Neonatology

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Neonatology
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Topics

• Newborns Neonates
• High-Risk Newborn Patients
• APGAR Scoring
• Newborn Resuscitation
• Special Situations

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Introduction

• Neonate
• An infant from the time of birth to
• one month of age
• Newborn
• A baby in the first few hours of its life,
• also known as newly born infant

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Term newborn
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Epidemiology

• Approx. 6 of field deliveries require life
  support.
• The incidence of complications increases as the
  birth weight decreases.
• Approx. 80 of newborns weighing 1500 g (3
  pounds, 5 ounces) at birth require resuscitation.

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• Determine at-risk newborns by considering
  antepartum and intrapartum factors that may
  indicate delivery complications.
• Antepartum before the onset of labor
• Intrapartum occurring during childbirth

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Pathophysiology

• Dramatic changes occur within the
• newborn to prepare it for extrauterine life.
• Fluid in the fetal lungs will be forced out of
• the lungs during delivery by compression
• of the chest and by entry of air into the
• lungs.

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Factors that stimulate the babys first breath

• Mild acidosis
• Initiation of stretch reflexes in the lungs
• Hypoxia
• Hypothermia

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Hemodynamic changes in the newborn at birth.
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Congenital Anomalies

• Diaphragmatic hernia
• Meningomyelocele
• Omphalocele
• Choanal atresia
• Cleft palate
• Cleft lip
• Pierre Robin Syndrome

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Assessment

• Assess the newborn immediately after birth.
• Ideally, one paramedic attends the mother while
  the other attends the newborn.
• Remembernewborns will be slippery and require
  both hands.

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• Normal heart rate 150180 per minute.
• Slowing to 130140 thereafter.
• A pulse less than 100 indicates distress.
• Normal respiratory rate 4060 per minute.
• Evaluate skin color as well.
• Use the APGAR score.

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APGAR Scale
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Treatment
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Establishing an Airway

• Airway management is one of the most critical
  steps in caring for the newborn.
• Suction the babys mouth first, then the
• nose, to avoid risk of aspiration.

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Position of newborn when first suctioning upon
delivery.
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Suctioning of the mouth using flexible suction
catheter.
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Intubation for removal of residual meconium.
Figure 1-4b
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Stimulate the newborn as required by flicking
its feet or rubbing its backDO NOT spank or
vigorously rub a newborn baby!
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Prevention of Heat Loss

• Heat loss can be life-threatening to newborns.
• Most heat loss results from evaporation.
• Core temp. can quickly drop 1 Celsius from its
  original temp.

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To prevent heat loss

• Dry the newborn immediately.
• Maintain room temperature at 7476 degrees.
• Close all windows and doors.
• Swaddle the infant in a warm, dry receiving
  blanket or other suitable material.
• In colder areas, use water bottles or rubber
  gloves filled with warm water.

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Dry the infant to prevent loss of evaporative
heat.
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Cutting the Umbilical Cord

• AFTER you have stabilized the patients airway
  and minimized heat loss, clamp and cut the
  umbilical cord.
• Do not milk or strip the cord.
• Apply the clamps within 3045 seconds after birth.

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Positioning of the infant before clamping the
cord.
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Clamping and cutting the cord.
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THE DISTRESSEDNEWBORN
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• The distressed newborn can either be full term or
  premature.
• Aspiration of meconium can cause significant
  problems and should be prevented.
• The most common problems experienced by newborns
  during the first minutes of life involve the
  airway.
• Of the vital signs, heart rate is the most
  important indicator of neonatal distress.
• A HR lt 60 should be treated with chest
  compressions.

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• Your success in treating at-risk newborns
• increases with training, ongoing practice,
• and proper stocking of equipment on board your
  unit.

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Inverted Pyramid for Resuscitation
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Resuscitation of the Distressed Newborn
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Positioning the newborn to open the airway.
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Ventilate with 100 oxygen for 1530 seconds.
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Evaluate heart rate.
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Initiate chest compressions if HR is less than
60 or is between 60 and 80 and is NOT increasing.
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• Evaluate heart rate
• Below 80continue chest compressions.
• 80 or abovediscontinue compressions.

