Week 2 Neonatal Assessment and Resuscitation (everything) Flashcards
There are some similarities between the initial assessment of the neonate and the initial assessment of an adult who requires resuscitation. In both situations, the physician should give immediate attention to
ABCs of resuscitation (i.e., airway, breathing, circulation).
what is the normal neonatal respiratory rate
30-60 Breaths per minute
neonatal breathing should begin at ____seconds and be regular by ____ seconds of age
30
regular at 90
if a neonate does not breath by 90 seconds of age this may indicate ____ or ____ apnea
primary or secondary apnea
what helps initiate breathing efforts during primary apnea
tactile stimulation can initiate breathing efforts
low heart rate is presented which apneas
primary and secondary
reduction of blood pressure is presented during which apneas
secondary apnea
if tactile stimulation does not result in the initiated of spontaneous breathing what is the next step
aggressive resuscitation must be initiated promptly if tactile stimulation does not initiate spontaneous breathing
how many weeks gestation is the fetus for meconium to be present in the intentional tract
31 weeks
which type of pregnancy has the higher incidence of meconium stained amniotic fluid
post term pregnancies
meconium stained amniotic fluid is present in
10-15% of all pregnancies
the preterm neonate- especially the VLBW infant is at higher risk for what problems
Multiple organ system problems simply because of immaturity
what is the treatment for meconium aspiration syndrome?
PPV and is associated with a 5-20% incidence of pneumothorax from pulmonary ark leaks.
what is meconium aspiration syndrome
respiratory distress in a neonate whose airway was exposed to meconium and whose chest radiograph exhibits characteristic findings (pulmonary consolidation and atelectasis)
what was the common practice for meconium aspiration syndrome- no longer done, but may still see it in practice
In an attempt to reduce inhalation of meconium from the pharynx and thus prevent or reduce the severity of MAS the practice of suctioning the mouth and pharynx after delivery of the head, and subsequent intubation to remove meconium from the trachea , was common practice. However, studies have documented that airway suctioning at birth does not prevent MAS
Congenital Anomalies can cause special issues related to what
special resuscitation issues.
congenital abnormalities that cause upper airway obstruction include
micrognathia, macroglossia,laryngeal webs, laryngeal atresia, stenosis , subglottic webs, tracheal agenesis, tracheal rings
what is Exit Procedure - ex utero intrapartum treatment procedure
delivers the fetal head and shoulders, but keeps the lower torso and umbilical cord intact within the uterus. allows surgeon to perform direct laryngoscopy, rigid bronch, tracheostomy. allowing establishment of an airways prior to completing delivery.
what is the benefit of the exit procedure
thereby maintaining placental perfusion and oxygenation
Congenital high airway obstruction syndrome (CHAOS)
Intrinsic airway obstruction of the larynx or upper trachea (e.g., laryngeal web, subglottic cyst, tracheal atresia) can lead to retention of bronchial secretions and subsequent pulmonary distention; this constellation of findings is often classified as
long term survival of children with congenital high airway obstruction syndrome long term survival results when “”” this procedure is used
exit procedure
talk to me about ethical considerations of non initiating resuscitating in the delivery room
extremes of prematurity < 23 weeks. (although massey said we can save down to 20) severe congenital anomalies (anencephaly, confirmed trisomy 13, 18)
talk to me about ethical considerations when stopping resuscitation is appropriate
once further information has been obtained and discussion with family has occurred.
-remember a trial of therapy may be appropriate
for those situation with a poor prognosis- unlikely survival or high morbidity (23-25 weekS) how to we handle the parents desires to initiation of resuscitation
should be supported
the fetus is connected by the
umbilical cord to the placenta
the fetus gets all needed nutrition and oxygen via
the blood vessels in the umbilical cord
“Life support”
Wast products and CO2 from the fetus are sent back through the umbilical cord and
placenta to the mother’s ciruculation to be removed
**the fetal circulatory system uses how many shunts?
3 shunts
**The purpose of these shunts in fetal circulation is to
bypass the lungs and liver
**The shut that bypasses the lungs
Foramen Ovale ***
-moves blood from the RA to the LA
This moves blood from the pulmonary artery to the aorta:
the Ductus arteriosus
enriched blood flows through the umbilical cord to the liver and
splits into 3 branches
The major vein connected to the heart
Inferior vena cava
Most blood is sent through the
ductus venosus
What is the role of the ductus venosus?
also a shunt
-lets highly oxygenated blood bypass the liver to the IVC and then to the RA of the heart.
