Care For The Newborn Flashcards
What are the factors identifying a high risk pregnancy?
This is broken up into maternal factors, labor and delivery factors and fetal factors
Name 10 maternal factors that lead to a high risk pregnancy
- Poor weight gain or obesity
- Smoking
- Alcohol consumption
- Sociology-economic factors
- Poor obstetric hx(previous stillbirth and >2 abortions)
- Elderly primigravida
- Diabetes, cardiac, renal disease
- HIV status
- Previous low birth weight
- Age: below 16 and above 35
Name 6 labour and delivery issues for a high risk pregnancy
- Maternal hypertension
- Maternal hypotension
- C-section
- Prolonged rupture of membranes
- Pre-term labour
- Breech
What are the fetal factors leading to a high risk pregnancy?
- Polyhydroamnios
- Oligohydramnios
- Multiple pregnancy
- Malformations
- Post-maturity
Why do newborn babies lose heat rapidly?
-the have a large surface area to body weight ratio
What is the weight for very low birth weight babies?
<1500g
What 3 questions do you need to answer at physical examination of a newborn baby?
- Is the baby breathing normal
- Is the heart rate above 100
- Is the baby centrally pink?
What are the 5 things that the Apgar score is based on?
- Heart rate
- Respiratory effort
- Colour
- Response to nasal catheter
- Muscle tone and movement
What is birth asphyxia?
Failure to initiate spontaneous, sustained respiration after delivery
What is fetal hypoxia?
Inadequate oxygenation before delivery
What is the leading cause of cerebral palsy in the developing world?
Hypoxia during labour
What can deep/over-zealous suctioning cause in a baby?
Laryngospasm and vagal bradycardia
In term babies, what do we do to resus the baby?
- start by bag masking the baby for about 30 seconds
- then change to oxygen if it does not improve
In preterm babies, what do we do to resuscitate them?
-In preterm babies we would give 100% oxygen until SATS are above 88% then we can change to room air after
When would we do an external cardiac massage?
-When the baby is bradycardiac <60bpm then we would do 3 chest compressions for one breath
How much adrenaline and when do we figure adrenaline to the baby?
Give 0,1-0,3ml/kg of 1:10 000 solution and we give this when the bradycardia is persistent
When do we give dextrose and how much of it do we give?
We give 2ml/kg of 10% dextrose for hypoglycaemia
What would the treatment be for a baby with with a pneumothorax?
-first do an X-ray to confirm then do an intercostal drain
What is the most important thing to do with regards to care following resuscitation?
- Maintain a clear airway
- Give oxygen and try to maintain SATS of above 88%
- Monitor temperature to avoid hyperthermia
- Monitor blood sugar level(tube feeding advisable especially at the beginning)
- Observe the baby for developing complications
What are the consequences of severe hypoxia?
- other than neurological factors, irritability and convulsions will ensue
- Persistent cyanosis
- renal damage
- hypoglycaemia, hyperglycaemia, hypercalcaemia may also occur
When do we examine a normal baby?
-immediately after birth hopefully in the presence of the mother and then soon before discharging the baby
What weight is a low birth weight baby?
<2500g
What are the normal values fro normal babies in regards to: Average weight Head circumference Height Respiratory rate Heart rate
- Boys: 3400g and girls 3000g
- Height: 48cm(between 46 and 52cm)
- Head circumference: 35 cm(33-37cm)
- Resp rate: 40-60
- Heart rate: 120-180 bpm
What is the thick white substance babies are born with?
Vernix caseosa
What are Mongolian spots?
These are blue-grey slate pigmentations that can be distributed over the sacral and gluteal areas
-they disappear within the few years of life
What are milia?
These are white, pin point spots over the bridge of the nose, chin or cheeks and are epithelial lined cystic inclusions of sweat gland ducts
What are erythema toxicum?
Small macules on a red base starting on they 2nd/3rd day of life and disappears within a few days
What is caput sacceddaneum?
-it is a soft, non-fluctuant swelling due to eodema of the presenting part during delivery
When should urine and stool be passed in a newborn baby?
Urine: first 24 hours
Stool: 36 hours which is usually meconium for 2-3 days then turns from green to bl;ack and then the yellow, soft, acid stools appear
What are some of the major factors leading to low birth weight babies?
- Poor sociology-economic background
- Adolescent moms
- Low maternal weight
- Physical exertion late into pregnancy
- Low grade amniotic fluid infection which is common in moms who practice unprotected sex during pregnancy
When a baby struggles to gain weight. What is the main cause?
