PC 619 Module 2 & 3 EXAM #2

Question 1

immediate care of the newborn

Answer 1

• Place neonate on mother’s abdomen (CNM begins to make brief, informal assessment of NB (before Apgar)→ congenital anomalies, tone, color, HR by palpating cord; remember you won’t wait for 1 minute apgar score to start resuscitation measures if needed)

Question 2

Assignment of Apgar

Answer 2

best if done by one NOT attending birth to decrease risk of bias)

Question 3

The “Golden Hour”

Answer 3

Concept of trauma victims, first 60 minutes are crucial

Question 4

If O2 is needed for resuscitation,

Answer 4

start with RA; 100% O2 can be hazardous to NB

Question 5

Skin-to-Skin Care

Answer 5

Decreases neonatal chilling, promotes breastfeeding, decreases NB crying, may help establish + maternal-child relationship
• Best source of heat to prevent hypothermia. Hypothermia causes significant physiological problems for NB-it makes the baby work really hard (depressed CNS, low BG, acidosis, tachypnea, resp. distress, decreased peripheral perfusion)
• Equal efficacy to incubators at rewarming “cold NBs” (remember we want to do this slowly anyway to prevent apnea)

Question 6

Cord-Clamping

Answer 6

Wait 2-5 min (while infant is skin-to-skin), decreases iron deficiency for 6mo of life, does NOT increase risk of PP hemorrhage, slight increased risk for NB jaundice (most do not require treatment, benefits outweigh risks). NOTE: Do not hold infant below level of perineum (no evidence for this, may cause too large/fast of bolus)

Question 7

Prevention of NB Hypoglycemia

Answer 7

Early & frequent breastfeeding (skin-to-skin helps this), At risk infants be screening (baby of DM mother, preterm, SGA, symptomatic)
• Screening→ Heel stick: Any value of 45-50 should be verified by venous sample & peds notified

Question 8

Initial Treatment

Answer 8

erythromycin : neonatal conjunctivitis

vitamin K: bleeding

Question 9

Ophthalmic→ Erythromycin

Answer 9

can cause chemical conjunctivitis (spontaneously resolves in 1-2 days), consider waiting until end of first hour to apply, used to prevent gonorrhoeae associated neonatal conjunctivitis/blindness (although chlamydia is the main cause of NB conjunctivitis)

Question 10

Vitamin K

Answer 10

NBs are deficient at birth because they don’t have adequate storage, have immature gut flora, and there are only low levels in breast milk.
• Deficiency can cause vitamin K-deficiency bleeding (early onset is with 24hrs, classic within 1-7 days, late within 2-12 weeks)
• Exclusively breastfed infants that do not receive vitamin K injection are especially at risk for late VKDB. Most of these infants have CNS bleeds :(
• Current recommendation: Vitamin K IM 1.0mg X1 (need more evidence for use of oral)

Question 11

NB exam is composed of 3 parts

Answer 11

NB history, Gestational age assessment, and Physical assessment

Question 12

NB History via chart and parent interview:

Answer 12

Environmental (e.g. home, safe drinking water, occupational exposure during pregnancy, health of other children and their ages), Genetic factors, Social factors (abuse, smoking, who is the decision-maker), Maternal medical and perinatal factors (labs, conditions that can impact NB), Neonatal factors (Apgar, any resuscitation-perinatal asphyxia increases risk fo temp instability and hypoglycemia)

Question 13

Gestational Age Assessment:

Answer 13

o Classify infant: preterm (42)
o Combine gestational age assessment with weight categories
o Vernix increases with gestation age
o Lanugo decrease with gestational age

Question 14

Physical Exam

Answer 14

• 3-minute hand scrub prior to exam
• Best to examine 1hr after feed
• Assess infant according to state (e.g. if quiet alert start with HR, RR)

Question 15

Anthropomorphic measurements, Evaluation of organ systems, Neurologic evaluation

Answer 15

o Avoid nondescript phrases like WNL
o Anthropomorphic measurement: length, chest, head (head is usually larger than chest, head circ. may decrease in first week of life d/t reducing caput, etc)
o Birth defects: Most minor malformations, found in isolation are simply physical variants (3 or more suggests underlying syndrome); ambiguous genitalia requires immediate consult (adrenal hyperplasia life threatening)