Does any blood go to the fetal liver?
yes, a small amount of blood goes straight to the liver to give it oxygen and nutrients
**Blood enters the fetal heart via the
RA
- from the RA blood flows through
the foramen ovale to the LA
*From the LA blood passes into
the LV
*From the LV blood passes to the
aorta
*From the aorta, blood is sent to
the heart muscle itself , the brain, and arms
*after blood circulates in the heart,brain, and arms, the blood (core circulation)
returns to the RA via the SVC
*When blood returns to the RA from the core circulation, is it oxygenated or not?
less oxygenated blood
In the RA it mixes with the oxygenated blood.
*After the core circulated blood has returned to the RA, instead of going back through the foramen ovale, it goes
to the RV
*This less oxygenated blood is pumpned from the RV into the
pulmonary artery
- a small amount of blood continues to the lungs
*From the lungs, the blood is shunted through the
ductus arteriosus to the descending aorta
*From the descending aorta, this blood enters the
umbilical arteries and flows into the placenta.
At birth, the umbilical cord is clamped and the baby no longer receives what from the mother
oxygen and nutrients
with the first breaths of life the lungs start to
expand and the alveoli are cleared of fluid
** an increase in the baby’s blood pressure and a major reduction in the pulmonary pressures reduce the need for the:
Ductus arteriosus to shut blood; so it helps the shunt close
The closing of the Ductus Arteriosus raises the pressure in the ____ and lowers the pressure in the ____.
left atrium ; right atrium
** The shift in pressure b/w RA and LA, stimulates what to occur?
the foramen ovale to close
*** What three things must happen to complete the change of fetal to newborn circulation?
the closure of the:
- ductus arteriosus
- ductus venosus
- foramen ovale
Preterm infants and infants requiring cesarean delivery without labor may have what difference to their lungs compared to a baby delivered vaginally?
residual liquid in the lungs.
The residual liquid that is in an infants lungs is far more in a C section baby compared to a vaginal baby, why is this (tell me the process)
If delivered by C section the infant may have greater amount of residual liquid after delivery owing to a reduced catecholamine surge at delivery that promotes sodium channel transport.
(I had always heard it was bc without vaginal delivery it could not be squeezed out lol)
*** The residual lung liquid in the infants lungs (more in there if C section) can cause what kind of issues?
leads to difficulty in initiation and maintenance of normal breathing patterns, and is the cause of transient tachypnea of the newborn. ***
What is Transient tachypnea of the newborn? (TTN)
benign, self limited condition that can present in infants of any gestational age, shortly after birth caused by delay of fluid clearance from the lungs.
Why is the neonate’s first breath important and how long after delivery does it occur typically?
This first breath is important because it establishes the neonate’s functional residual capacity. (FRC)
9 sec after delivery for first breath.
Why do preterm infants have more liquid in their lungs? (we already know why C -section babies do)
2/3 of the liquid is expelled from the lungs of the term neonate by the time of delivery.
(so if pre-term more in the lungs and if pre-term c-section then even more!)
Tell me a major physiologic stimulus for the release of lung surfactant into the alveoli? (bold in ppt)
Lung inflation
WHY is surfactant important?
Surfactant is the liquid in alveoli that decreases surface tension, without it the alveoli would not stay open, they would collapse and no oxygen could make it’s way down to them and no exchange of CO2 and O2 would occur. (collapse lungs)
When is surfactant present within the: alveolar lining cells? lumen of the airways? terminal airways? (it shows up in each place at different weeks of gestation)
alveolar lining cells = 20 weeks
lumen of the airways = 28-32 weeks
terminal airways = 34-38 weeks.
(surfactant can show up in the terminal airways sooner IF stimulated by chronic stress or maternal corticosteroid administration.)
What negative thing can occur (for the fetus) if there is stress during labor and delivery?
(what can get into the babies lungs?)
