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pediatrics > 9. The newborn infant. Morphological and functional characteristics. Routine delivery room and initial care for the newborn. > Flashcards

9. The newborn infant. Morphological and functional characteristics. Routine delivery room and initial care for the newborn. Flashcards

1
Q

what are the steps for immediate care of the newborn ?

A

1) clear airway
2) dry the newborn
3) clamp the cord
4) ensure onset of respiration
5) correct surfactant defficiency
6) APGAR SCORE
8) asses for gross abnormalities
9) obtain footprints
10) apply identification bans
11) administer vitamin k and eye prophylaxis
12) promote bonding

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2
Q

when do we clear the airway ?and with what ?

A

when the head emerges from vagina with towel

bulb suction to aspirate secretion from oropharynx

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3
Q

why should we clear the airway

A

delivery causes compression of the chest wall resulting discharge of fluid from mouth and nose

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4
Q

suction should not be used on nose initially why?

A

initiate the gasp , cause bradycardia from vagal reflex

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5
Q

when clearing the airway if there is moderate meconium present ?

A

Tracheal tube to suction

Inhaled nitric oxide - reduce the pulmonary hypertension

Continuous positive air way pressure mask

Glucocorticoid for anti inflammatory

Surfactants are given

If serious
Mechanical ventilation
Extracorporeal membrane oxygenation

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6
Q

how long does it take for the umbilical arteries usually close spontaneously and umbilical vein ?

A

45-60 second after birth whereas the umbilical vein remains 3-5 minutes longer.

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7
Q

what can happen if there is a delay in clamping the cord ?

A

neonatal jaundice and tachypnea can occur if there is a delay in clamping

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8
Q

what is the ideal time in clamping the cord ?

A

ideal time 20-30seconds after birth

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9
Q

when should the onset of respiration take place ?

A

within first 30 seconds of birth

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10
Q

what if the onset of respiration not commenced after 30 seconds or HR is less than 100

A

less than 100 percent positive pressure ventilation with oxygen should be started
if no improvement after 90 seconds - oxygen should b increased

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11
Q

surfactant deffieicncy is common in what types of babies ?

A

premature infant

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12
Q

surfactant deficiency is responsible for ?

A

respiratory distress syndrome

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13
Q

surfactant deficiency is treated with ?

A

exogenous surfactant ensured either given by tracheal injection at birth or can be given after the syndrome has developed to reduce its severity and prevent mortality

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14
Q

what is the APGAR score ?

A

A - appearance of skin colour / 0-blue pale all over, 1-blue at extremeties and body is pink , 2 - no cyanosis and extremities pink
P- pulse / 0 - absent , 1- <100bpm , 2 .100bpm
G- grimace - no response to stimulation -0/ grimace on action or aggressive stimulation -1/ cry on stimulation -2
A- activity - no response to stimulation -0/ some flexion -1/ flexed arms and legs that resists extension -2
R- respiration - 0 absent / weak irregular gasping , strong robust cry

normal APGAR score is 7 or greater in one minute after delivery , then 9-10 after 5 minutes of delivery

if the infant scores between 7-10 maintain NTE (normal temp and environment ) and observe

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15
Q

If the APGAR score is between 4 -6 this indicates what ? and what should be the response

A 
moderate depression (ex. Meconium
aspiration

O2 by bag and Mask (B/M),

warming and stimulating the infant should

Monitor vital signs reevaluate in 5 minutes.

CPAP - continuous positive
airway pressure

or Mechanical Ventilation (MV) may be necessary.

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16
Q

A score of 1-3 indicates? and what is the response ?

A

probably a cardiac or respiratory arrest
or a condition caused by severe bradycardia, hypo ventilation, or CNS depression

Most low Apgar scores are caused by difficulty in establishing adequate
ventilation

Apgar score of 0 to 3 with asphyxia manifest into 
 fetal acidosis (pH <7) seizures, coma, or
hypotonia; and multiorgan dysfunction often occur.

low Apgar scores respond to assisted ventilation by facemask or by endotracheal intubation

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17
Q

What are the causes of a very low apgar score

A

uterine and placental :

- placenta abruption 
placenta previa 
post maturity of placenta 
velamenouts cord insertion 
uterine rupture

