1. Neonatal Assessment
RSPT 1471

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

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

4. 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

6. Normal Gestation

7. Mildly Premature ~35 Weeks

8. Prematurity ~33 Weeks

9. Prematurity ~29 Weeks

10. Prematurity ~27 weeks

11. Prematurity ~26 Weeks

16. Jacob at ~27 weeks

17. Jacob later…

18. 24 Weeks

19. 24 Week Gestation

20. Multiple Births

21. Neonatal Recovery Team
Physician or Neonatal Nurse Practitioner
Nurse
Respiratory Therapist

22. 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

23. 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….

24. 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.

25. 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. Other Assessment Tools
Ballard Gestational Age Assessment
Silverman Score

36. Ballard Gestational Age Assessment

37. Ballard Gestational Age Assessment

38. Silverman

39. 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

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

41. 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: mmHg
Preterm infants PaO2: mmHg.

42. Newborn Normals
HR =
RR = 30-60
BP = 70/50 mmHg

43. RT Interventions Suctioning Oxygen PPV Bronchial Hygiene treatments
CPT
Nebulizer

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

45. 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!

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

51. 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.

52. Bag Mask Ventilation

53. Continuous ventilation necessitates intubation

55. PPV
Infant Ventilator
Time Cycled Pressure Limited

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

57. PIP
I.T.
Rate

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

59. 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

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

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

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

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