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19 Cards in this Set

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Apgar Scoring System measures what five parameters?

How often is it performed?

What scores are normal and what scores are abnormal?
Heart Rate
Respiratory Rate
Muscle Tone
Reflex Irritability (facial expression)
Color

It is performed at 1 minute and then again at 5 minutes.

8-10 = Normal
4-7 = Moderate distress or impairment
0-3 = Needs immediate Resuscitation!!!


Color–0 for blue, 2 for pink
Heart rate–0 for none, 1 for <100/min, 2 for > 100/min
Grimace Reflex–0 for none, 1 for grimace, 2 for cough/sneeze
Activity/ Muscle tone–0 for limp, 2 for full flexion
Respiratory effort : 0 for absent, 2 for strong crying
Laryngoscope Blade sizes for a premie and a full term neonate???
Premie: Miller 0
Full Term: Miller 1
What meds should be avaliable for neonatal resuscitaton?
Epinephrine 1:10,000 (0.1 mg/mL), 3-10 mL ampules
Isotonic crystalloid (NS or LR) for volume expansion (100-250 mL)
Sodium Bicarbonate 4.2% (5 mEq/10 mL): 10 mL amplules
Naloxone HCl 0.4 mg/mL: 1-mL ampules (or 1 mg/mL: 2 mL ampules).
Normal Saline 30 mL
Dextrose 10% 250 mL
Antepartum Risk Factors for the need for neonatal resusitation
Maternal Diabetes
Pregnancy-induced HTN
Chronic HTN
Chronic maternal illness
Cardiovascular
Thyroid
Neurologic
Pulmonary
Renal
Anemia
Previous fetal or neonatal death
Bleeding in second or third trimester
Maternal Infection
Polyhydraminos
Oligohydraminos
Premature rupture of membranes
Postterm gestation
Multiple gestation
Size-dates discrepancy
Drug Therapy (lithium carbonates, magnesium, Adrenergic Blocking Drugs).
Maternal Substance Abuse
Fetal malformation
Diminished fetal activity
No prenatal care
Age < 16 yrs and > 35 yrs
Intrapartum Risk Factors Suggesting an Increased Risk of needing neonatal resuscitation...
Emergency C-section
Forceps or vaccum assisted delivery
Breech or abnormal presentation
Premature labor
Precipitous labor
Chorioamnionitis
Prolonged rupture of membranes (> 18 hrs before delivery).
Prolonged labor > 24 hrs
Prolonged second stage of labor > 2 hours.
Fetal bradycardia
Non-reassuring fetal heart rate patterns.
Use of general anesthesia.
Uterine tetany
Narcotics administered to mom w/n 4 hours of delivery.
Meconium stained amniotic fluid
Prolapsed cord
Abruptio placentae
Placenta previa.
Describe the physiology of the transition to birth
Vaginal canal squeeze the amniotic fluid from baby's lungs. The rest is eliminated in first breath...it's pushed across the aveolar epithelium.

Cord is clamped, this increases SVR and makes the baby hypoxic.

Hypoxic baby now has stimulated carotid body chemoreceptors, and takes it's first breath...this decreases PVR. Minute ventilation is increased.

Lung Expansion and aeration is a stimulant for surfactant release.

Stoke Volume increases from 150- 400 mL/kg/min due to closure of the DA and FA. (FA closes when PVR decreases with first breath. Right atrial pressure decreases and Left Atrial Pressure increases. DA closes with increased O2 tension, cats, and decr prostaglandin.)
On average healthy vigorous infants have a oxygen saturation of ___ with a pH of ____ and a Pco2 of __ mm Hg.
On average healthy vigorous infants have a oxygen saturation of 21% with a pH of 7.24 and a Pco2 of 56 mm Hg.
Reasons for fetal asphyxia and hypoxia at birth:
During labor – uterine contactions decrease blood flow through the palcenta( or even stop flow completely) (autotranfustion of catecholamines)

On the fetal side – cord compression during the final stage of labor in vaginal deliveries.(occurs in about 33% of normal deliveries)
How does the neonate respond to asphyxia?
Initially there is an increase in BP.

Then, hypoxia and acidosis cause the myocardium to fail and BP then decreases.

Minute ventilation will initially increase due to chemoreceptor stimulation. Then, the baby becomes apneic...

PRIMARY APNEA - caused by hypoxia and acidosis...infant will breathe again if stimulated.

SECONDARY APNEA - baby starts with irregular gasping (Cheynnes Stokes) which slows and ceases and will not respond to stimulation. Must provide positive pressure ventilation, intubate, and ventilate ASAP.

Primary apnea comes first, but you won't know if it's primary or secondary so you must assume secondary and ventilate.
Explain what happens when an infant becomes apneic and stays apneic...what physiological changes occur and what are some other conditions that develop?
Primary apnea leads to gasping and then secondary aprea.

Baby has increased BP initially and increase HR, then both fall. (heart can no longer compensate due to fixed stroke volume)

Anaerobic glycolysis occurs due to hypoxia. This increases CO2 and lactic acid buildup, baby's pH drops.

Low pH (less than 7.0) will inhibit further anaerobic glycolysis, which is pH dependent, so baby becomes hypoglycemic!!

Must ventilate the baby ASAP!! blow off the CO2 and oxygenate!!
What can cause mechanical blockage of the airway in neonates and lead to the need for resuscitation?
Meconium aspiration or mucus blockage - Baby will have meconium stained amniotic fluid and/ or poor chest wall movement. Tx: Intubate: Then suction out and ventilate.

Choanal Atresia - Baby will have tissue blocking nasal airway..baby's are nasal breathers so baby will become apneic when not crying. (Pink when crying, cyanotic when quiet). Tx: Put in an oral airway or intubate. Surgeon will have to come and remove the blockage.

Pharyngeal Airway Malformation: Baby will have persistent retractions and poor air entry - Tx: Pt baby in the prone postion to open the airway. Consider a posterior nasopharyngeal tube.
Resuscitation Equipment in the Delivery Room:
See nagelhout page 1140
Normal RR of a neonate is...
40-60
What indicates the need for resuscitation?
Apnea
Apgar 7 or below
Resp Distress
HR < 100
When do you have a neonate medication for bradycardia and what med do you give (dose?)
If infants HR less than 80 beats/min after ventilation and compressions for 30 seconds or asystolic.
What is the problem with using sodium bicarb and volume expanders in premies?
The use of sodium bicarbonate and volume expanders like albumin in premature infants(less than 36 weeks) has been shown to precipitate intracranial hemorrhage due to the immature cerebral vasculature.
When does meconium staining most often occur?
In infants that are > 34 weeks gestation.

Hypoxia causes anal spinchter to relax and meconium to leak out into amniotic fluid.
What do you do when a baby is born with stained meconium?
DO NOT orosuction the head once it is presented...this will cause crying and you don't want crying...will induce respiratory distress.

Vigorous infants that are not intubated are at no risk of aspiration. If infant has aspirated and is vigorous..don’t intubate. Only intubate if they are obtunded, apneic, etc.

Depressed infants should be intubated and suctioned via the ETT before stimulation. There are two intubations:
1) The meconium aspirator should be applied to ETT and 120 mm Hg pressure should be applied as the tube is then removed.
2) With the second intubation and after suction is applied, PPV should then be applied via the ETT.
What are the proper sized tubes for neonates 1000g to > 3000g?
< 1000g = 2.5 ETT
1000g- 2000g = 3.0 ETT
2000g - 3000g = 3.5 ETT
> 3000g = 4.0 ETT