Neonatology Flashcards
What are the affects of hypoxia in neonates?
Normal labour will result in hypoxia due to compression of the placenta- reduced gaseous exchange.
Hypoxia can lead to bradycardia which will further the hypoxia.
Further hypoxia can lead to unconsciousness and reduced respiratory effort- further existing hypoxia.
Extended hypoxia can lead to hypoxic-ischaemic-encephalopathy which will present as cerebral palsy.
What are the considerations for neonatal resuscitation?
Large SA:V therefore lose heat faster
Born wet so lose heat faster
Can be born through meconium- can get in mouth/airway
What are the steps of neonatal resuscitation?
1) Dry the baby- with towel, place in warm room under warm lamp. <28wks place in plastic bag whilst wet and under heat lamp.
2) Calculate APGAR score at 1, 5 and 10 minutes.
3) Stimulate breathing- position and dry the baby. If meconium obstructing the airway then aspirate.
4) If not responding to stimulated breathing then initiate 2 cycles of 5 inflation breaths (3 secs each). If still poor breathing then begin ventilation breaths (30 secs). If still not managing and HR<60 start compressions, co-ordinate with ventilation breaths (3:1 VB:C). Use air for term babies, use mix of air and O2 for preterm).
Some babies may be severe and so to reduce risk of HIE, start IV drugs and intubation. Can also consider therapeutic cooling as a method of managing severe.
What is the APGAR score?
Score based on:
Appearance- Blue appearance and pale extremities (0), Blue extremities (1), Pink (2)
Pulse- Absent (0), <100 (1), >100 (2)
Grimace- No response (0), little response (1), good response (2)
Activity- Floppy (0), Flexed arms and legs (1), Active (2)
Respiration- Absent (0), Slow/irregular (1), Strong/crying (2)
What is delayed cord clamping?
‘Placental transfusion’.
Shown that delaying the clamping of the cord, even by 1 minute, helps to improve Hb and iron stores, BP, reduces risk of interventricular haemorrhage and necrotising enterocolitis. Can increase risk of jaundice- require phototherapy.
Avoid in neonates in need of resuscitation to avoid HIE.
What is the normal care routine after birth?
Skin to skin contact- Allows for better mother-baby interaction, encourages breast feeding, relaxes baby, warms baby. Cord clamping Dry baby Keep baby warm with hats and blankets Vitamin K injection- Babies usually born with deficiency (therefore increased risk of bleeds i.e. intracranial/gastrointestinal) so given IM shortly after birth- can help to initiate cry to expand the lungs. Can also give orally but will take much longer over several wks. Label the baby Measure and weigh the baby Heel prick test New born hearing test
What is the heel prick test?
Done at day 5 (latest at day 8), need 4 drops of blood and parents consent.
Results within 6-8wks
Testing for 9 diseases: CF Congenital hypothyroidism Sickle cell disease Homocysteine Phenylketonuria GA-1 IVA MCADD Maple Syrup Urine Disease
What is the new born examination?
Screening tool.
Within 72 hrs of birth and repetaed by GP at 6-8wks.
Examination of head, shoulders, chest, abdomen, genitalia, legs and reflexes.
What are examples of birth injuries?
Caput Succedaneum- Oedema between the scalp and periosteum due to traumatic/prolonged birth or instrumental delivery i.e. ventouse. No/little discolouration, passing over the suture lines and will self resolve within a few days.
Cephalohematoma- Blood between the periosteum and skull, will not pass over the suture lines- can differentiate for caput succedaneum. Also blood collection will lead to discolouration. Will self resolve but need to monitor for jaundice and anaemia.
Erb’s palsy- In macrosomia, traumatic birth. Leads to waiters tip.
Facial nerve palsy- Can occur after forceps delivery. Function will return within a few months, if not then contact neurosurgeons.
Clavicular fracture- Can occur in traumatic birth, macrosomia. Asymmetry of shoulders, lack of movement, distress and pain on movement. Confirm with X-Ray or USS. Manage conservatively with splinting, will self resolve. Complications include brachial plexus injury.
What are the common organisms of neonatal sepsis?
What are the RF?
Commonly GBS (Group B Strep). Also E.coli, listeria, Staph.aureus.
RF: Maternal GBS vaginal colonisation Previous GBS pregnancy Prolonged rupture of membranes Early rupture of membranes Maternal sepsis Spontaneous labour Prematurity
What are the common features of neonatal sepsis?
What are the Red Flags?
Features: Fever Poor weight gain Poor feeding Seizure Hypoglycaemia Jaundice within 24hrs Vomiting Respiratory distress Hypoxia Tachycardia/bradycardia
Red Flags:
Sibling from same birth with presumed sepsis
Term baby requiring mechanical ventilation
Respiratory distress 4hrs after birth
Confirmed/suspected maternal sepsis
Seizures
Signs of shock
How is presumed neonatal sepsis managed?
Commonly due to maternal GBS. Therefore if known vaginal GBS give prophylactic benzylpenicillin in labour.
If one RF/clinical feature then observe for 12hrs.
If ≥ 2 RF/clinical features OR 1 red flag give Abx.
Start Abx within 1hr of deciding.
Ensure blood culture before initiating Abx.
Check baseline FBC and CRP. If ?meningitis then need LP.
First line- benzylpenicillin and gentamycin.
Second line- add cefotaxime
Repeat CRP after 24hrs and repeat blood cultures at 36hrs.
Stop Abx if baby is well and blood cultures are negative after 36hrs and CRP <10.
If need to continue Abx then recheck CRP on day 5.
If any CRP results are >10 consider LP.
What is hypoxic-ischaemic encephalopathy?
What are the causes?
Refers to hypoxia which leads to brain injury, this can lead to cerebral palsy.
Suspect if; perinatal/intrapartum hypoxia, umbilical blood gas acidic pH, features of mild/moderate/severe HIE, poor APGAR scores, multi-organ failure etc.
Causes of hypoxia:
Intrapartum haemorrhage
Maternal shock
Prolapsed cord- Compression of cord during labour can lead to hypoxia
Nuchal cord- Cord wraps around the neck of the fetus
What are the features of mild/moderate/severe HIE?
Mild- Poor feeding, irritability. Will resolve within 24hrs, prognosis is normal.
Moderate- Poor feeding, hypotonia, seizures, lethargic. Will resolve within weeks. 40% will develop cerebral palsy.
Severe- Flaccid, absent/poor reflexes, reduced consciousness. 50% mortality, 90% cerebral palsy.
How is hypoxic-ischaemic encephalopathy managed?
What is therapeutic hypothermia?
Supportive management in the neonatal unit including ventilatory support, cardiovascular support, nutrition, treatment of seizures, therapeutic hypothermia etc.
Children with long lasting disabilities should be followed up by paediatrics to provide support.
Therapeutic hypothermia involves reducing body temperature to 33-34 degrees for 72 hrs to limit brain and neuronal damage. Temperature is measured rectally and is increased back to normal gradually within 6hrs.