Stress during labor and delivery can lead to the passage of meconium into the amniotic fluid and gasping efforts by the fetus, which may result in the aspiration of amniotic fluid into the lungs.
What time period of pregnancy is associated with a surge of catecholamines?
Transition to extrauterine life!
hours before delivery and at delivery
** Catecholamines have an important role in the following areas: (four answers)
(1) the production and release of surfactant,
(2) the transition to active sodium transport for absorption of lung fluid,
(3) the mediation of preferential blood flow to vital organs during the period of stress that occurs during every delivery, and
(4) thermoregulation of the neonate.
* ***
What is the major mechanism for neonatal heat regulation?
nonshivering thermogenesis
What two things does the neonate do in response to cold?
what do said responses cause?
raise their metabolic rate and release norepinephrine.
these responses above facilitates the oxidation of brown fat, which contains numerous mitochondria.
Thermal stress (cold) can be a big issue for what type of infants?
infants with low fat stores, such as preterm infants or infants who are small for gestational age. (they do not have as much brown fat and thus can not warm themselves as well)
For most infants, right after they are born, what do we do in order to try and keep them warmer?
dry them and place them in in an appropriate thermoneutral environment, for example with a radiant warmer.
True or false
nonshivering thermogenesis does not consume any oxygen bc no actual shivering is occuring?
False
This process may lead to significant oxygen consumption, especially if the neonate has not been dried and placed in an appropriate thermoneutral environment
What is an alternative method to drying and warming the baby immediately?
An alternative method to eliminate heat loss from evaporation is to provide an occlusive wrap rather than drying the infant.
For what infants would NOT drying and using an occlusive wrap be recommended?
For infants born at less than 28 weeks’ gestation, the use of polythene wraps or bags is recommended to minimize heat loss.
What is the actual temp. for neutral thermal environment for a newborn baby?
34-35 degrees C
Who is the only exception to the “keep warm” after birth rule? You want to keep these infants cool for a while.
the neonate with a perinatal brain injury, mild hypothermia therapy through selective head or whole-body cooling is initiated in the first 6 hours of life and may be neuroprotective in the setting of hypoxia-ischemia.
A nonreassuring FHR tracing is considered a predictor of the need for WHAT?
neonatal resuscitation.
what percentage of neonates require some level of resuscitation?
10%
Infants with congenital anomalies (e.g., tracheoesophageal fistula, diaphragmatic hernia, CNS and cardiac malformations) may need what after they are born?
resuscitation and cardiorespiratory support.
True or False
Preterm delivery increases the likelihood that the neonate will require resuscitation?
True
Anything that causes neonatal depression at birth can increase the likelihood that the neonate will need resuscitation, can you think of some examples of things that cause neonatal depression? (not bold, but just a knowledge check)
neonatal depression at birth can result from acute or chronic uteroplacental insufficiency or acute umbilical cord compression.
Fetal hemorrhage, viral or bacterial infection, meconium aspiration, and exposure to opioids or other CNS depressants also can result in neonatal depression.
What are the parameters for the APGAR score? (what do the letters stand for?)
A- apperance P- pulse G- grimace A- activity R- respirations
at what time intervals after birth is the APGAR assessed?
Apgar score done a 1, 5 and 10 minute interval post delivery.
What points are you assigned based on the APGAR scale? (slide 12)
0, 1, or 2 points assigned for each parameter.
slide 12
APGAR acronym tells you what to look for after birth of an infant but according to the ppt the paramerters are also listed as?
(these parameters are the same essentially as the direct APGAR signs to letters stuff, but I guess this was just another way to say it??)
Parameters are: Heart Rate Respiratory Rate Muscle Tone Reflex Irritability and color
(see it covers the same things as A, P, G, A, R)
APGAR was developed by who?
Developed in 1953 by Anesthesiologist Virginia Apgar.
fetal lungs contain a liquid composed of an
ultrafiltrate of plasma
- that’s secreted by the lungs inutero.
volume of fetal lung ultrafiltrate plasma?
30 mls
at the time of labor and delivery, partial reabsorption of the fetal lung fluid occurs and what happens to the rest?
2/3 is expelled from the lungs of the neonate by the time of delivery
