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Neonatal emergencieslecture 1
Dr. Miada Mahmoud Rady
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Lecture topics
1. Important definitions.
2. Transition from fetal to neonatal circulation.
3. Epidemiology of fetal distress.
4. Neonatal resuscitation .
5. Apgar score.
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Definitions
I. Newborn : A recently born infant, usually during the
first few hours of life.
II. Neonate : Baby during the first 28 days of life.
III. Preterm : less than 37 completed weeks.
IV. Term : 38 to 42 completed weeks.
V. Post-term : more than 42 weeks.
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Transition from fetal to neonatal circulation
With the first breath, circulation changes.
1. Larger amount of blood is sent to the lungs
2. Ductus arteriosus begins to wither and close off
3. Circulation to the lungs increases left atrium
flow, increased pressure causes the foremen
ovale to close and blood circulates normally
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Transition from fetal to neonatal circulation
Respiratory system must suddenly initiate and
maintain oxygen:
– Change from maternal circulation (placenta) to
neonatel circulation.
– Chest expands, fluid is forced from lungs and oxygen
exchange begins.
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• Stimulant for the first breath:
1. First breath triggered by mild hypoxia and hypercapnia
from partial occlusion of the umbilical cord during
delivery.
2. Also Tactile stimulation and cold stress promote early
breathing.
During the first breath , pulmonary vascular
resistance drops .
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Delay in drop pulmonary pressure leads to:
a.Delayed transition
b.Hypoxia
c. Brain injury
d.Death
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Epidemiology of fetal distress• Incidence
– Approximately 6% of deliveries require life support
– Incidence of complications increases as Birth Weight
Decreases
• Morbidity / mortality
– Neonatal mortality risk can be determined based on birth
weight and gestational age
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Risk factors of fetal distress
A. Antepartum factors
1. Multiple gestation
2. Inadequate prenatal care
3. Mother’s age <16 or >35
4. Post-term gestation
5. Drugs / medications
6. Toxemia, hypertension, diabetes
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Risk factors of fetal distress
B. Intrapartum factors
1. Meconium-stained amniotic fluid
2. Rupture of membranes greater than 24 hours prior to delivery
3. Abnormal presentation
4. Prolonged labor or precipitous delivery
5. Prolapsed cord
6. Sever bleeding
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Neonatal resuscitation
1. Initial steps of neonatal resuscitation include:
I. Airway (position and clear)
II. Breathing (stimulate to breathe)
III. Circulation (assess heart rate and oxygenation)
2. Additional resuscitation steps :
• They are used based on need and include →
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Additional Resuscitation Steps Include:
1. Supplemental oxygen.
2. Positive pressure ventilation.
3. Intubation.
4. Chest compressions.
5. Medications.
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Initial steps of stabilizing a newborn
I. Warming the newborn to prevent hypothermia.
II. Positioning the newborn
III. Clearing the airway if necessary
IV. Drying and stimulating breathing
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1. Place on prewarmed towels or blankets and dry.
2. Replace wet towels with dry, prewarmed ones.
3. When resuscitation is complete, place the newborn on
the mother’s chest or abdomen, another heat source, or
under a radiant warmer.
I. Warming the newborn to prevent
hypothermia:
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II. Positioning the newborn:
1. Position on the back or side with the neck in the sniffing
position.
2. Use a small shoulder roll to keep the head in this position.
II. Clearing the airway :
1. Use a bulb syringe or suction catheter.
2. Turn the head to the side.
3. Suction the mouth before the nose to prevent aspiration.
4. Return the head to the sniffing position.
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IV. Drying and stimulating breathing:
1. Dry the head and body with towels to provide
stimulation.
2. Additional tactile stimulation methods include:
3. Slapping/flicking soles of the feet
4. Rubbing gently on the back or trunk
5. Keep appropriate position of the head throughout
stimulation.
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Basic requirement of neonatal delivery
1. Warm, dry blankets
2. Bulb syringe
3. Two small clamps or ties
4. A pair of clean scissors
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Equipment for Neonatal Resuscitation
1. Manual resuscitator (infant)
2. Masks (2 sizes, term and premature)
3. Dry towels/blankets
4. Suction equipment
5. ET tubes (sizes 2.5, 3.0, 3.5)
6. Laryngoscope and blades (sizes 0, 1)
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APGAR SCORE
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APGAR test
Definition :
1. A quick test performed on a baby at 1 and 5
minutes after birth.
• The 1-minute score determines how well the
baby tolerated the birthing process.
• The 5-minute score determines how well
the baby is doing outside the mother's womb.
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How the test is done?.............................