Question 16

Neuroexam

Answer 16

Assess reflexes, cranial nerves, and special senses
o hypo and hyper responses are cause for concern; reflexes should be symmetrical
o Should have responses to oral, auditory, and olfactory stimulation
o Eyes: pupillary reflex, red reflex (best is awake, alert state), doll’s eye reflex (present=normal, turn head, eyes go opposite), blink reflex
o Upper Extremities: Palmar Grasp
o Lower Extremities: Patellar, Plantar, and Babinski reflex
o Torso: Anal wink, tonic neck reflex
o Moro Reflex: assesses primitive reflex, brainstem, should be present around 25wks gestation. Normal→ abduction & extension of arms, thumb & finger make “C”. No not confuse with “startle pattern” (startle is flexion rather than extension response)

Question 17

APGAR score

Answer 17

Developed by Virginia Apgar. It is a way of assessing adaptation to extrauterine life of a newborn at 1 minute and 5 minutes. (This is very different from assessing intrauterine status prior to birth). Five components including: cardiovascular, circulatory, lung function and neuro-muscular integrity. [Color, heart rate, reflex irritability, muscle tone, respiratory effort]. In order to avoid bias, the person assigning Apgar score must be person not responsible for conducting birth is: obgyn or midwife.

Question 18

limitation of Apgar

Answer 18

• Inappropriate to use Apgar to help predict specific neurological outcome
• No consistent data on Apgar score in preterms; elements of the score partly depend on maturity
• Not to be used to predict diagnosis of asphyxia
• Not to be used to dictate NRP resuscitative actions (do not delay necessary interventions for 1 min score)
• Limitation of Apgar: subjectivity (may be reduced if person assigning isn’t person who delivers); multiple factors can influence score (maternal drugs, resuscitation, trauma, congenital anomalies, infections, hypovolemia)
• Helps assess response to resuscitation, particularly change in score between 1 & 5 min
• Normal score=7-10 at 5 minute; Intermediate score=4-6; 3 and under may predict poor neurologic outcomes (however, shouldn’t be used alone to predict later dysfunction)

Question 19

Circumcision talking points

Answer 19

Current evidence indicates that health benefits outweigh the risks and that the benefits justify access to this procedure for families who choose it” → Benefits supported by evidence, HOWEVER, AAP states that benefits ARE NOT great enough to recommend ROUTINE circ (choice lies with family)

Question 20

circumcision Benefits

Answer 20

Reduced UTI in 1st year of life (NOTE: baseline risk is incredibly low), Reduced risk of heterosexual HIV acquisition and transmission
Reduced UTI, Reduced STI, Reduced penile cancer, Prevents phimosis and associated consequences (only a small percentage of males will have phimosis)

Question 21

circumcision Complications

Answer 21

When performed in neonates rare and are usually minor
Bleeding, infection (very rare
Painful violate of nonconsenting infant
, pain (can disrupt behavior-sleep, parental-child interaction

• May be associated with orgasm difficulties in men and a variety of sexual difficulties in their female partners
• May cause decreased sensitivity

Question 22

Anesthesia should always be used

Answer 22

if not associated with crying, low SpO2, gagging, choking, and emesis; plus…come on UNETHICAL ;)

Question 23

pain control circumcision

Answer 23

• Dorsal penile nerve block most effective pain intervention (decreases crying time, increases SpO2, lower HR, lower pain scores)
• EMLA cream effective reduces pain (less effective than DPNB)
• Tylenol, sucrose, pacifiers, music not shown to be statistically effective (does not impact pain scores or other objective measurements)

Question 24

contraindications (circumcision)

Answer 24

anuria, unstable infants, herpes infection, coagulopathy (any family hx of bleeding disorder), hypospadias, epispadias, chordee

Question 25

• Postcircumcision care:

Answer 25

o Gomco→ use petrolatum gauze
o Plastibell→ avoid petrolatum (can loosen screens)
o Avoid alcohol-containing whipes
o Should void in 6-8hrs
o Reasons for concern: swelling of entire shaft, erythema of entire short or on abdomen at base of penis, bleeding > small spots on diaper, drainage (serous or purulent
o Sponge bath until heals (usually around same time cord separates)

Question 26

vitamin K (reasons)

Answer 26

Newborns do not have Vit K stores and it is also low in breastmilk. Neonates gut flora is immature and so does not produce enought vit K. Def can result in HDN (hemorrhagic disease of the newborn). Early HDN (first 24 hrs of life), classic HDN ( day1-7), late HDN (2-12 wks). Controversy lies in route of administration of vit K. Standard dose 1.0mg IM dose vit K, however some evidence shows 1.omg oral vit K may also be effective

