1818 .958 -2.473 3.130 Table 7 shows that A significant increase in unkind lactate levels with snowballing HIE sternness was found in the post-hoc Tukey HSD study. Lactate concentrations in neonates through HIE Stage 3 were noticeably higher than those in Stage 1 (p = 0.000), indicating significant anaerobic ingestion as well as tissue hypoxia in Spartan cases. However, A plateau in lactate advancement beyond reasonable hypoxic grievance was suggested by the unremarkable change flanked by Stages 2 and 3 (p = 0.958). These results support lactate as a crucial biological marker of asphyxia strictness. Figure 5: Comparison of APGAR scores besides blood gas strictures across HIE grades (ANOVA). Figure 5 illustrates a progressive decline in mean Apgar scores at 1 and 5 minutes between HIE Grade I and Grade III, indicating a worsening of neonatal depression through an increase in asphyxia strictness. Correspondingly, blood gas limitations revealed dropping pH and bicarbonate stages alongside growing PCO₂, PO₂, base additional, and lactate absorptions across developed HIE grades. In contrast to the severity of hypoxic-ischemic brain disorder, these findings suggest wide-ranging metabolic acidosis to increasing hypoxia.

The present study examined the correlation between umbilical cord measures of acidosis and the association between cord pH, Apgar scores, and the severity of birth asphyxia among intramural neonates in a tertiary care hospital. A significant relationship was found between umbilical cord pH and Apgar scores with the severity of asphyxia, emphasizing their value in early neonatal assessment. Although several clinical indicators such as Apgar score, base excess, fetal scalp pH, and meconium-stained amniotic fluid have been employed, none have demonstrated absolute reliability in predicting perinatal asphyxia (15). The Apgar score remains among the most effective treatment instrument for prompt assessment and making choices (16).Researchers have also looked into new biomarkers like activin A along with enolase that targets neurons to see if they can find hypoxic injury to the brain (17). The demographic perinatal variables identified in the present investigation closely correspond with the findings published by Singh et al. (2021) (18), who characterized a comparable distribution of underweight neonates, male dominance, as well as different methods of childbirth. In gravidity, the prevalence of meconium-stained amnionic fluid and its vertex manifestation were identical. The similarities in perinatal behaviors and pregnancy appearances between revisions suggest a stability in the obstetric conditions linked to neonatal asphyxia. Apgar scoring patterns mirrored previous reports, showing low initial values that improved at five minutes, consistent with Singh et al. (18). Conversely, The clinical difference between dying and non-asphyxiated babies was highlighted by Bernardo et al. (2017) (19), who reported significantly higher Apgar medians in healthy term neonates. Despite being widely used, Apgar scoring is subjective by nature and can be impacted by factors such as the mother's age, medications, or birth defects (20). The distribution of resuscitative interventions observed was similar to earlier studies, reflecting that most affected neonates required only minimal stimulation, while a smaller proportion necessitated positive-pressure ventilation or intubation (16). Arterial blood gas patterns were indicative of metabolic acidosis, consistent with prior studies (19), which also demonstrated lower pH and bicarbonate values in asphyxiated neonates. The HIE distribution followed the classic Sarnat and Sarnat staging, with mild encephalopathy being the most frequent presentation (19). Other recent series reported similar rates of moderate and severe HIE. The findings of Armstrong L,et al. (2014) (21), Ahmadpour Mousa et al. (2019) (20), and others were consistent with the need for NICU hospitalization and the use of inotropes, prescription antibiotics, or assisted feeding. both of whom reported higher intervention rates among neonates with cord pH < 7.2. Mortality while discharge developments were analogous to regional data, indicating a uniform clinical trajectory among equivalent cohorts about asphyxiated long-term neonates. Statistical analysis confirmed that reduced Apgar scores, pH, and bicarbonate levels correlated with increased HIE severity, while rising lactate levels were linked to worsening signs of brain damage. Comparable relatives have been known by Taheripanah et al. (2018) (22) in addition Umbilical cord acidosis is a strong predictor of poor newborn outcomes, according to Malin et al. (2010) (23). Previous studies have shown that low cord pH and low five-minute Apgar scores significantly predict opposite neurological sequelae using logistic deterioration models. All things considered, umbilical cord blood gas analysis provides an unbiased evaluation of fetal acid-base balance and serves as a reliable adjunct in predicting perinatal outcomes. The transition from moderate to severe hypoxic damage is indicated by a progressive drop in Apgar scores, pH, and bicarbonate levels, as well as an increase in lactate. These findings confirm that early physiological evaluation combined with clinical scoring makes it easier to identify and treat asphyxiated neonates quickly, which may improve survival and neurodevelopmental outcomes. Strength This study correlates Apgar scores with umbilical cord arterial blood gas values, providing both clinical and biochemical perspectives to assess birth asphyxia severity. Conducted in a tertiary care setting with intramural neonates, it ensures standardized care and reliable data, strengthening internal validity and the clinical relevance of the findings. Limitation It was a single centre study with small sample size. The other markers of neonatal birth asphyxia like neuronal-specific enolase, glial fibrillary acidic protein, as well as nucleated red blood cells in cord blood, IMA levels and imaging were not assessed in our study.

In order to assess neonatal birth hypoxia, our study evaluated the predictive value of the APGAR score in addition to umbilical cord arterial blood gas (ABG) strictures. Results showed that, in addition to negative neonatal outcomes, the 5-minute APGAR score showed a strong correlation with birth asphyxia, while cord blood lactate too the 1-minute APGAR score likewise confirmed predictive value. In addition, the severity of hypoxic-ischemic brain disorder (HIE) was knowingly associated with APGAR scores at 1 and 5 minutes, pH, bicarbonate (HCO₃⁻), and lactate. Notably, Newborns with lower unkind pH values had worse neurological outcomes, more fetal distress, and required resuscitation. Strength This study correlates Apgar scores with umbilical cord arterial blood gas values, providing both clinical and biochemical perspectives to assess birth asphyxia severity. Conducted in a tertiary care setting with intramural neonates, it ensures standardized care and reliable data, strengthening internal validity and the clinical relevance of the findings. Limitation It was a single centre study with small sample size. The other markers of neonatal birth asphyxia like neuronal-specific enolase, glial fibrillary acidic protein, as well as nucleated red blood cells in cord blood, IMA levels and imaging were not assessed in our study.

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