Lecture 2: Perinatal Care Flashcards
When is a comprehensive newborn assessment to be completed?
Within 24 hours after birth
What is a pre-term baby?
Born prior to 36 weeks and 7 days.
What is a late-term/near-term baby range?
34 weeks - 36 6/7 weeks
What is a term baby range?
37 weeks - 41 weeks 7 days.
What is a post-term baby range?
Greater than 42 weeks
What are we worried about in a late-term/near-term baby?
- Hypoglycemia
- Jaundice
- Respiratory distress
- Temp instability
- Feeding challenges
- Increased readmission
How do we monitor a late-term baby?
- 48 hrs of obs
- Passing carseat test
What is considered SGA birthweight, LGA, and AGA?
- SGA: Less than 10th percentile
- LGA: Greater than 90th percentile
- AGA: 10-90th percentile
GA = gestational age
What is the primary cause of FGR/IUGR?
FGR = fetal growth restriction, IU = intrauterine
Early first-trimester insults like chromosomal or congenital abnormalities, resulting in global growth delay
What characterizes asymmetrical FGR?
Uteroplacental insufficiency or malnutrition that often occurs later, such as 2nd-3rd trimester, causing growth delays due to blood redistribution
What are LGA neonates most at risk for?
Birth trauma, such as brachial plexus inj, clavicle fx, or scalp hematomas
Image of fetal lung physiology
Image of Fetal Circulation
- PDA
- PFO
- Ductus Venosus
Image of fetal lung adaptation at end of gestation
- Increased surfactant production
- Production of fetal lung fluid
Image of stimuli that result in respiratory adaptation
- Thermal stimulation
- Exposure to light & sound
- Tactile stimulation via contractions
Image of CV adaptation
- Increased O2 in blood
- Increased blood flow in lungs
- Increased venous return to LA
- LA pressure increase closes PFO
- O2 constricts ductus arteriosus
Image of CV adaptation Part 2 (Shunt closure)
- Umbilical vein and ductus venosus close
- Increased SVR & O2
- Shunts all close
What does crying do for a newborn fetus?
- Lung expansion and protect lung volume
- Change to rhythmic breathing pattern
What muscles are primary in actual ventilation for a newborn? Quiet breathing?
- Ventilation: diaphragm + intercostals + accessory + abdominal
- Quiet breathing: Diaphragm only
What does clamping of the umbilical cord do?
- Ceases low-resistance circuit in placenta
- Increases systemic BP and relaxing lung vessels
How does fetal life pulmonary circulation differ from live?
- High pulmonary vascular resistance
- Low blood flow
- Most blood is just shunting via ductus arteriosus from the right side of the heart straight to the aorta
When is intubation recommended for a newborn?
Only if concerned for airway obstruction after PPV
What is the preferred site for IV meds for a fetus?
Umbilical vein
What are the 3 considerations to take into concern immediately at birth?
- Is it term?
- What is the tone? (extremity flexion)
- Breathing or crying
Yes to all = no resuscitation
Why is skin to skin preferable for a newborn?
Golden hour!
- Temp regulation
- Trigger mother to produce milk
What 5 steps should we take if 1 of the 3 birth considerations is not met?
- Cut cord and take to warmer
- Stabilize by warming, drying, position airway, clear secretions
- Tactile stimulation during drying
- If bulb suction needed, clear mouth before nose
- Start APGAR clock
What is the resuscitation protocol for a newborn with labored breathing/cyanosis?
- Position and clear airway
- Place spo2 monitor on RIGHT hand/wrist
- Provide supplemental O2 PRN
- Consider CPAP
When is PPV indicated via BVM for a newborn?
Apnea/gasping & HR < 100 BPM
How fast do we ventilate a newborn via BVM?
40-60 breaths per minute
What mnemonic should we keep in mind if PPV does not appear to be working during newborn resuscitation?
- Mask adjustment
- Reposition
- Suction
- Open mouth
- Pressure increase
- Airway change
MR SOPA
When are compressions recommended for newborn resus?
HR < 60 BPM despite 30s of PPV
What is the CPR ratio for newborn resus? (Compressions to breaths)
3:1, 3 compressions per breath for 30 inflations and 90 compressions
Use thumbs to depress sternum
What medication should be considered for a newborn remaining under 60 BPM?
IV Epi @ 1:10,000 concentration via venous or ET tube
If we have bagged a newborn, given epi, and it is still not responding well, what should we consider?
- Hypoglycemia (D10W infusion)
- Hypovolemia (NS or PRBCs)
- Pneumothorax
After how much time should we consider ceasing attempts at newborn resuscitation?
20 minutes
When can PPV be discontinued during resuscitation?
- HR > 100 BPM
- Spontaneous respirations
If a newborn >= 36 weeks received resuscitation, what should we examine for?
Signs of HIE (Hypoxic ischemic encephalopathy) or therapeutic hypothermia
What are the risk factors for respiratory distress in a newborn?
- C-section deliveries
- Decreased gestational age
- Low wt
- Male
- Maternal asthma or gestational diabetes
What are the two factors that result in an increased work of breathing for a newborn?
- Decreased lung compliance
- Increased airway resistance
What is TTN? (Transient tachypnea of the newborn)
- Normal resp is 30-60 bpm
- Correlated with increased C-sections
- Delayed resorption of lung fluid leading to pulmonary edema
What might be seen on CXR for a newborn with TTN?
- Hyperexpansion
- Perihilar densities with fissure fluid
- Pleural effusions
When does TTN present?
First 2 hours, lasting up to 72 hours but typically resolving within 12-24 hrs.
How do we manage TTN?
Supportive care, self-limiting
DO NOT USE LASIX!
Lasix is CI due to wt loss and hyponatremia.
What is meconium aspiration syndrome? (MAS)
- Fetal sterile intestinal fluid that will eventually become its first stool.
- Respiratory distress
- Hypoxia
- Trigger: Uterine stress during delivery
What is the diagnostic criteria for MAS?
- Meconium present in amniotic fluid or trachea during intubation
- CXR: Bilateral fluffy densities with hyperinflation
What is the progression of MAS?
- Meconium aspiration
- Inflammation/obstruction/surfactant inactivation
- Atelectasis
- Rupture of alveoli
- V/Q mismatches
How do we manage MAS?
- Dry, warm, stimulate
- O2 for HR < 100 or CPR for HR < 60
- NOT RECOMMENDED TO INTUBATE
What is the leading respiratory disorder for pre-term infants?
Respiratory distress syndrome (RDS)
Lower age = higher risk
What is pathognomonic for RDS?
Ground-glass appearance on CXR
Differentiates from TTN, which is pulm edema