-undue heat loss
What things mean that the baby can be discharged?
- Temperature control
- Breast feeding has been fully established
- Baby is gaining weight-at least 1% of total body weight daily
- BCG and polio immunization done
- Supplements like multivitamins, folate, iron and vitamin D
What rapid and superficial observations can we make that would direct us to think the baby is preterm or intra-uterine growth restriction?
- Muscle tone
- Nipple development
- Palmar creases
There are a number of systems affected in a preterm (immature neonate) Explain what will happen to each system: 1. Respiratory centre 2. Lung immaturity 3. Liver immaturity 4. GIT immaturity
- Apnoeic and periodic breathing >20 seconds, they are also more sensitive to hypoxia
- Leads to surfactant deficiency and hyaline membrane disease
- Early development of neonatal jaundice and tendency to bleed due to lack of vitamin K dependent coagulation factors
- <35 weeks sucking and feeding is poor. Risk of regurgitation and aspiration
Continued:
- Renal system
- Neurological system
- Bone marrow
- Immaturity immunity
- Oedema caused by decreased GFR and they are unable to excrete water and solute load.
- Intraventricular haemorrhage caused by: fetal hypoxia, birth asphyxia, fluctuations in the blood pressure
- Anaemia- due to exaggerated physiological factors
- Less antibodies transferred from mom to baby due to short 3rd trimester-increased risk of gram negative infections
What are the 14 signs of illness in a neonate?
- Central cyanosis
- Peripheral cyanosis
- Grunting
- Pallor
- Convulsions
- Apnoea
- Lethargy
- Failure to feed
- Fever
- Hypothermia
- Jaundice
- Vomiting
- Diarrhea
- Failure to move a limb
How do most babies lose heat?
-by evaporation and radiation
What is brown fat?
-it is an important site for heat production for which energy is obtained from metabolism of glycogen stored in the liver and myocardium
By how much mortality rate does hypothermia increase the mortality rate in low birth rate babies?
25%
What is the most common cause of hypothermia in a baby?
-low ambient temperature at birth
What factors lead to increased chance of hypothermia in a low birth weight baby?
- Hypoxia
- Hypotonia
- They also have no brown fat to get heat from
What is the management in combating hypothermia in neonates?
- Prevention is better than rewarding a baby
- Wrap baby in a warm towel and include head
- Skin to skin contact with mom is essential
- You can also use incubators, cotton wool, aluminum swaddlers etc.
What is neonatal cold injury?
-caused by prolonged exposure to the cold
What are the features of neonatal cold injury?
- Oedema
- Poor feeding
- Lethargy
- Generalised redness
- Hypoglycaemia
- Convulsions
- Hypoxia
- Sepsis
- Haemorrhage associated with cold injury
What happens when we overheat a baby?
- Vasodilation which leads to dehydration and hypernatraemia
- apnoeic episodes with heat loss and eventually death
What is the value that leads us to classify a baby as hypoglycaemic?
<2 mmol/l or serum blood glucose of <2,5mmol/l
What causes hyperinsulinism in neonates?
-Babies born to diabetic moms and severe erythoblastosis fetalis
What causes increased glucose consumption in neonates?
- hypothermia and hypoxia
- respiratory distress and infection
What is the management of hypoglycaemia in neonates?
- Start the baby on feeds within two hours of birth
- 10% glucose solution must be infused intravenously as soon as possible at 65ml/kg/day
- Increase to 15% if the baby does not respond
- If control is not achieved, give glucagon (0,1ml/kg per dose) intramuscularly
What are the problems a neonate will encounter if from a diabetic mom?
- neural tube, vertebral defects
- sacral agenesis
- cardiac malformations like VSD, transposition and coarctation of the aorta
What are the clinical signs of hyperinsulism in a neonate?
- hypoglycaemia especially in the first 2 hours
- birth injuries like shoulder dystocia (big baby)
- jaundice
- poor feeding, sucking
- respiratory distress syndrome
- polycythemia
- small left colon syndrome presenting as transient intestinal obstruction
- renal vexing thrombosis presenting as macroscopic haematuria
What is hyperglycaemia in a neonate?
HGT of >7,5 mmol/l with glucosuria
What is the management of hyperglycaemia in a neonate?
-give a infusion of insulin at 0,05-0,1 unit/kg/hr and monitor strictly to prevent hypoglycaemia
What are the 4 features you need to consider before diagnosing respiratory distress?
- Tachypnoea>60
- Recession-subcostal and intercostal
- Central cyanosis while breathing air
- expiratory grunting
Having 2 or more of these point to respiratory distress
What are the pulmonary causes of neonatal respiratory distress?