Question 27

vitamin K (controversy)

Answer 27

Controversy surrounds oral vit K’s efficacy at preventing LATE HDN (it has been shown to prevent early/classic HDN, but is less effective than parenteral at preventing late HDN). As of right now, we should be encouraging parenteral vit K for all NBs, especially those who are exclusively breastfed (AAP, 2009). Any association with parenteral vitamin K and childhood cancer has been conclusively ruled out at this point. BBC Highlights→ Parents may have old info and need further education (e.g. that is causes childhood cancer: no it doesn’t; that it is associated with being toxic: no it isn’t, an OLD form was toxic, the current supplementation is not toxic).

Question 28

• Types of Vit K

Answer 28

VK1 (naturally occurring, found in plants); VK2 (naturally occurring created by intestinal bacteria); VK3 (synthetic vitamin)

Question 29

Eye prophylaxis (reason)

Answer 29

Erythromycin is used to prevent blindness associated with Neisseria gonorrhoeae and/or Chlamydia trachomatis. Newborns can develop chemical conjunctivitis from Erythromycin (resolves 24-48 hrs). Interrupts eye to eye contact between mother and newborn, some practitioners wait until newborn is one hour old having been skin to skin with mother

Question 30

eye prophylaxis (controversy)

Answer 30

Erythromycin and tetracycline effective against gonococcal infections, however, they have not been shown effective against chlamydial infections

Question 31

3. Supplemental feeding

Answer 31

• Exclusive breastfeeding preferred until 6 mo (thrive best if fed every 2-4hrs)
• Normal to nurse 5 minutes on both side for first 4 days (this seem low to me); after 4 days at least 10 minutes at each breast
(Thureen et al., 2005, p. 250 & p. 263):
• Treatment of breastfeeding-associated jaundice
• Nursing at least 8-10X/day
• Avoid supplementation with water OR sucrose→ actually be shown to increase bili
• interruption of nursing no necessary (most rapid decline of bili occurs with phototherapy and adequate intake of either breast milk or formula)
• If supplementation required consider casein-hydrolysate forumla
• Breast milk alone may not be adeqaute to maintain glucose in immediate hours after birth, HOWEVER, if asymptomatic and BG>25 feeds alone MAY be adequate
(Brucker & McHugh, 2015, p.1251):
• BF every 2-4 hrs
• Normal to lose 5-7% of birth weight in first few days; should begin gaining weight back at end of 1st week
(Riordan, 2010, p. 373)
• Neonates with jaundice who only need phototherapy should continue to breastfeed
• Feedings should be temporarily stopped if infant requires exchange transfusion
• Adequate breastfeeding should be documented prior to discharge (F/U at 3-5 days)

Question 32

Cord care benefits

Answer 32

current Cochrane review shows babies with antiseptic care to the cord are no more or less likely to develop omphalitis. However studies were done in developed countries with clean conditions. Few studies have been done in low-resource countries where babies are more likely to die from this condition

Question 33

cord care controversy

Answer 33

Antiseptic use for cord care is associated with a delay in cord separation

Question 34

Treatment for jaundice

Answer 34

Treatment includes phototherapy or in severe cases, an exchange transfusion. AAP has guidelines for newborn jaundice that is not completely evidence based but is followed throughout the USA. Home phototherapy is not as effective as hospital but it is less expensive and allows mothers and babies to be together

Question 35

treatment for jaundice controversy

Answer 35

• Worrisome Bili Levels (not associated with physiologic jaundice)→ Visible jaundice in first 24hrs, TSB>5 @ 24hrs; TSB>12-13 @48hrs. Consider phototherapy→ TSB >8 @24hrs; TSB> 13 @ 48hrs; TSB >16 @ 72hrs
• If phototherapy not elected, repeat bili in 12hrs
• Nurse at least 8-10X/day
• Avoid pacifiers and supplementation with water or sucrose
• Use casein-hydrolysate formula IF supplementation is need
• Phototherapy: changes bilirubin’s shape and makes it more water-soluble and is able to be excreted without conjugation; most effective during first 24-48hrs of therapy

Question 36

• Breast milk jaundice

Answer 36

(later onset, due to substance in mother’s milk), bili is usually < 10, if bili gets really high, you can temporarily d/c breastfeeding for 24-48hrs (RARELY IS THIS NEEDED) → This results in a rapid decline in bili, once BFing resume bili will increase but usually to lower levels

