9. The newborn infant. Morphological and functional characteristics. Routine delivery room and initial care for the newborn. Flashcards
what are the steps for immediate care of the newborn ?
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
when do we clear the airway ?and with what ?
when the head emerges from vagina with towel
bulb suction to aspirate secretion from oropharynx
why should we clear the airway
delivery causes compression of the chest wall resulting discharge of fluid from mouth and nose
suction should not be used on nose initially why?
initiate the gasp , cause bradycardia from vagal reflex
when clearing the airway if there is moderate meconium present ?
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
how long does it take for the umbilical arteries usually close spontaneously and umbilical vein ?
45-60 second after birth whereas the umbilical vein remains 3-5 minutes longer.
what can happen if there is a delay in clamping the cord ?
neonatal jaundice and tachypnea can occur if there is a delay in clamping
what is the ideal time in clamping the cord ?
ideal time 20-30seconds after birth
when should the onset of respiration take place ?
within first 30 seconds of birth
what if the onset of respiration not commenced after 30 seconds or HR is less than 100
less than 100 percent positive pressure ventilation with oxygen should be started
if no improvement after 90 seconds - oxygen should b increased
surfactant deffieicncy is common in what types of babies ?
premature infant
surfactant deficiency is responsible for ?
respiratory distress syndrome
surfactant deficiency is treated with ?
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
what is the APGAR score ?
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
If the APGAR score is between 4 -6 this indicates what ? and what should be the response
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.
A score of 1-3 indicates? and what is the response ?
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
What are the causes of a very low apgar score
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
how goes the resuscitation of the newborn
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
what is the definition of perinatal period ?
29th gestational week to 7th day of extrauterine life
what does it mean by large for gestational age
newborn is heaver than the 90 th percentile
what does it mean small for gestational age
new-borns lighter than the 10th percentile
what is normal birthweight in a full term baby ?
2500-4000g
in new born assessment what is the optimal length of full term baby ?
45-60cm
newborns can loose up to how much of the birth weight fr it still to be normal ?
10 percent
what is the normal head circumference of a new born
33-38 cm
about half the baby’s body length in cm plus 10 cm
what is the normal chest cirucumferenfc of a new born?
31-36 cm
Normal axillary temperature
36-37°C
Normal heart rate of new born
110–160 bpm
normal resp rate for new born ?
30–60/minute
what are the head morphological features we look for in a new born ?
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
what should we look ou for in inspection of face ?
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
what should the morphology check of the baby’s neck be?
deep folds of skin
webbing associated with down syndrome
assess for full range of motion
palpate for abnormal masses
note the position of trachea
what should morphology check of the baby’s chest be?
shape should be cylindrical
bellshapped chest - underdeveloped lungs
evaluate respiratory effort and movement
osculate the lung fields and heart sounds
unequal breath sounds - penumothorax
what’s should the morphology check of the abdomen be ?
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
female genital and anal assessment ?
newborn labia majora covers labia minora and clitoris
Mucoid vaginal discharge due to maternal hormones
Hymenal tag may be present
anus patent
what is the male genital and anal assessment ?
rugae present on scrotum
scrotal edema may be present due to maternal hormones
testes descended
check for placement if meatus
anus should be patent
what is the assessment of the extremities ?
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
what is the morphological assemsemt of the spine ?
spine should be straight
flat
shoulders scapular and iliac crest line up int he same plane
evaluate dimpling - associated with spinabifida
or fissures
what is the morphological assessment of the skin ?
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
what is the assessment of the neurological reflexes in newborns ?
infant alert and responsive
reflexes should be present - the indicate the maturity of the baby and the CNS system
what are the neurological reflexes that needs to be looked at in a new born baby
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
the moro reflex is in its incomplete form when ?
during preterm after the 25th weeks incomplete form
and in complete form in 30 th week
what is exaggerated moro reflex indicate
severe brain damage which occurred in utero - microcephaly and hydrocephaly
moderate hypoxemic ischemic encephalopathy
when does the rooting reflex disappear ?
four months
when does the moro reflex disappear ?
3-6 months
if the palmar grasp reflex persists what is the clinical significance
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.
what is the clinical significance if it has passed 6 months for the asymmetrical tonic neck reflex and tonic labyrinth reflex to disappear ?
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).
what is the significance of symmetrical tonic neck reflex ?
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
The presence of the Babinski sign in adults indicate what
upper motor neurone lesion damage to corticospinal tract
disease of the spinal cord and brain in adults,
how is there a behavioural assessment taken ?
sleep wake cycles
activity
social interactions
response to stimuli
what are the ways we can assess neonatal gestational age ?
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
Ballard score can be used up to ?
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
how do you asses posture to gestational age ?
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).
how do you assess square window ?
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
how do you asses arm recoil
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
how do you assess the popliteal angle ?
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
how do you assess the scarf sign ?
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
how do you assess the hteel to ear sign ?
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
how can we asses the skin in ballard score
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
how do you asses lanugo to ballard score
none sparse abundant thinning bald areas mostly bald sparse = full term
plantar surface assessment ?
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
breast assessment
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
eye and ear assessment
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
genitals male assessment ?
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
female genetelia assessment ?
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
how does the ballard scoring work ?
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)
what is apnea ?
cessation of respiration for more than 30 seconds WITH bradycardia and acidosis
what are two types of apnea ?
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
how do we treat apnea ?
tactile stimuli oxygen theophylline - cns stimulant pap mechanical ventialtion
what is asphyxia neonatrum ?
all conditions manifesting to hypoxia , hypercapnia and acidosis
an all neonates experience asphyxia as a result of delivery
what causes asphyxia ?
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
what re the effects of asphyxia
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
what is the pathophysiology of meconium aspiration occurring after birth ?
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
what is the pathophysiology of meconium aspiration after the birth ?
once he baby’s head and chest are delivered
the baby starts to breath and pulls the meconium deep into the airway
meconium aspiration is particularly common in ?
post term babies
fetus less than 34 week old rarely passes meconium
small for gestational age ,
breech birth
what are the harmful effect of meconium aspiration ?
ball valve obstruction
bacterial infection
= sterile before birth but not after
chemical pneumonitis
what are the signs and symptoms of meconium aspiration baby ?
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
what s the treatment for meconium aspiration
suction out of oropharynx
intubate
asses the vita signs and the
oxygen = 70 percent to 100 percent
administer antibiotics
beta 2 agonist = bronchodilators
what is complication of meconium aspiration ?
pneumothorax
persistent pulmonary hypertension