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More Thoughts on the Inverted Pyramid
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Drying, Warming, Positioning, Suctioning,
Stimulating

• Never suction for more than 10 seconds.
• Suction first with bulb syringe and using a DeLee
  suction trap if meconium is present.
• If there is a great deal of meconium, place an
  appropriately sized ET tube and suction directly
  from the tube.

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Endotracheal Intubation Tracheal Suctioning in
the Newborn
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Position the infant.
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Insert the larynogscope.
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Elevate the epiglottis by lifting.
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Visualize the cords.
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Suction any meconium present.
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Insert a fresh tube for ventilation.
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Remove the laryngoscope.
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Check proper tube placement.
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Oxygen

• If central cyanosis is present, administer
  supplemental oxygen.
• If possible, oxygen should be warmed and
  humidified.
• Never deprive a newborn of oxygen in the
  prehospital setting, for fear of toxicity.

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Estimating oxygen concentration
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Ventilation

• Begin positive-pressure ventilation if any of the
  following is present
• Heart rate less than 100 beats per minute
• Apnea
• Persistent central cyanosis

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• Endotracheal intubation of a newborn should be
  carried out in the following situations
• The BVM does not work.
• Tracheal suctioning is required.
• Prolonged ventilation will be required.
• A diaphragmatic hernia is suspected.

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Use of a bag-valve mask
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Chest Compressions

• Initiate chest compressions if either of the
  following conditions exists
• The heart rate is less than 60 beats per minute.
• The heart rate is between 60 and 80, but does not
  increase with 30 seconds of positive-pressure
  ventilation and oxygenation.

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Finger positions for infant sizes
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Medications Fluids

• Most cardiopulmonary arrests in newborns result
  from hypoxia, so initial therapy consists of
  oxygen and ventilation.
• When oxygen ventilation fail, fluids and
  medications should be administered.
• Vascular access can be managed by using the
  umbilical vein.

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The umbilical cord
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Maternal Narcotic Use

• May complicate delivery.
• Shown to produce low birth weight infants.
• Such infants may demonstrate withdrawal symptoms,
  such as tremors, startles, decreased alertness,
  and respiratory distress.
• Naloxone is the drug of choice for respiratory
  depression, secondary to maternal narcotic use.

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Healthy newborns should be allowed to begin the
bonding process with the mother as soon as
possible.
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Neonatal Transport

• Paramedics are called upon to transport a
  high-risk newborn from one facility to a neonatal
  intensive care unit (NICU).
• During transport, help to maintain body
  temperature, control oxygen, and maintain
  ventilatory support.

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Neonatal transport isolette
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Specific Neonatal Situations
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Meconium-Stained Amniotic Fluid

• Occurs in approx. 1015 of deliveries.
• An infant born in the presence of thin meconium
  may not require treatment, but those born through
  thick meconium should be intubated immediately.

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Intubating the infant
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Apnea

• Usually due to hypoxia or hypothermia other
  causes include
• Narcotic or CNS depressants
• Weakness of respiratory muscles
• Septicemia
• Metabolic disorders
• CNS disorders

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Diaphragmatic Hernia

• Most common posterolaterally.
• A rare condition (1 in every 2200 births).
• Survival rate is 50.
• Do not use BVM if necessary, provide
  positive-pressure ventilation via ET tube.

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Head and thorax elevated
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Bradycardia

• Most commonly caused by hypoxia.
• Resist the temptation to treat bradycardia in a
  newborn with pharmacological measures alone.

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Premature Infants

• Are at a greater risk of respiratory depression,
  head injury, changes in blood pressure,
  intraventricular hemorrhage, and fluctuations in
  fluid osmolarity.

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Other Problems

• Seizuresmay indicate serious illness.
• Feveruncommon and may also indicate serious
  underlying illness.
• Hypothermiamay indicate sepsis.
• Hypoglycemiacheck blood glucose on all sick or
  unhealthy infants.
• Vomiting/diarrheamay cause dehydration and
  electrolyte imbalance.

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Cardiac Resuscitation, Post Resuscitation,
Stabilization

• The incidence of neonatal cardiac arrest is
  related primarily to hypoxia.
• Risk factors include
• Bradycardia, intrauterine asphyxia
• Prematurity, maternal drug use
• Congenital diseases
• Intrapartum hypoxemia

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Summary

• Newborns Neonates
• High-Risk Newborn Patients
• APGAR Scoring
• Newborn Resuscitation
• Special Situations