• You will examine the baby's:
1. Breathing effort
2. Heart rate
3. Muscle tone
4. Reflexes
5. Skin color
Each category is
scored with 0, 1, or
2, depending on the
observed condition
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• This test is done to determine whether a newborn
needs help breathing or is having heart trouble.
Normal Results
1. The APGAR rating is based on a total score of 1 to
10.
2. The higher the score, the better the baby is doing
after birth.
3. A score of 7, 8, or 9 is normal and is a sign that
the newborn is in good health.
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APGAR score
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A for appearance
1. Appearance (Skin color):
• If the skin 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
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2. Pulse (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.
P for pulse
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G for grimace
3. Grimace response ( reflex irritability ):
• It is a term describing response to stimulation 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 vigorous cry, the
infant scores 2 for reflex irritability.
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3. Activity ( Muscle tone):
– If muscles are loose and floppy, the infant scores 0 for
muscle tone.
– If there is some muscle tone, the infant scores 1.
– If there is active motion, the infant scores 2 for muscle
tone.
A for activity
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R for respiration
1. Respiration ( Breathing )effort:
– If the infant is not breathing, the respiratory score
is 0.
– If the respirations are slow or irregular, the infant
scores 1 for respiratory effort.
– If the infant cries well, the respiratory score is 2.
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Review Questions and Home Work
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Neonatal Emergencies Lecture 2
Dr. Miada Mahmoud Rady
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Neonatal resuscitation algorithm
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Neonatal Resuscitation Steps :
1. Dry the baby with a clean cloth
2. Check for:
Breathing or crying
Pink central color
Good tone
• If All present, Continue Routine Care
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• If baby Does Not have good respiratory effort, pink
central color and good tone:
1. Position infant in neutral position
2. Clear airway
3. Stimulate the newborn.
4. Give oxygen if available.
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Neonatal Resuscitation Guidelines:
• If baby responds to positioning and stimulation by
turning pink and breathing, return to routine care
• If baby does not respond to these measures within 30
seconds:
1. Apply mask and ventilation bag to infant
2. Give 5 slow breaths
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• If baby responds and begins breathing, continue to observe
closely, return to giving routine care
• If baby is not breathing after 5 slow breaths:
1. Check position of infant
2. Continue bag and mask ventilation
3. Check to see if chest is rising: if there is no chest movement,
suction airway, reposition infant, then resume bag and mask
ventilation.
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Neonatal Resuscitation Guidelines:• If not breathing after 30 seconds:
– Check heart rate• If heart rate is > 60 beats per minute:
1. Continue to ventilate at 40 breaths per minute2. Use oxygen to ventilate if available3. Watch for chest rise4. Monitor position of infant5. Stop ventilation every 1-2 mins to see if HR is greater than 60
beats per minute6. Stop compressions if HR is > 100 beats per minute7. Stop ventilations when breathing is > 30 breaths per minute8. Continue oxygen therapy until infant is pink and has good
tone
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Neonatal Resuscitation Guidelines:• If not breathing after 30 seconds:
– Check heart rate• If heart rate is > 60 beats per minute:
1. Continue to ventilate at 40 breaths per minute2. Use oxygen to ventilate if available3. Watch for chest rise4. Monitor position of infant5. Stop ventilation every 1-2 mins to see if HR is greater than 60
beats per minute6. Stop compressions if HR is > 100 beats per minute7. Stop ventilations when breathing is > 30 breaths per minute8. Continue oxygen therapy until infant is pink and has good
tone
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• If heart rate is < 60 beats per minute:
– Continue effective Positive Pressure Ventilation and
begin chest compressions at a rate of 90
compressions/minute
– Continue chest compressions until HR>60 beats per minute
– Continue to ventilate at 40 breaths per minute
– Use oxygen to ventilate if available
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– Watch for chest rise
– Monitor position of infant – should be neutral head position
– Stop ventilation every 1-2 mins to see if HR is greater than 60
beats per minute
– Stop compressions if HR is > 100 beats per minute
– Stop ventilations when breathing is > 30 breaths per minute
– Continue oxygen therapy until infant is pink and has good tone
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Neonatal Resuscitation Guidelines:
• Cessation of resuscitation
– If after 20 minutes the baby is not breathing and there is no
pulse, the recommendation is to stop resuscitation efforts
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Thank you
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Arrival of the newborn
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History taking 1. Woman’s age
2. Length of pregnancy
3. Presence and frequency of contractions
4. Presence or absence of fetal movement
5. Any pregnancy complications
6. If membranes have ruptured ( Timing , color of fluid ).
7. Medications being taken
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Resuscitation oriented history
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If delivered in the ambulance………….
