Fetus and Newborn CPS Flashcards
How long should skin to skin post birth last
At least an hour uninterrupted
WHO recommends 8 hours per day
Benefits of skin to skin care
Improved duration and volume of breastfeeding
Lower mortality, hypothermia, suspected sepsis
Cardiopulmonary stability
Colonization of infant microbiome
Pain management in infants
Stress regulation
Neurodevelopmental benefits
Improved parent infant interaction and parental mental health
Which infants may need delay of skin to skin care?
Extremely preterm infants
May be warranted for concerns regarding handling and neuroprotection
3 relative contraindications for skin to skin care
Abdominal wall or neural tube defects
Postoperative instability
Significant instability associated with clinical handling, or prolonged recovery
Definition of
1. Preterm
2. Very preterm
3. Extremely preterm
Infants
- 37 weeks or less
- < 32 weeks
- < 28 weeks
Duration of DCC for
1. Preterm and extremely preterm
2. Term
singleton infants
- 60 to 120 s
- 60 s
Benefits of DCC in preterm and extremely preterm singletons
Decreases newborn mortality and morbidity
Improves hemotological outcomes (slightly increased hematocrit and ferritin)
Reduced risk of death or adverse neurodevelopmental outcomes at 2 years
Risk with DCC longer than 60s in term infant
Increases risk of hyperbilirubinemia requiring phototherapy
Is DCC recommended in twins?
Yes, unless contraindications
Presumed 30 to 60 s duration
When do you give uterotonic medications in
1. Preterm
2. Term
infants
- After clamping cord (avoid bolus of blood)
- With delivery of anterior shoulder (higher risk for maternal PPH)
6 absolute contraindications for DCC
Fetal hydrops
Certain fetal anomalies (diaphragmatic hernia)
Need for immediate resus of mom or babe
Disrupted utero-placental circulation (bleeding vasa previa or placenta previa, placental transection or abruption)
Twin to twin transfusion syndrome
Twin anemia polycythemia sequence
3 relative contraindications to DCC
Risk factors for severe hyperbilirubinemia in term infants
High maternal antibody titers
First infant in a pair of monochorionic twins
Is umbilical cord milking recommended
No
Increased risk for severe IVH in very preterm infants
How long do you need to observe an infant at risk for NAS for?
72 hours
Are preterm infants at higher or lower risk for NAS? Why?
Lower
Shorter in utero exposure time, decreased placental transmission, inability to fully excrete drugs by immature kidneys and liver, minimal fat stores, and limited capacity to express classic NAS symptoms by the immature brain
Poor neonatal adaption syndrome
Can occur in infants born to mothers on SSRIs or SNRIs
Symptoms → poor muscle tone, tremors, jitteriness, irritability, seizures, feeding difficulties, sleep disturbances, hypoglycemia, and respiratory distress
Mechanism is not completely understood, but may relate to either a withdrawal from maternal SSRI or SNRI exposure, or overstimulation from serotonin toxicity
Management of PNAS
Managing PNAS includes providing a quiet environment, swaddling, skin-to-skin care, and frequent small feeds. Breastfeeding should be encouraged
Should prophylactic surfactant be given to newborns with RDS?
No
Surfactant should be reserved for infants who need it
What oxygen levels should surfactant be
1. considered
2. given
in a baby with RDS
- 30-50%
- 50%
How long should you use corrected age to?
3 years
Early signs of CP
- Hand preference
- Stiffness or tightness in the legs
- Inability to sit by 9 months corrected age
- Persistent fisting of hands beyond 4 months CA
- Delayed or asymmetrical movement
How much iron should premature breastfed infants get? For how long?
2-3 mg/kg/day
For at least 1 year
Should immunizations be based on chronologic or corrected gestational age?
Chronologic
Brachial plexus palsy is a result of injury to which spinal levels?
C5-T1
Risk factors for brachial palsy
Shoulder dystocia
Uterine abnormalities like bicornuate uterus
Maternal diabetes
Forceps or vacuum
Episiotomy
Fetal or birth asphyxia
Macrosomia
LGA
Group 1 brachial plexus palsy
1. Name
2. Roots involve
3. Symptoms
- Classic Erb’s palsy
- C5 or C6
- Absent shoulder abduction, external rotation, elbow flexion, and forearm supination
Group 2 brachial plexus palsy
1. Name
2. Roots involve
3. Symptoms
- Extended Erb’s palsy
- C5 to C7
3.Absent shoulder abduction, external rotation, elbow flexion, and forearm supination, absence of wrist and digital extension
Group 3 brachial plexus palsy
1. Name
2. Roots involve
3. Symptoms
- Total palsy without Horner’s syndrome
- C5-T1
- Complete flaccid paralysis
Group 4 brachial plexus palsy
1. Name
2. Roots involve
3. Symptoms
- Total paralysis with Horner’s syndrome
- C5-T1 and sympathetic chain involvement
3.Complete flaccid paralysis with Horner’s (miosis, ptosis, ipsilateral facial anhidrosis), may have phrenic nerve palsy and elevated ipsilateral hemi-diaphragm
Definitions of
1. Neuropraxia
2. Axonotmesis
3. Neurotmesis
And expected recovery
- Temporary conduction block due to interruption of the myelin sheath. Full recovery within weeks
- Disruption of the nerve fibers and likely the myelin sheath. Some improvement but incomplete
- Nerve disruption and avulsion of the nerve roots from the spinal cord. No chance of recovery
When should infants with brachial plexus palsy be referred to specialized center?
