Neonatal Assessment RSPT 1471

From Labor and Delivery NICU admits: From Labor and Delivery Prematurity Multiple births Low Apgar Scores Congenital Abnormalities Others…

NICU admits: Tachypnea Respiratory depression Grunting Hypoxemia From Newborn Nursery Tachypnea Respiratory depression Grunting Hypoxemia

Prematurity 36-40 Weeks Gestation is considered “Term” 32-36 Prematurity; Lower percentage of infants ventilated 28-32 Prematurity; Half the infants in need of mechanical ventilation 24-28 Severe Prematurity; Frequently in need of mechanical ventilation

Normal Gestation

Mildly Premature ~35 Weeks

Prematurity ~33 Weeks

Prematurity ~29 Weeks

Prematurity ~27 weeks

Prematurity ~26 Weeks

Jacob at ~27 weeks

Jacob later…

24 Weeks

24 Week Gestation

Multiple Births

Neonatal Recovery Team Physician or Neonatal Nurse Practitioner Nurse Respiratory Therapist

Neonatal Recovery Team A team should be designated and ready to respond immediately and with no warning to Labor and Delivery. “Drop-in”: No prenatal care Previously unrecognized problem For example, these situations give no warning

Neonatal Recovery Team The team also receives prior notice (so that they can be in place at the time of delivery) in the following conditions: Prematurity (<36 Weeks) Multiple Births Cesarean Section Other abnormality….

Neonatal Recovery Team Other abnormalities Breach birth Decelerating heart rate during contractions Difficult labor Infant of diabetic mother (IDM) Possible infant depression due to pain medicine, magnesium or other drug.

Necessary Equipment Isolation gear: Gown, Mask, Gloves Resuscitation box: Airways, Bags, suction equip, etc… Radiant warmer bed Towels and blankets Oxygen outlet or supply Transport isolette Stethoscope

Procedures Don’t Worry… Exact procedures in the use of equipment will be outlined later in Pediatric and Neonatal class RSPT 2453, and in NRP (Neonatal Resuscitation Program) training.

Neonatal Assessment Apgar score Each of these categories is scored with 0, 1 or 2, depending on the observed condition of the newborn. Heart Rate Respiratory Rate Muscle Tone Color Reflex Irritability

Apgar Score Heart rate Heart rate is evaluated by stethoscope. This is the most important assessment: If there is no heartbeat, the infant scores 0 for heart rate. If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate. If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.

Apgar Score Respiratory Effort If there are no respirations, the infant scores 0 for respiratory effort. If the respirations are slow or irregular, the infant scores 1 for respiratory effort. If there is good crying, the infant scores 2 for respiratory effort.

Apgar Score Muscle Tone: If the muscle tone is flaccid, the infant scores 0 for muscle tone. If there is some flexion of the extremities, the infant scores 1 for muscle tone. If there is active motion, the infant score 2 for muscle tone.

Apgar Score Reflex Irritability Reflex irritability is a term describing the level of newborn irritation in response to stimuli (such as a mild pinch): If there is no reaction, the infant scores 0 for reflex irritability. If there is grimacing, the infant scores 1 for reflex irritability. If there is grimacing and a cough, sneeze or a vigorous cry, the infant scores 2 for reflex irritability.

Apgar Score Color If the color is pale blue, the infant scores 0 for color. If the body is pink and the extremities are blue, the infant scores 1 for color. If the entire body is pink, the infant scores 2 for color.

Apgar Score The 1-minute APGAR score assesses how well the infant tolerated the birthing process. The 5-minute APGAR score assesses how well the newborn is adapting to the environment.

Other Assessment Tools Ballard Gestational Age Assessment Silverman Score

Ballard Gestational Age Assessment

Ballard Gestational Age Assessment

Silverman

pH an the Newborn During the transition from fetal circulation to normal circulation, the pH drops. Umbilical Cord pH, drawn after birth, can reveal the stress on the infant. It is expected for the pH to drop as low a 7.20 during delivery. Below 7.0 is considered extreme stress. Infant arterial pH is (generally) slightly acidosis after birth ~7.33

Cord Arterial: Blood leaving the baby… on the way to the gas exchange organ….the placenta.

PO2 and the Newborn Lower levels of PO2 are seen in the infant compared to adults. Partly due to the Infant Hemoglobin’s increased infinity for oxygen. Normal term infants PaO2: 62-86 mmHg Preterm infants PaO2: 52-67 mmHg.

Newborn Normals HR = 100-160 RR = 30-60 BP = 70/50 mmHg

RT Interventions Suctioning Oxygen PPV Bronchial Hygiene treatments CPT Nebulizer

Suctioning Infant head is suctioned upon delivery (first). Again, after delivery and as needed. May use “bulb” syringe to clear mouth, then nose.

Oxygen May use 100% oxygen at delivery by “blow-by” Other devices: Masks Oxy Hoods When available, use a blender to regulate oxygen and avoid over-oxygenation!

PPV In delivery room use bag/mask ventilation when: Infant is apenic Heart rate is <100 and not increasing Color is not improving.

PPV When to use continuous ventilation: Many infants will need a “boost” from PPV to get started breathing in the first few minutes of life. After this brief period of assisted breathing, the infant may be given a chance to breathe spontaneously. If this effort fails, the infant will be intubated.

Bag Mask Ventilation

Continuous ventilation necessitates intubation

PPV Infant Ventilator Time Cycled Pressure Limited

PPV Initial settings Mode = SIMV PIP = 16-28 cmH2O I.T. =.3-.5 seconds Flow = 8-12 l/m RR = 20-40 bpm PEEP = 3-10 cmH2O FIO2 = to maintain PaO2>50

PIP I.T. Rate

PPV In Pressure Ventilation, tidal volume is variable…. In Infant Pressure Ventilation the tidal volumes are so small as to be hard to measure.

PPV PIP indirectly controls this tidal volume and it follows that PIP is directly related to tidal volume…in other words, turn up PIP, and increase the tidal volume

PIP and Rate PPV PaCO2 tells us the adequacy of ventilation. The Infant Ventilator Settings that control PaCO2 are: PIP and Rate

FIO2 and PEEP PPV The ventilator settings that control PaO2 are: And to a lesser degree, PIP

PPV Flow 8-12 and I.T. of .3-.5 Are usually set by physician preference, and left alone.

Other Interventions High Frequency Ventilation Nitrous Oxide ECMO Jet Ventilation Oscillator Nitrous Oxide ECMO