PROM = delivery must occur in 24 hrs to prevent infection

umbilicals cord prolapse or compression

eryhtoblastis fetalis - haemolytic anema of newborn

diabetes mellitus in pregnancy

cardiopulmonary problems of the mother

trauma during deliver
cephalopelvic diproportion
fetal presentation - breech , brow or face

drugs administered to mother during labor or delivery :
inhaled anaesthetics
local anaesthetic
substance abuse

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18
Q

how goes the resuscitation of the newborn

A

ABCD

A - airway
clearing the airway by suctioning
endotracheal tubing - esp if there is hiatal hernia - if bag and valve used the oxygen also goes into the stomach
fetal hydrop - bilateral thoracocentosis

b - breathing
- mask and bag with manometer

c - circulation
external cardiac massages - no pulse , asystole
120 compression per minute compression and breaths given at a ratio of 3:1

D - drugs
unresponsive to ventilation and systole and no pulse
epinephrine should be given -IV through umbilical vein
or injected through the endotracheal tube

pneumothorax should be thought of before medication with poor pulse
illumination of the thorax through each side of the thorax and over the sternm - if one sid transmits are light then the other suggest pneumothorax
breath sounds diminishes
shift f heart tones away from the side of tension

CNS depression due to narcotics - naloxone intravenously or through endotracheal tubing
= DO NOT GIVE IF IT IS A MOTHER ADDICTED TO DRUGS or is on methadone maintencae
= experience severe withdrawal seizures

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19
Q

what is the definition of perinatal period ?

A

29th gestational week to 7th day of extrauterine life

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20
Q

what does it mean by large for gestational age

A

newborn is heaver than the 90 th percentile

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21
Q

what does it mean small for gestational age

A

new-borns lighter than the 10th percentile

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22
Q

what is normal birthweight in a full term baby ?

A

2500-4000g

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23
Q

in new born assessment what is the optimal length of full term baby ?

A

45-60cm

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24
Q

newborns can loose up to how much of the birth weight fr it still to be normal ?

A

10 percent

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25
Q

what is the normal head circumference of a new born

A

33-38 cm

about half the baby’s body length in cm plus 10 cm

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26
Q

what is the normal chest cirucumferenfc of a new born?

A

31-36 cm

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27
Q

Normal axillary temperature

A

36-37°C

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28
Q

Normal heart rate of new born

A

110–160 bpm

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29
Q

normal resp rate for new born ?

A

30–60/minute

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30
Q

what are the head morphological features we look for in a new born ?

A

Fontanels need to be open and soft

Depressed fontanel indicates dehydration

Bulging fontanel may indicate increased intracranial pressure

Molding result of fetal pressure from passage through birth canal ( resolves in 24-48hrs)

Cephalhematoma result from trauma (resolves in few weeks
hemorrhage between skull and periosteum
cause prolonged second stage of labour or instrumental delivery - forceps
lead to damage of subperiosteal vessels
because swelling is subperiosteal the boundaries are limited to the individual bones as in contrast to caput succedaneum

Caput succedaneum pressure from delivery resolves in 1-2 weeks
edema between periosteum and overlying skin
during labour venous drainage of the blood from the head can be stopped due to the high pressure - resulting in edema

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31
Q

what should we look ou for in inspection of face ?

A

Inspect face for symmetry of eyes, nose, lips, mouth and ears

Eyes usually blue or gray, permanent color established in 3- 12 months

Nose midline with patent nares
Red reflex present cornea intact

Can see up to 2 1⁄2 feet
clearest vision is 8 to 12 inches

Subconjunctive hemorrhages may be present due to the pressure from delivery

Ears aligned with outer canthus of eyes;
pinna well formed, open auditory canal
( low set ears associated with chromosomal abnormalities)

Mouth mucosa pink and moist;

tongue mobile, strong suck,

hard/soft palate intact

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32
Q

what should the morphology check of the baby’s neck be?

A

deep folds of skin

webbing associated with down syndrome

assess for full range of motion

palpate for abnormal masses

note the position of trachea

33
Q

what should morphology check of the baby’s chest be?

A

shape should be cylindrical

bellshapped chest - underdeveloped lungs

evaluate respiratory effort and movement

osculate the lung fields and heart sounds

unequal breath sounds - penumothorax

34
Q

what’s should the morphology check of the abdomen be ?

A

umbilical cord with two arteries and one vein

flat abdomen - diaphragmatic hernia

ausculate for bowel sounds

suprapubic area palpated for bladder distention

femoral pulse palpated if unable to locate -coractaton of aorta

35
Q

female genital and anal assessment ?

