1. Provincial Reciprocity Attainment Program Neonatal Assessment

2. The Need for Resuscitation Most term newborns require no resuscitation beyond maintenance of temperature, suctioning of the airway, and mild stimulation  Approximately 6% of deliveries require life support  Incidence of complications increases as birth weight decreases

3. The Need for Resuscitation Antepartum (before labor and delivery) and intrapartum (during labor and delivery) risk factors may affect the need for resuscitation  When any of these risk factors are present during delivery or imminent delivery, prepare equipment and drugs that may be required for neonatal resuscitation  Medical direction should also be advised of the situation so that the appropriate destination hospital can be determined.

4. Antepartum Risk Factors Multiple gestation Inadequate prenatal care Mother’s age  Less than age 16 or more than 35 History of perinatal morbidity or mortality Post-term gestation Drugs/medications Toxemia, hypertension, diabetes

5. Intrapartum Risk Factors Premature labor Meconium-stained amniotic fluid Rupture of membranes greater than 24 hours before delivery Use of narcotics within 4 hours of delivery Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding

6. The Premature Infant Refers to a baby born before 37 weeks gestation  The weight of these newborns is often between 0.6 to 2.2 kg [1.5 to 5 pounds] Premature infants have an increased risk for:  Respiratory depression  Hypothermia  Head and brain injury Resuscitation should be attempted if the infant has any signs of life

7. Congenital Anomalies Choanal atresia  A bony or membranous occlusion that blocks the passageway between the nose and pharynx  Can result in serious ventilation problems in the neonate Cleft lip  One or more fissures that originate in the embryo  A vertical, usually off-center split in the upper lip that may extend up to the nose

8. Congenital Anomalies Cleft palate  A fissure in the roof of the mouth that runs along its midline  May extend through both the hard and soft palates into the nasal cavities Pierre Robin syndrome  A complex of anomalies including: A small mandible Cleft lip Cleft palate Other craniofacial abnormalities Defects of the eyes and ears

9. Diaphragmatic Hernia Protrusion of a part of the stomach through an opening in the diaphragm Risk factors  Bag and mask ventilation can worsen condition Pathophysiology  Abdominal contents are displaced into the thorax  Heart may be displaced  Respiratory compromise

10. Physiological Adaptations at Birth At birth, newborns make three major physiological adaptations necessary for survival  Emptying fluids from their lungs and beginning ventilation  Changing their circulatory pattern  Maintaining body temperature

11. Transition From Fetal to Neonatal Circulation Respiratory system must suddenly initiate and maintain oxygenation Infants are very sensitive to hypoxia Permanent brain damage will occur with hypoxemia Apnea in newborns

12. Causes of Hypoxia Compression of the cord Difficult labor and delivery Maternal hemorrhage Airway obstruction Hypothermia Newborn blood loss Immature lungs in the premature newborn

13. Hypothermia Newborns are at great risk for rapidly-developing hypothermia because of:  Their larger body surface area  Decreased tissue insulation  Immature temperature regulatory mechanisms Newborns attempt to conserve body heat through vasoconstriction and increasing their metabolism, placing them at risk for:  Hypoxemia  Acidosis  Bradycardia  Hypoglycemia

14. Assessment and Management Initial steps of neonatal resuscitation (except infants born through meconium): 1.Prevent heat loss 2.Clear the airway by positioning and suctioning 3.Provide tactile stimulation and initiate breathing if necessary 4.Further evaluate the infant

15. Prevention of Heat Loss Immediately after delivery  Dry the infant's head and body  Remove any wet coverings from the infant  Cover with dry wrappings  Cover the newborn's head Accounts for 20% of the newborn’s BSA

16. Opening the Airway Position Suction  Technique Mouth first, than nares Nasal suctioning is a stimulus to breathe  Equipment Bulb suction Suction catheters

