01 Newborn Management

Overview

Key to newborn management:

• make sure good breathing and circulation

Timeline

Timeline includes expected milestones for baby after delivery. However, if there is a problem, stay in that window until problem is fixed and then move on.

• Preparation

• Min 0 to 1: overcome apnea, airway patency

• 1 - 5: oxygenation, HR second, apgar third

• 5 - 10: oxygenation and HR, apgar

• after 10: TTN/RDS. Begin standard of care

Preparation

Equipment

• towel

• warmer on

• respiratory equipment

Knowledge

• GxPx

• Prenatal care

• gestational age

Min 0 to 1

Goal: overcome apnea and ensure airway patency.

O2

Primary apnea can be overcome with stimulation: Between min 0 and min 1, overcome primary apnea and induce 1st deep breath via stimulation:

• rub back with towel

• tap feet

SpO2:

• SpO2 should be 60-65%

• SpO2 can be improved with suctioning first the mouth and then then the nose to avoid meconium aspiration

PPV

If no improvements, start bagging and use positive pressure ventilation

Intubation

If baby starts secondary apnea (apnea after first few min), bagging may not be enough and need intubation

HR

• goal HR: > 100

• HR < 100: use PPV, probably O2 problem. Get O2 flowing, then worry about heart

Min 1 to 5

Move from airway to oxygenation. O2 more important than hr.

Apgar

• 1st Apgar should be > 7

• Apgar < 7: do something to fix

O2

• SpO2 80-85

• Give FiO2 (supplemental O2) if needed and respiratory look good

• consider PPV and intubation

HR

• Good > 100

• 60-100: probably respiratory issue, PPV

• < 60 and good chest movement: cardia problem, CPR

  • 3 compressions : 1 ventilation

  • access umbilical vein, give Epi

Min 5 to 10

O2 should be stabilized. Worry about HR and apgar.

Apgar 2

• Goal: > 7 or improving

O2

• goal: 90-95%

• FiO2, PPV

HR

• same as min 1 - 5

After min 10

Watchout for TTN and RDS

• Standard care

• Continue Apgar if resuscitation not improving

Standard of Care

1. Measure baby

   1. weight, length, height, head circumference

2. Look at cord

   1. 2 arteries, 1 vein

   2. clam cord close to baby, remove excess

3. Shots, drops

   1. Vit K

   2. Hep B vaccine or IVIG based on mom status

   3. Drops: conjunctivitis prophylaxis, erythromycin

4. Treat: specific problems

5. PE

   1. scalp: fontanelle not sunken or bulging, look for hematomas

   2. Eye: red reflex, retinoblastoma

   3. mouth: cleft lip/palate

   4. bones: feel for crepitus, especially clavicles for fractures

   5. murmurs (pda not audible first day)

   6. abnormal lung sounds (bowel sounds in lungs)

   7. assess cord: gastroschisis/omphalocele

   8. genitalia: gender, defects (hypo/epispadius)

   9. anus: imperforate anus, clue for VACTRL syndrome

   10. skin: jaundice

   11. Ortolani, barlow maneuvers for ortho problems

Apgar

	0	1	2
Appearance	Blue/pale	Acrocyanosis	Pink baby
HR	Absent	<100	>100
Grimace	Absent	Require a lot stimulation	Achieved with little stimulation
Activity	No activity	Can flex, no resist extension	Flex and resist extension
Respiratory	Absent	Present, irregular	Strong and regular

TTN and RNDS

TTN:

• patho: self limiting. Baby didn't squeeze through canal right, didn't get stimulated with contractions

• demographics: C section babies, no stimulation; near term/term baby, healthy

• symptoms: grunting, tachypnea

• diagnosis: chest x-ray. Hyperextended and wet lungs (edema)

• treatment: PPV, usually go away in 6 hours

RDS:

• patho: insufficient surfactant

• demographics: premature, delivered because perinatal stress

• diagnosis: hypoextended lungs, atelectasis

• treatment: intubation, surfactant

Hypoglycemia

• patho: LGA, SGA, diabetic moms, IUGR. Any baby abnormally size or has glucose problems in uterus. Can be potentially from sepsis

• symptoms: can be asymptomatic. Symptoms include jittery, tremors, lethargy (baby coma), progress to seizures

• diagnosis: look for cx of infection

• treatment

  • asymptomatic: just feed

  • Symptomatic: IV bolus sugar. 2 ml/kg D50. If persists, drip D5/D10