Neonatology

1. Neonatology

2. OpeningCase Neonatology

3. 2-Week-Old Monica • Mom called due to high fever • Patient is limp • Breathing 32/min • P 130 • SpO2 98%

4. You should suspect that baby Monica is suffering from • A case of the flu • Tuberculosis • An upper respiratory infection • Cardiogenic shock

5. You should suspect that baby Monica is suffering from • A case of the flu • Tuberculosis • An upper respiratory infection • Cardiogenic shock

6. SICK? Sick or Not-yet-sick? Why? or NOT YET SICK?

7. What does a sunken fontanelle indicate?

8. What does a sunken fontanelle indicate?

9. Neonatology Terminology Newborn Fetus Full-term infant Premature Newborns Neonates Infants Overdue infants

10. Newborn • Infant just delivered from mother

11. Fetus • Infant while it is still living inside the mother

12. Full-Term Infants • Normal gestation is 40 weeks • Estimates of this date are made from information gathered from the mother

13. Premature Newborns • Infant less than 37 weeks of gestation • Body weight between 700–1000 grams (about 1.5–2.2 pounds)

14. Street Secret • Premature infants have difficulty maintaining their body temperature, and hypothermia is likely even when appropriate steps for normal-sized newborns are used.

15. Newborns • Neonate: infant during the hospitalization phase immediately following birth. • Newly born: infants specifically at the time of birth • Newborn: After the infant is sent home

16. Infants • Baby from the time of birth until the child has reached the first birthday

17. Overdue Infants • Infants born after expected due date • Babies are larger than normal • May have irritated skin

18. Prenatal Care • Important • Determines due date and possible complications

19. Epidemiology of Resuscitation

20. Respiratory Complications • Most likely complication • 10% of all newly born infants require some assistance in breathing

21. Birth Weight Complications • About 80% of newborns weighing less than 1500 g (1.5 kg or 3.3 lbs) • Low birth weight can cause complications

22. Labor • Antepartum factors: variables that are present before labor begins • Intrapartum factors: variables that occur during labor or the birthing process

23. Antepartum Factors Smoking No prenatal care Illicit drug use or medications Mother’s age (less than 16 or more than 35) Medical conditions • Hypertension • Diabetes • Renal disease Multiple gestations Trauma • Maternal distress • Premature rupture of membranes Intrapartum Factors Abnormal fetal presentation (any non-vertex) Premature labor Precipitous labor (both out-of-hospital and rapid) Prolonged rupture of membranes (over 18 hours) Prolonged labor (beyond 24 hours) Use of narcotics within the past four hours Meconium stained amniotic fluid Prolapsed cord Abruptio placentae (placenta breaks off uterine wall) Placenta previa (placenta implanted in lower uterine segment) Antepartum and Intrapartum Factors

24. Pathophysiology of CirculatoryChanges During Birth

25. Pathophysiology • During fetal life, the lungs are essentially nonfunctional • Complete support comes from the mother via the placenta

27. Pathophysiology • The newborn’s metabolic system begins to change over as the chest emerges from the vaginal canal • This squeezing phenomenon prepares the lungs for the first breath by pushing some of the amniotic fluid out of the nose and mouth

28. Street Secret • The optimal position for the birth of an infant allows for the immediate resumption of self-supported metabolic processes; this position is the head first, face down position.

29. The First Breath

30. Chemical Factors • Low oxygen levels in the hemoglobin (hypoxemia), high levels of carbon dioxide, and a low (acidic) pH level • This combination stimulates the respiratory center in the medulla

31. Thermal Factor • Stimulates the respiratory center as the body responds to the air temperature

32. Circulatory Transition • Pulmonary arterioles start to dilate, allowing more oxygen to enter the pulmonary bloodstream • This increased oxygen supply stimulates the closure of the fetal shunting system

35. Problems Preventing the Transition to Fetal Circulation

36. Fetal Circulation Problems • Persistent pulmonary hypertension—newborn (PPHN) • Persistent fetal circulation (PFC)

37. Street Secret • If meconium-stained fluid is present, early tracheal suction should be performed.

38. Primary and Secondary Apnea • Respiratory system is the first system to fail when the newborn is compromised

39. Primary Apnea • The newborn’s futile attempt to compensate while fatigued • Manifests as a period of rapid respirations followed by a period of apnea

40. Secondary Apnea • Occurs when the infant ceases to breathe and there is a considerable drop in both heart rate and blood pressure

41. The AHA Initial Resuscitation Algorithm for Newborns

42. Stimulate and Check for Responsiveness • If the infant has completely emerged, perform bulb suction only if spontaneous respirations have not yet started • Head and neck should always be supported

43. Stimulate • Rubbing the soles of feet or back stimulates breathing • Also act of drying

44. Street Secret • It is unnecessary to immediately clamp and/or cut the umbilical cord after the infant is born • However, an uncut cord does restrict how much movement you have, so it should be cut as soon as practical

45. Skin Color Check • Normal newborns may be pink all over, or they may have a pink body and bluish colored extremities • The combination of central and peripheral cyanosis is a problem

46. Is Resuscitation Needed? • Is this a term baby? • Condition of amniotic fluid • Respiratory status? • Cardiovascular status? • Muscle tone?

47. What is the minimum normal APGAR score? • 5 • 6 • 7 • 8

48. What is the minimum normal APGAR score? • 5 • 6 • 7 • 8

49. APGAR Score • Tool that quantifies the findings of the neonatal assessment • Evaluates appearance, pulse, grimace, activity, and muscle tone

50. The APGAR Assessment Note: APGAR scores should be assessed at one and five minutes and as needed.