17. Provision of Tactile Stimulation If drying and suctioning do not induce respirations, provide additional tactile stimulation  Two safe and appropriate methods are: Slapping or flicking the soles of the feet Rubbing the infant's back If the infant remains apneic after a brief period (5 to 10 seconds) of stimulation:  Immediately initiate positive-pressure ventilation with a pediatric bag-valve device and supplemental oxygen (40 to 60 ventilations/min)

18. Evaluation of the Infant Observe and evaluate the infant's respirations Evaluate the infant's heart rate by stethoscope, or by palpating the pulse in the umbilical cord or brachial artery  HR < 100 Provide ventilation via BVM for 30 seconds and reassess  HR < 60 Provide ventilation via BVM for 30 seconds and reassess If not resolved begin CPR (a rate of > 100)

19. Evaluation of the Infant Evaluate the infant's color  If Central cyanosis, bradycardia and other signs of distress are present in an infant with spontaneous respirations and an adequate heart rate, administer free-flow oxygen at 5 LPM  A maximum oxygen concentration of about 80% can be achieved when the tube is one-half inch from the infant's nose  Peripheral cyanosis is common in newborns and should resolve

20. Apgar Score Enables rapid evaluation of a newborn’s condition at specific intervals after birth  Routinely assessed at 1 and 5 minutes of age Sign012 Appearance (Skin Color) Central cyanosis, palePeripheral cyanosisPink HRAbsent< 100 bpm> 100 bpm Grimace (Irritability)No responseGrimaceCough, sneeze, cry Muscle toneLimpSome flexionActive motion Respiratory EffortAbsentSlow, irregularGood, crying

21. Resuscitation of the Distressed Newborn Risk factors associated with the need for resuscitation include:  Premature delivery  Maternal health problems  Complicated pregnancies  Delivery complications Reevaluating components of the resuscitation process

22. Resuscitation

23. Neonatal Transport During transport of the neonate:  Maintain body temperature  Oxygen administration  Ventilatory support In the prehospital phase of care, transport strategies are usually limited to:  Providing a warm ambulance  Free-flow oxygen administration  Warm blankets

24. Specific Situations

25. Respiratory Disorders Respiratory insufficiency in the neonate is generally managed by:  Stimulation and positioning of the airway  Prevention of heat loss  Oxygenation and ventilation  Suction  Ventilatory support (if needed)

26. Apnea Respiratory pauses that exceed 20 seconds  Common finding in preterm infants, and if prolonged, can lead to hypoxemia and bradycardia  Primary apnea self-limited condition (controlled by pCO 2 levels) that is common immediately after birth  Secondary apnea describes respirations that are absent and that do not begin again spontaneously

27. Apnea Risk factors  Hypoxia  Hypothermia  Narcotic or CNS depressants  Airway or respiratory muscle weakness  Oxyhemoglobin dissociation curve shift  Septicemia  Metabolic Disorders  CNS Disorders

28. Respiratory Distress and Cyanosis Prematurity is the single most common factor for respiratory distress and cyanosis in the neonate  Occurs most frequently in infants less than 1200 g (2.5 pounds) and 30 weeks gestation  Risk factors (see next slide): Can lead to cardiac arrest Requires immediate intervention to support respirations

29. Other Risk Factors Lung or heart disease Primary pulmonary HTN CNS Disorders Mucous obstruction of nasal passages Spontaneous pneumothorax Choanal atresia Meconium aspiration syndrome Amniotic fluid aspiration Lung immaturity Pneumonia Shock and Sepsis Metabolic acidosis Diaphragmatic hernia

30. Dyspnea and Cyanosis S/S may include  Tachypnea  Tachycardia  Paradoxical breathing  Intercostal retractions  Nasal flaring  Expiratory grunting  Central cyanosis

31. Cardiovascular Disorders All neonates with cardiovascular disorders should be assessed for treatable causes of hypoventilation Bradycardia  A heart rate of less than100 beats/min  Causes Hypoxia (most common) Increased intracranial pressure Hypothyroidism Acidosis  Considered a minimal risk to life in neonates if corrected quickly