A

newborn labia majora covers labia minora and clitoris

Mucoid vaginal discharge due to maternal hormones

Hymenal tag may be present

anus patent

36
Q

what is the male genital and anal assessment ?

A

rugae present on scrotum

scrotal edema may be present due to maternal hormones

testes descended

check for placement if meatus

anus should be patent

37
Q

what is the assessment of the extremities ?

A

assess full range of motion

symmetry

assess muscle tone

hyper flexibility of joints = down syndrome

hips assessed for dislocation

nail beds pink - persistent cyanosis associated with hypoxia

palms should have normal creases - simian crease - down syndrome

no signs of polydactyly

38
Q

what is the morphological assemsemt of the spine ?

A

spine should be straight
flat
shoulders scapular and iliac crest line up int he same plane
evaluate dimpling - associated with spinabifida
or fissures

39
Q

what is the morphological assessment of the skin ?

A

asses the colour

trauma

rashes

birth marks :
mongolian spots
stork bites/ angel kisses - temporary birth marks
caused by dilations (or stretching) in your baby’s capillaries (tiny blood vessels) visible through the skin

milia - are small, bump-like cysts found under the skin. They are usually 1 to 2 millimeters (mm) in size. They form when skin flakes or keratin, a protein, become trapped under the skin. Milia most often appear on the face, commonly around the eyelids and cheeks

lanugo = fine soft hair

texture - soft or peeling

turgor

elasticity

Vernix caseosa, also known as vernix, is the waxy or cheese-like white substance found coating the skin of newborn human babies

40
Q

what is the assessment of the neurological reflexes in newborns ?

A

infant alert and responsive

reflexes should be present - the indicate the maturity of the baby and the CNS system

41
Q

what are the neurological reflexes that needs to be looked at in a new born baby

A

sucking - by 4 months it becomes voluntary

rooting

grasping - 4-6 month disappear

extrusion - 4-6 months after birth
causes your baby’s tongue to move forward as soon as his lips are touched

asymmetrical tonic neck - should disappear in 4-6 months

When the face is turned to one side, the arm and leg on the side to which the face is turned extend and the arm and leg on the opposite side flex

symmetrical tonic neck reflex should go in 9-11 months
more than 2-3 years it is a problem
placing the child in quadruped position on the floor and passively flexing the head forward and then extend it backwards. The expected response would be forward head flexion producing flexion of the upper extremities and extension of the lower extremities while extension of the head will produce extension of the upper extremities and flexion of the lower extremities

tonic labyrinth reflex -
31/2 years of age

when the head is tilted back, the back arches, the legs straighten, and the arms bend.

persistant non physiological TLS the child cannot roll over
however if the start t roll over before 3 months strong tl suspected and high likely of motor impairment

moro - spreading out the arms , pulling the arms in and then crying
- asymmetry is almost always a nerve disease

stepping

babinski - disappear around 12 months of age
persistence beyond 2-3 years is a problem

truncal incurvation / galant reflex =
4th month
holding the newborn in ventral suspension (face down) and stroking along the one side of the spine. The normal reaction is for the newborn to laterally flex toward the stimulated side.

blinking

majority of reflex diasspaera 4-6 months

42
Q

the moro reflex is in its incomplete form when ?

A

during preterm after the 25th weeks incomplete form

and in complete form in 30 th week

43
Q

what is exaggerated moro reflex indicate

A

severe brain damage which occurred in utero - microcephaly and hydrocephaly
moderate hypoxemic ischemic encephalopathy

44
Q

when does the rooting reflex disappear ?

A

four months

45
Q

when does the moro reflex disappear ?

A

3-6 months

46
Q

if the palmar grasp reflex persists what is the clinical significance

A

delays motor function the hands

Palmar grasp reflex in adults is pathologicamay signify frontal lobe damage, or may be a sign of anterior cerebral artery syndrome.

47
Q

what is the clinical significance if it has passed 6 months for the asymmetrical tonic neck reflex and tonic labyrinth reflex to disappear ?

A

child has developmental delays,

children with cerebral palsy, the reflexes may persist and even be more pronounce

hinder functional activities such as rolling, bringing the hands together, or even bringing the hands to the mouth.

causing the head of the femur to partially slip out of the acetabulum (subluxation) or completely move out of the acetabulum (dislocation).

48
Q

what is the significance of symmetrical tonic neck reflex ?