If they have no active elbow extension at 1 month
Which infants should get a routine head US? When is the repeat imaging?
< 32 weeks, get HUS at 4-7 days post birth
Repeat 4-6 weeks post birth
Term imaging if < 26 weeks
Criteria A for HIE cooling
Cord pH 7.0 or less, OR base deficit -16 or more
Criteria B for HIE cooling
pH 7.01 to 7.15 or base deficit -10 to -15.9 on cord gas or blood gas within 1 hour AND
- History of acute perinatal event (prolapse, abruption, uterine rupture, etc)
AND - APGAR score 5 or less at 10 minutes, or 10+ minutes of PPV
Criteria C for HIE cooling
Evidence of moderate to severe encephalopathy → seizures, OR at least 1 sign in 3 or more of the following 6 categories: LOC, spontaneous activity, posture, tone, reflexes, autonomic system
Contraindications to cooling for HIE
- Moribund infants
- Infants with major congenital or genetic abnormalities for whom no further aggressive treatment is planned
- Infants with severe IUGR
- Infants with clinically significant coagulopathy
- Infants with evidence of severe head trauma or intracranial bleeding
- Isolated IVH is not not an absolute contraindication
Side effects of cooling
- Sinus bradycardia
- Hypotension
- Mild thrombocytopenia
- Persistent pulmonary hypertension with impaired oxygenation
- Prolonged bleeding time
- Subcutaneous fate necrosis
Target temperature for cooling for HIE
33.5 +/- 0.5 degrees for whole body cooling
How long to cool HIE babies for and how fast to rewarm
72 hours
Rewarm infants by 0.5 degrees every 1 to 2 hours
When should MR be done post cooling for HIE?
Typically done after rewarming, so on days 4-5
Time frames for
1. Early
2. Classic
3. Late
Vitamin K deficiency bleeding
- first 24 hours
- 2 to 7 days
- 2 to 12 weeks, but can be up to 6 months
Causes of
1. Early
2. Classic
3. Late
Vitamin K deficiency bleeding
- Maternal medications that inhibit vitamin K activity
- Low intake of vitamin K
- Chronic malabsorption and low vitamin K intake
How can we give vitamin K if parents refuse IM dosing
2 mg at first feeding
Repeat at 2-4 weeks of age
Repeat at 6-8 weeks of age
Early onset sepsis risk factors (5)
- Maternal intrapartum GBS colonization
- GBS bacteruria at any time during current pregnancy
- Previous infant with invasive GBS disease
- Prolonged ROM 18 hours +
- Maternal fever
What is adequate maternal treatment for GBS positive mothers
1 dose at least 4 hours before birth of IV pen G or IV cefazolin
Clinda and erythro or vanco is INADEQUATE
Does an LP need to be done if blood cultures are positive in an infant <7 days
YES
Findings on a CBC associated with early onset sepsis
WBC < 5
ANC < 1.5
Abnormal CSF WBC count in term infants
> 20-25
How to manage newborn infants with resp distress who appear stable and have no perinatal risk factors
Can be observed for up to 6 hours to monitor for resolution
If not, will need investigation for sepsis and antibiotics
How to manage:
GBS + mom with ADEQUATE prophylaxis, no other risk factors
No investigations or treatment if infant is well
Discharge home at normal time
How to manage:
GBS + mom with INADEQUATE prophylaxis, no other risk factors
Careful assessment, close observation
Vitals q3-4 x 24 hours
Labs not indicated
Discharge between 24-48 hours
How to manage:
GBS + mom with other risk factors, with or without prophylaxis
Consider severity of each risk factor
Observe closely for 24 to 48 hours
CBC after 4 hours may be helpful
How to manage:
GBS - or unknown mom with other risk factors
Manage same as born to GBS + moms if only 1 risk factor
Individualized management if multiple risk factors
How to manage:
Infants born to moms with chorioamnionitis
Term and well appearing = observe for 24 hours
Multiple risk factors, no antibiotics, mom unwell = consider investigation and antibiotics
