1. MMR Neonatal emergencies lecture 1 Dr. Miada Mahmoud Rady

2. MMR Lecture topics 1.Important definitions. 2.Transition from fetal to neonatal circulation. 3.Epidemiology of fetal distress. 4.Neonatal resuscitation. 5.Apgar score.

3. MMR 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.

4. MMR 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

5. MMR 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.

6. MMR 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.

7. MMR  Delay in drop pulmonary pressure leads to: a.Delayed transition b.Hypoxia c.Brain injury d.Death

8. MMR 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

9. MMR Risk factors of fetal distress A.Antepartum factors 1.Multiple gestation 2.Inadequate prenatal care 3.Mother’s age 35 4.Post-term gestation 5.Drugs / medications 6.Toxemia, hypertension, diabetes

10. MMR 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

11. MMR 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 →

12. MMR Additional Resuscitation Steps Include: 1.Supplemental oxygen. 2.Positive pressure ventilation. 3.Intubation. 4.Chest compressions. 5. Medications.

13. MMR 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

14. MMR 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:

15. MMR 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.

16. MMR 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.

17. MMR Basic requirement of neonatal delivery 1.Warm, dry blankets 2.Bulb syringe 3.Two small clamps or ties 4.A pair of clean scissors

18. MMR 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)

19. MMR APGAR SCORE

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21. 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.

22. MMR 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

23. MMR 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.

24. MMR APGAR score

25. MMR 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

26. MMR 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

27. MMR 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.

28. MMR 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

29. MMR 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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33. Review Questions and Home Work

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35. Neonatal Emergencies Lecture 2 Dr. Miada Mahmoud Rady

36. MMR Neonatal resuscitation algorithm

37. MMR 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

38. MMR 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.

39. MMR 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

40. MMR 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.

41. MMR 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 minute 2.Use oxygen to ventilate if available 3.Watch for chest rise 4.Monitor position of infant 5.Stop ventilation every 1-2 mins to see if HR is greater than 60 beats per minute 6.Stop compressions if HR is > 100 beats per minute 7.Stop ventilations when breathing is > 30 breaths per minute 8.Continue oxygen therapy until infant is pink and has good tone

42. MMR 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 minute 2.Use oxygen to ventilate if available 3.Watch for chest rise 4.Monitor position of infant 5.Stop ventilation every 1-2 mins to see if HR is greater than 60 beats per minute 6.Stop compressions if HR is > 100 beats per minute 7.Stop ventilations when breathing is > 30 breaths per minute 8.Continue oxygen therapy until infant is pink and has good tone

43. MMR 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

44. MMR –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

45. MMR 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

46. MMR Thank you

47. MMR Arrival of the newborn

48. MMR 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

49. MMR Resuscitation oriented history

50. MMR 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

51. MMR 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.

52. MMR 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.

53. MMR Opening the Airway Wrong positioning : Right positioning

54. MMR 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

55. MMR 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.

56. MMR Additional resuscitation steps…..

57. MMR Airway management 1.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.

58. MMR 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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61. Other Conditions that may require oral airways: 1.Pierre Robin sequence 2.Macroglossia (large tongue) 3.Craniofacial defects that affect the airway

62. MMR Breathing

63. MMR 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.

64. MMR 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.

65. MMR  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

66. MMR 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

67. MMR Gently pull infant’s jaw forward to mask Use a “C-grip” to hold mask to infant’s face, using the 3 rd finger to hold jaw up to mask

68. MMR  Correct positioning : Watching for chest-rise- if chest is rising and falling you are performing adequate ventilation

69. MMR 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.

70. MMR 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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