32. Cardiac Arrest Incidence is rare Risk factors  Intrauterine asphyxia  CNS depressants or other drugs taken by Mom  Congenital neuromuscular disorder  Congenital deformities  Intrapartum Hypoxia Arrest protocols are covered in Pediatrics

33. Hypovolemia May result from:  Dehydration  Hemorrhage  Trauma  Sepsis May be associated with myocardial dysfunction

34. Hypovolemia Signs and symptoms  Mottled or pale skin  Cool  Tachycardia  Diminished peripheral pulses  Delayed cap refill  Pressure is not a good indicator Prehospital care  Airway  Fluid @ 10 ml/kg over 5 - 10 minutes (ALS)

35. Gastrointestinal Disorders Occasional vomiting or diarrhea is not unusual in the neonate  Vomiting mucus (that may occasionally be blood streaked) is common in the first few hours of life 5 to 6 stools per day is considered normal, especially if the infant is breast feeding.  Persistent vomiting and/or diarrhea should be considered warning signs of serious illness

36. Seizures Are usually fragmented and not sustained Subtle seizures may include  Eye deviation  Blinking  Sucking  Swimming movement of arms and peddling of the legs  Apnea Causes  Hypoglycemia  Hypoxic ischemia encephalopathy  Intracranial hemorrhage  Metabolic disturbances  Meningitis or encephalopathy  Development abnormalities  Drug withdrawal

37. Fever Rectal temperature > 38ºC Often a response to an acute viral or bacterial infection  May also be result of Lack of internal temperature control Dehydration May lead to metabolic acidosis  From ↑ O 2 demand and ↑ glucose metabolism

38. Fever Assessment may include  ALOC Irritable Somnolence  History of decreased intake or not feeding at all  Warm or hot skin Treatments are supportive only

39. Hypothermia Body temperature drops below 35 º C BSA and surface to volume ratio makes them susceptible Infants may die of cold exposure at temperatures adults find comfortable Increased metabolic demand may cause metabolic acidosis, pulmonary HTN, and hypoxemia

40. Hypothermia Assessment may include  Pale skin  Cool (especially in the extremities)  Respiratory distress  Apnea  Bradycardia  Central cyanosis  Irritability progressing to lethargic  Absence of shivering Treatment

41. Hypoglycemia A blood glucose screening test less than 4 mmol/L indicates hypoglycemia Risk factors  Asphyxia  Toxemia  Being smaller twin  CNS hemorrhage  Sepsis

42. Hypoglycemia S/S  Twitching or seizure  Limpness  Lethargy  Eye rolling  High pitched cry  Apnea  Irregular respirations  Cyanosis possibly Treatment  1.0 cc/kg D 50 IV (D 10 or D 25 preferred) – Requires ALS

43. Common Birth Injuries 2 - 7 % out of 1000 births results in an injury Risk factors include uncontrolled explosive delivery Types of injuries seen:  Cranial injuries Molding of head and overriding of parietal bones Soft tissue from forceps Subconjunctival and retinal hemorrhage Skull fracture

44. Common Birth Injuries  Intracranial hemorrhage  Spine or spinal cord injury  Peripheral nerve damage  Liver or spleen or kidney  Clavicle or extremity fracture  Hypoxia ischemia Prehospital care  Support vital functions  Rapidly transport to an appropriate medical facility for definitive care

45. Psychological and Emotional Support Be aware of the normal feelings and reactions of parents, siblings, other family members, and caregivers while providing emergency care to an ill or injured child  These events also are often highly charged and emotional for the EMS crew

46. Psychological and Emotional Support As a rule, emergency responders should:  Never discuss the infant’s chances of survival with a parent or family member  Not give “false hope” about the infant’s condition  Assure the family that everything that can be done for the child is being done  Assure the family that their baby will receive the best possible care during transport and while at the emergency department