Dr. Miada Mahmoud Rady EMS/481 Neonatal emergencies lecture 1 Introduction Dr. Miada Mahmoud Rady EMS/481 Neonatal emergencies lecture 1

Introduction Newborn : babies within the first few hours after birth. Neonates : within the first month after birth. Paramedic is usually called to take care of newborn in two cases : For transport in case hospital delivery. In case of unscheduled either ( home or in the field delivery ).

Introduction Unscheduled delivery means two patient , at least , the mother and the baby. Most of new born will need minimal stimulation . The need for further intervention is affected by several factors.

Neonatal resuscitation Factors that may indicate the need for further intervention include : Antepartum Factors. Intrapartum Factors.

Factors that may indicate the need for resuscitation : Antepartum Factors Intrapartum Factors Multiple gestations Inadequate prenatal care Mother’s age (<16 or >35) History of prenatal morbidity or mortality. Post term gestation. Drugs or medications. Premature labour Meconium stained amniotic fluid Ruptured membranes more than 24 hours prior to delivery Narcotics within 4 hour of delivery Abnormal presentations.

Transition From Fetal To Neonatal Circulation Dramatic changes occurs as the newborn prepares for extra uterine life : Fluid in the fetal lungs is forced out through chest compression during delivery. Newborn usually takes first breath within seconds of delivery independent of cutting cord.

Transition from Fetal to Neonatal Circulation Stimulant of the First Breath include : Mild acidosis. Initiation of stretch reflexes in the lungs. Hypoxia. Hypothermia .

Transition from Fetal to Neonatal Circulation Changes that occur with the first breath: At birth , the lung expand as become filled with air and alveolar fluid gradually leaves the lungs . At the same time , lung arterioles open allowing considerable amount of blood to enter the lung. As result , the blood that was passing through the ductus arteriosus enter the lung where it pick up oxygen and then this blood is carried to supply the newborn tissue , so the ductus starts to close.

Circulation to the lungs increases left atrium flow, increased pressure causes the foremen ovale to close and blood circulates normally. During the first breath , pulmonary vascular resistance drops .

Transition from Fetal to Neonatal Circulation Delay in drop pulmonary pressure leads to: Delayed transition. Hypoxia. Brain injury. Death.

Assessment of the newborn

Assessment general guidelines Assess the newborn immediately after birth. Ideally, one paramedic attends the mother while the other attends the newborn. Newborns will be slippery and require both hands. Use the following parameters to assess newborn : heart rate , respiratory rate , skin color and APGAR score.

General parameters Normal heart rate 150–180/min : Slowing to 130–140 thereafter. A pulse less than 100 indicates distress. Normal respiratory rate 40–60/min.

Normal appearance Head : shows molding which is the irregular shape of a baby's head from the birth process. Normal shape usually returns by the end of the first week. Vernix : This is a white, greasy, cheese-like substance on the skin of many babies at birth. It protects the baby's skin during pregnancy. Lanugo : This is soft, downy hair on a baby's body , It's more prominent in premature babies , gradually disappear.

Normal appearance Color : A baby's skin coloring can vary greatly . When first born, the skin is a dark red to purple color. As the baby begins to breathe air, the color changes to red. This redness normally begins to fade in the first day. A baby's hands and feet may stay bluish in color for several days , due to underdeveloped blood circulation. Blue coloring of other parts of the body, however, isn't normal.

Normal appearance Milia : are tiny, white, bumps on a newborn's nose, cheeks, chin and forehead, milia form from oil glands and disappear on their own.

APGAR test Definition : 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.

How the test is done?............. You will examine the baby's: Breathing effort Heart rate Muscle tone Reflexes Skin color Each category is scored with 0, 1, or 2, depending on the observed condition

Why the test is done?? This test is done to determine whether a newborn needs help breathing or is having heart trouble. Normal Results The APGAR rating is based on a total score of 1 to 10.  The higher the score, the better the baby is doing after birth. A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health.

APGAR score

A for appearance 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.

P for pulse 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.

G for grimace 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.

A for activity 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.

R for respiration 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

Neonatal resuscitation

Neonatal resuscitation Initial steps of neonatal resuscitation include: Airway (position and clear) Breathing (stimulate to breathe) Circulation (assess heart rate and oxygenation) Additional resuscitation steps : They are used based on need and include →

Additional Resuscitation Steps Supplemental Oxygen. Positive Pressure Ventilation. Intubation. Chest Compressions. Medications.

Initial steps of stabilizing a newborn Warming the newborn to prevent hypothermia. Positioning the newborn Clearing the airway if necessary Drying and stimulating breathing

Warming the newborn to prevent hypothermia Place on prewarmed towels or blankets and dry. Replace wet towels with dry, prewarmed ones. When resuscitation is complete, place the newborn on the mother’s chest or abdomen, another heat source, or under a radiant warmer.

Four mechanisms of heat loss in newborn and corresponding interventions Evaporation : Dry infant immediately. Conduction : Place on mothers body skin to skin. Convection : Cover with a blanket, wear a cap. Radiation : Keep away from cold windows and cold objects.

Mechanisms of heat loss

So why warming the newborn is so important???

Effect of Cold Stress Increased oxygen need. Decreased surfactant production. Respiratory distress. Hypoglycemia. Metabolic acidosis. Jaundice. Vasoconstriction can cause a return to fetal circulation patterns.

Warming the newborn to prevent hypothermia Neutral thermal environment which helps prevent heat loss and help the infant to maintain stable body temperature. Thermoneutral zone should be 32° to 35° C.  Elevated temperature causes increased need for oxygen and glucose and vasodilation leads to increased insensible fluid loss. So Closely monitor warming equipment to prevent overheating of infant.

Any question????