Question 37

• Breast milk jaundice

Answer 37

extension of physiologic jaundice seen in healthy NBs that have good weight gain

Question 38

• “Breasting-feeding associated jaundice”

Answer 38

better described as inadequate BFing or starvation jaundice. If jaundice is caused by poor BFing, it should not be considered physiologic (we need to fix poor feeding). Jaundice associated with breastfeeding should be a diagnosis of exclusion

Question 39

breast feeding care

Answer 39

• Unwise to send any couple home that have not established effecting breast feeding (should be evaluated BID in hospital by trained individual)
• F/U care after D/C @ 3-5 days of life or 1-3 days after D/C
• All newborns get bilirubin level screen before discharge (expert opinion), If transcutaneous level is > 15 obtain serum; if level is > 75% on nomogram NB is at risk for significant hyperbilirubinemia, consider delaying D/C
• 75th-95th percentiles of bili level on nomogram strongly predicts that dangerously high bili levels can be anticipated
• Parent teaching: watch for early signs of bilirubin encephalopathy→ lethargy, poor feeding, vomiting, and irregular respirations (this stage may be REVERSIBLE)
• If NB requires exchange transfusion, feeding would be temporarily interrupted
• If treated only with phototherapy, BFing should be continued; oral feedings increase efficacy of phototherapy; IV fluid only needed if there are signs of dehydration
• Home phototherapy is not appropriate for significant hyperbilirubinemia

Question 40

early breastfeeding

Answer 40

Early & frequent feedings (infants fed in the first 1-3hrs of life pass meconium sooner, which decreases risk for enterohepatic recirculation of bili; colostrum acts as laxative); frequent, short feedings are more effective than infrequent prolonged feedings
• Signs of inadequate milk intake: delayed meconium, fewer BMs (< 4-6 wet diapers in 24hrs), weight loss >7%
• Bili F/U AAP recommendations
o If D/C <24hrs→ F/U by 72hrs
o If D/C 24-48hrs→ F/U at 96hrs
o If D/C 48-72→ F/U at 120hrs

Question 41

• Hyperbilirubinemia management

Answer 41

o Consider supplementation (expressed breastmilk or formula) only if there are signs of inadequate intake, excessive weight loss, or signs of dehydration
o If phototherapy is needed, there is no advantage to discontinuing breastfeeding (if levels are <25); any interruption of BFing should be avoided
o If bili approaches 15→ augment feedings, stimulate breastmilk with pumping, and use phototherapy per AAP guidelines
o obtain total bilirubin levels (gold standard for assessment of NB jaundice)
o If using transcutaneous to SCREEN, measurements at sterum have been reported to more more accurate than forehead measurements

Question 42

Routine lab-work

Answer 42

• Universal Newborn Screening (aka “PKU”), state mandated (each state may include different screens) → should only draw after several feeds around 24-48hrs
• Some recommend routine screening of bili before D/C; others state screening (with cutaneous or serum) should be obtain if their are risk factors or visual jaundice is present
• No evidence to support routine blood glucose screening (only perform on high risk and those with symptoms)
• NO WHERE IN THE READINGS: but we always routinely get cord blood on any NB born to a mother with type O blood AND/OR Rh negative status.
• Other non-lab testing: SpO2 (identifies undiagnosed congenital heart defects; should be >95% and less than 3% different between foot and hand), universal screening for hearing (50% have no risk factors, screen ALL),

Question 43

Routine bulb suctioning

Answer 43

• Not recommended per AAP/NRP guidelines, only needed for those requiring assistance. “Normally a gentle face wipe and holding the NB’s head down will use gavity and lung expansion to do the trick?
• Routine suctioning should be abandoned
• DeLee or endotracheal suction of vigorous infant with mec is not recommended
• routine suction at perineum (with mec or not) is not recommended

Question 44

6. Discuss skin to skin or kangaroo care. Why is this practice the preferred method to re-warm a baby?

Answer 44

• Associated with short and long term benefits→ SHORT-TERM: increased temp when compared to infants cared in warmer or dressed/wrapped, less difference between NB’s core temp and skin temp, sleep longer, spend more time in quiet state, better organized at 4hrs of age. LONG-TERM: longer duration of breastfeeding, more maternal positive feelings towards mothering, improved scores for maternal affection & attachment, 90% maternal satisfaction with skin-to-skin (compared to 59% in routine care),
• It is safe, inexpensive, and effective method for regulating thermal environment for healthy NB