A

It is a bridging or transitional brainstem reflex that is an important developmental stage and is necessary for a baby to transition from lying on the floor to quadruped crawling or walking
In order to progress beyond this development stage, the baby needs to have been successful in unlinking the automatic movement of the head from the automatic movement of the arms and legs

49
Q

The presence of the Babinski sign in adults indicate what

A

upper motor neurone lesion damage to corticospinal tract

disease of the spinal cord and brain in adults,

50
Q

how is there a behavioural assessment taken ?

A

sleep wake cycles

activity

social interactions

response to stimuli

51
Q

what are the ways we can assess neonatal gestational age ?

A

BALLARD SCORE

neuromuscular maturity 
-posture 
-square window 
-arm recoil 
-popliteal angle 
-scarf sign 
- heel to ear sign 
each  given -1 - 4 except popliteal angle to 5

and physical maturity

  • skin
  • lanugo
  • plantar surface
  • breasts
  • eye and ear
  • genetelia

scored -1 - 4
except skin and lanugo

52
Q

Ballard score can be used up to ?

A

4 days after birth

usually used in the first 24 hours

accurate only within plus or minus 2 weeks, it should be used to assign gestational age only when there is no reliable obstetrical information

53
Q

how do you asses posture to gestational age ?

A

As maturation progresses, the foetus gradually assumes increasing passive flexor tone at rest that precedes in a centripetal direction with lower extremities slightly ahead of upper extremities.

Term newborn (flexed posture) and preterm newborn (extended posture).

54
Q

how do you assess square window ?

A

Wrist flexibility and resistance to extension of wrist as the baby matures is responsible for the resulting angle of flexion at the wrist.

The examiner applies gentle pressure on the dorsum of the hand, close to the fingers.

From extremely preterm to post term,
the resulting angle between the palm of the infant’s hand and forearm is gradually diminished

55
Q

how do you asses arm recoil

A

Arm recoil examines the passive flexor tone of the biceps

. With the infant lying supine, the examiner places one hand beneath the infant’s elbow for support taking the infant’s hand, the examiner briefly sets the elbow in flexion, then momentarily extents the arm before releasing it. The angle of recoil, to which the forearm springs back into flexion is noted

the angle or recoil decreases as gestational age increases

56
Q

how do you assess the popliteal angle ?

A

This maneuver assesses the maturation of passive flexor tone of the knee extensor muscles

. With the neonate lying supine, the thigh is placed gently on the abdomen of the knee fully flexed. The examiner gently grasps the foot at the sides with one hand while supporting the side of the thigh with the other. Care is taken not to exert pressure on the hamstrings. The leg is extended until a definite resistance to extension is appreciated. At this point the angle formed at the knee by the upper and lower leg is measured

decreases with age

57
Q

how do you assess the scarf sign ?

A

It is tests the passive tone of the flexors about the shoulder girdle.

With infant lying supine, the examiner adjusts the infant’s head to the midline and supports the infant’s hand across the upper chest with one hand. The thumb of the examiner’s other hand is placed on the infant’s elbow. The examiner tries to pull the elbow gently across the chest, feeling for the resistance

more resistance as grow older

58
Q

how do you assess the hteel to ear sign ?

A

This measures the passive flexor tone of the posterior hip / girdle flexor muscles.

The infant is placed supine and the flexed lower extremity is brought to rest on the cot. The examiner supports the infant’s thigh laterally alongside the body with the palm of one hand. The other hand is used to grasp the infant’s foot at the sides and to pull it towards the ipsilateral ear. The examiner feels for the resistance to extension of the posterior pelvic girdle flexors and notes the location of the heel where significant resistance is appreciated

heel becomes less closer to ear when aeging

59
Q

how can we asses the skin in ballard score

A

sticky, friable, transparent -1

gelatinous, red, translucent = 0

smooth pink visible veins = 1

superficial peeling &/or rash, few veins

cracking, pale areas, rare veins

parchment, deep cracking, no vessels

leathery, cracked, wrinkled

60
Q

how do you asses lanugo to ballard score

A 
none 
sparse 
abundant 
thinning 
bald areas 
mostly bald 
sparse = full term
61
Q

plantar surface assessment ?