- respiratory distress syndrome
- meconium aspiration
- congenital pneumonia
- transient tachypnea
What are the extra-pulmonary causes of respiratory distress?
- Cardiac failure
- septicaemia
- cold exposure
- cerebral damage
- metabolic disturbances
What are the congenital abnormalities leading to respiratory distress?
- pneumothorax
- lung cysts
- diaphragmatic hernia
- tracheo-oesophageal fistula
What 2 conditions cause upper airway obstruction in neonates?
- Choanal atresia
2. Pierre Robin syndrome
What should be considered if the baby presents with increased secretions, chokes, coughs and becomes cyanosed with feeding?
-oesophageal atresia and this is usually confirmed by failure to pass a nasogastric tube through the stomach
What is the management for respiratory distress in babies?
- Oxygen with nasal cannula kept at 89-92%
- Blood gas analysis
- Whole blood transfusion if HB <12g/dl
- Normal saline or Ringers Lactate infusion given if peripheral and pulse volume is weak
- Capillary refill time is checked often for circulation
- AB given if congenital pneumonia
- HGT must be monitored
What is the degree of cyanosis in a neonate based on?
- pH
- Haematocrit
- Temperature of the baby
- Arterial oxygen saturation
What are the main causes of cyanosis?
- pulmonary pathology
- hyopglycaemia
- hypothermia
- congenital cardiac defects
- septicaemia, meningitis
- severe intracranial disturbance(intra-cranial haemorrhage)
What is hyaline membrane disease?
- It is a condition where the surfactant is deficient which causes collapse of the alveoli
- This is because there is no production or the type 2 alveolar cells are not able to release the surfactant
How do we measure the maturity of the type 2 alveolar cells?
- we use the lecithin to sphingomyelin ratio(L-S ratio), the closer it is to 2:1 the better
- we can do the bubble/shake test where we take amniotic fluid and mix it with alcohol in a 10ml tube for 30 seconds. If there’s bubbles then the lungs are more matured
What are the effects of HMD on the lungs?
- Increased minute volume and work of breathing
- Reduced lung compliance
- Decreased alveolar ventilation and functional residual capacity
- Right to left shunt because of pulmonary vasoconstriction
What are the radiological findings of HMD?
- Air bronchogram +reticulogranular pattern
What is the management to hyaline membrane disease in neonates?
- give them prepared surfactant replacement therapy through endotracheal tubes
- oxygen and the usual
What are the indications for a baby to be put on NCPAP?
- Tachypnoea>60 bpm, apnoea, intercostal and subcostal recession, expiratory grunting, SATS<88%,
- Blood gases of: PaO2<8kpa, PaCO2>6kpa, pH<7,3(respiratory acidosis)
What can we do for the baby other that put them on CPAP?
- Surfactant replacement therapy
2. Give antenatal steroids
What will happen to the lungs if there is meconium aspiration?
- Atelectasis because of small airway obstruction
- Pneumonitis with varying degrees of shock
- Pneumothorax
- Persistent pulmonary hypertension of the newborn
What is persistent pulmonary hypertension of the newborn?
- it is a condition where there is right to left shunting of blood through the foramen ovale and ductus arteriosus
- this occurs because of increased pulmonary vascular resistance
How do we manage persistent pulmonary hypertension of the newborn?
- Start but giving MgSO4- at 200mg/kg IV over 20-30 minutes
- Surfactant replacement therapy
- Sildenafil or nitric oxide
What is transient tachypnoea of the newborn/wet lung syndrome?
- a benign condition that usually occurs to term babies
- they usually present with respiratory distress but this settles within a couple of days
If a neonate experiences apnoea whta must we consider immediately?
-convulsions because neonates rarely have normal signs of convulsions
What is the management of apneoic episodes in neonates?
- Gentle pharyngeal suction
- Oxygen via bag mask ventilation
- Stimulate baby by flicking the foot
- intermittent positive pressure ventilation
- If pulse increases but is of poor quality then give plasma 10ml/kg
- If apnoea of immaturity is diagnosed then give theophylline 5mg/kg
When is chronic lung disease considered in a neonate?
-When the baby is being ventilated or on oxygen for more than 28 days and chest X-ray is has characteristic findings
How do we treat a baby with chronic lung disease aka bronchopulmonary dysplasia?
- Theophylline to help wean the baby off oxygen or ventilator
- Salbutamol or ipratromium bromide can be given as a nebuliser
- Be wary about HIV and TB and cytomegalovirus in these babies