1. Cover the foot of the stretcher with clean, warm
blankets for the initial stabilization.
2. After confirming adequate airway, breathing, and pulse
rate, place the newborn on the mother’s chest.
3. If more extensive resuscitation is necessary, transition
newborn to a second ambulance with a neonatal
transport incubator
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4. Suction the mouth, then the nose with a bulb syringe
once the head is delivered.
5. Keep the newborn at the level of the mother after
delivery, with head slightly lower than the body.
• ►►►If the cord comes out ahead of the newborn, the
blood supply to the fetus may be cut off (prolapsed
cord) , ►►►so relieve pressure on the cord by gently
moving the newborn’s body off the cord and pushing the
cord back.
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6. Do an initial rapid assessment simultaneous with
treatment interventions.
• Note time of delivery.
• Monitor ABCs.
• Assess airway patency, respiratory rate and effort, tone, pulse
rate, and color.
7. Position the newborn in the sniffing position to ensure a
patent airway, clear secretions, and assess the
respiratory effort.
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Opening the Airway
Wrong positioning:
Right positioning
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7. Newborn is at risk for hyperthermia , so ensure
thermoregulation by:
Placing the newborn on prewarmed towels or radiant
warmer
Drying the head and body thoroughly
Discarding wet towels and covering with a dry towel
Covering the head with a cap
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Finally ……………………….
8. All babies are cyanotic right after birth , If the newborn
stays vigorous and begins to turn pink in the first 5
minutes:
Maintain ongoing observation.
Continue thermoregulation with direct skin-to-skin
contact with mother while en route.
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Additional resuscitation steps…..
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Airway management1. Free-flow oxygen:
If a newborn is cyanotic or pale, provide supplemental oxygen ,
until a pulse oximetry reading can give an accurate reading.
Oxygen flow rate should be 5 L/min.
oxygen can initially be delivered through:
1. PPV (first choice unless not indicated)
2. Oxygen mask
3. Oxygen tubing cupped and held close to the newborn’s nose and
mouth.
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1. Oral airways :
• Rarely used on newborns , but it can be life saving in Bilateral
Choanal Atresia .
• Bilateral Choanal Atresia : Bony or membranous obstruction of
the back of the nose.
• Management :
1. Surgical correction is definitive treatment.
2. First aid measure : keeping newborn mouth open either by oral
air way or gloved finger .
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• Other Conditions that may require oral airways:
1. Pierre Robin sequence
2. Macroglossia (large tongue)
3. Craniofacial defects that affect the airway
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Breathing
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If a newborn baby fails to breathe after
bulb suctioning, then Positive Pressure
Ventilation With A Bag-and-mask is
the single most important step in
neonatal resuscitation.
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Bag-mask ventilation• Indicated when a newborn:
1. apneic
2. Has inadequate respiratory effort
3. Has a pulse rate of less than 100 beats/min after:
Airway is cleared of secretions.
Tongue obstruction is relieved.
Newborn is dried and stimulated.
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Signs of respiratory distress suggesting need for bag-mask
ventilation include:
1. Periodic breathing
2. Grunting on expiration
3. Nasal flaring
4. Intercostal retractions
The correct ventilation time (40 to 60 breaths/min) is important
because a higher rate can cause:
1. Hypocapnia
2. Air trapping
3. Pneumothorax
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• Continue PPV as long as the pulse rate is less than 100 beats/min
or the respiratory effort is ineffective.
• If more than 1 minute of PPV is needed, hook the system to a
pressure manometer.
• Causes of ineffective bag-mask ventilation:
I. Inadequate mask seal on the face
II. Incorrect head position
III. Copious secretions
IV. Pneumothorax
V. Equipment malfunction
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• Gently pull infant’s jaw forward to mask
• Use a “C-grip” to hold mask to infant’s face, using the
3rd finger to hold jaw up to mask
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Correct positioning : Watching for chest-rise- if chest is rising
and falling you are performing adequate ventilation
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Intubation• Indications :
1. Meconium aspiration .
2. Diaphragmatic hernia .
3. No response to bag-mask ventilation and chest compressions,
necessitating ET administration of epinephrine
4. Prolonged PPV needed.
5. Craniofacial defects impede an adequate airway.
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• Complications of ET tube placement include:
1. Oropharyngeal or tracheal perforation
2. Esophageal intubation with subsequent persistent
hypoxia
3. Right main stem intubation
• Risks can be minimized by:
1. Ensuring optimal placement of laryngoscope blade
2. Noting how far the ET tube is advanced
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