A

heel to toe
40–50 mm

more than 50 mm
no crease

Faint red marks

Anterior transverse crease only

Creases over anterior 2/3 of sole

Creases over entire sole

62
Q

breast assessment

A

Imperceptible

Barely perceptible

Flat areola
no bud

Stippled areola
1–2 mm bud

Raised areola
3–4 mm bud

Full areola
5–10 mm bud = full term

63
Q

eye and ear assessment

A

Lids fused
Loosely: -1
Tightly: -2

Lids open
pinna flat
stays folded

Sl. curved pinna
soft; slow recoil

Well-curved pinna
soft but ready recoil

Formed & firm
instant recoil

Thick cartilage = full term
ear stiff

64
Q

genitals male assessment ?

A

Scrotum flat,
smooth

Scrotum empty, = 23 wks in abdomen
faint rugae

Testes in upper canal,
rare rugae

Testes descending, 26-28 wks pass through inguinal canal
few rugae

Testes down,
good rugae

Testes pendulous, = full term
deep rugae

65
Q

female genetelia assessment ?

A

Clitoris prominent & labia flat

Prominent clitoris & small labia minora

Prominent clitoris & enlarging minora

Majora & minora equally prominent

Majora large, minora small

Majora cover clitoris & minora

66
Q

how does the ballard scoring work ?

A

A simple formula to come directly to the age from the Ballard Score is Age=((2*score)+120)) / 5

score -10 - 50 
from 20(-10) weeks to 44 (50)
67
Q

what is apnea ?

A

cessation of respiration for more than 30 seconds WITH bradycardia and acidosis

68
Q

what are two types of apnea ?

A

primary - cessation of breathing occurs immediately after birth
for 30 with bradycardia and acidosis
lasts 1 min
followed by gasping lasting several mins

= primary apnea responds to pain and cold and oxygen therapy

primary apnea can go into normal respiration or secondary apnea

secondary paean = dos not respond to pain or cold or touch or oxygen oxygen
produces severecyanosisi
bradycardia

resuscitative efforts must begin immediately

69
Q

how do we treat apnea ?

A 
tactile stimuli 
oxygen 
theophylline - cns stimulant 
pap 
mechanical ventialtion
70
Q

what is asphyxia neonatrum ?

A

all conditions manifesting to hypoxia , hypercapnia and acidosis

an all neonates experience asphyxia as a result of delivery

71
Q

what causes asphyxia ?

A

intrauterine
hypoxiemia ischemia = placenta abruption etc

intrapartum
cephalopelvic disproportion
dystocia
umbilical cord compression

post partum 
myasthenia graves 
myopathy 
pneumonia 
china atresia 
laryngeal webs 
goiter 
pneumothorax diaphragmatic hernia 
pneumothorax
72
Q

what re the effects of asphyxia

A

cns - hypoxemic ischemic encephalopathy
seizures
hypotonia

cv - MOCARDAL ICHEMIA ,

Pulmonary - perisitant pulmonary hypertension , cor pulmonale , respriatory distress syndrome

renal - acute tubular or cortical necrosis

adrenal - adrenal haemorrhages

gastrointestinal - ulceration and necrosis

73
Q

what is the pathophysiology of meconium aspiration occurring after birth ?

A

decreased placental blood flow or maternal hypoxia = can lead to fetal hypoxia

in face of severe fetal hypoxia and acidosis the fetus will respond to peripheral vasoconstriction

further decreasing he oxygen status

and prolonged anoxia causes the chemoreceptors to trigger breathing and aspirate amniotic fluid

if the oxygen saturation drop below 30 the baby will loose consciousness and have bowel movement and pass meconium

74
Q

what is the pathophysiology of meconium aspiration after the birth ?

A

once he baby’s head and chest are delivered

the baby starts to breath and pulls the meconium deep into the airway

75
Q

meconium aspiration is particularly common in ?

A

post term babies
fetus less than 34 week old rarely passes meconium

small for gestational age ,

breech birth

76
Q

what are the harmful effect of meconium aspiration ?

A

ball valve obstruction

bacterial infection
= sterile before birth but not after

chemical pneumonitis

77
Q

what are the signs and symptoms of meconium aspiration baby ?

A

baby has meconium stains on head and face

old meconium = yellow

new mecum = black and tar like

APGAR score low

silverman is high

RDS

breath sounds = whetting , expiratory grunting

xray = air trapping , consolidation and atlelectasisi

78
Q

what s the treatment for meconium aspiration

A

suction out of oropharynx

intubate

asses the vita signs and the
oxygen = 70 percent to 100 percent
administer antibiotics
beta 2 agonist = bronchodilators

79
Q

what is complication of meconium aspiration ?

A

pneumothorax

persistent pulmonary hypertension

pediatrics (19 decks)

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