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Neonatology By Assist Prof. Dr. Amin Turki. Evaluation of newborn history:. Perinatal history should concentrate on the following:. 1 . Demographic and social data : socioeconomic status, parents age, race.
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Evaluation of newborn history: Perinatal history should concentrate on the following: 1 .Demographic and social data: socioeconomic status, parents age, race 2. past medical illnesses in the family: cardiopulmonary disorders, infectious diseases, genetic disorders, diabetes mellitus. 3. Prior maternal reproductive problems: stillbirth, prematurity, blood group sensitization.
4. Events occurring in the present pregnancy: vaginal bleeding, drugs used during pregnancy, acute illnesses, duration of rapture of membranes. 5. Description of labor: duration, fetal presentation, fetal distress, fever. 6. Delivery: mode of delivery (vaginal or cesarean section), use of anesthesia or sedations, use of forceps, Apgar score, need for resuscitation.
Physical -1 0 1 2 3 4 5 maturity Growth and gestational age assessment: Physical signs may be useful in estimating gestational age at birth. Commonly used the newBallard score (NBS), in which the gestational age is assist according to maturity of six physical signs which are; skin, languo hair, ears, breasts, genitals, and the planter surface creases. It's accurate to plus minus 2 wks
Apgar score It is a practical method of systematically assessing newborn infants immediately after birth to help identify infants requiring resuscitation. Its should be done at 1st min. after delivery then repeated at 5 min, 10 min, and 20 min or according to the general status of the newborn.
Although the 1- and 5-minutes Apgar scores have almost no predictive values for long-term outcome, serial scores provide useful description of the severity of perinatal depression and the resuscitative efforts need. The Apgar score consist of 5 physical signs, as following:
Sign 0 1 2
** Total score of 10 indicates an infant in the best possible conditions. ** An infant with a score of 0-3 requires immediate resuscitation. ** Apgar score of 0-3 at 20 min predicts high mortality and morbidity.
Care of the well newborn infants: 1. Maintenance of body heat: Infant should be dried immediately after birth and either wrapped in blanket or placed under warmer while having skin-to-skin contact with the mother and if the newborn need resuscitation after birth, its should be done under radiant heat source.
Effects of cold injury on newborn infants: 1. Metabolic acidosis. 2. Hypoglycemia. 3. Hypoxemia. 4. Increased renal excretion of water and solutes.
2. Antiseptic skin and cord cares: To reduce the incidence of skin and periumbilical infections (omphalitis), the following measures should be undertaken for any newborn infant : a. The entire skin and cord should be cleansed once infant temperature has stabilized, with sterile cotton soaked in warm water or a mild, non medicated soap.
b. Then dried and wrapped in sterile blankets and taken to the nursery, the outer blanket can be discarded at the nursery door to reduce the chance of carrying pathogenic organisms to the nursery. c. Daily treament of the umbilical cord with triple die, bactericidal agent or bacitracin to reduce colonization with s.aureusand other pathogenic bacteria, or alternatively use chlorhexidine washing.
d. Rigidly enforcing hand-to-elbow washing for 2 min initially and for 15-30 sec in the second wash for staff and visitors entering the nursery, shorter washes between handling infants should also be required.
3. Eyes care: All infants should be protected against gonoccocal infection by installing 1% silver nitrate drops (best prophylactic therapy) or erythromycin 0.5% and tetracycline 1% sterile ophthalmic ointments within 1 hr of birth.
4. Vitamin K: intramuscular injection of 1 mg of water-soluble vitamin K1 is recommended for all infants immediately after birth to prevent hemorrhagic disease of newborn. Larger I.V. doses predispose to hyperbilirubinemia (jaundice) and kernicterus and should be avoided.
5. Feeding: The first feeding usually occurs by 3 hr of life in healthy term neonates, often as early as possible in the delivery room. You should encourage breast feeding, and the factors for successful breast feeding are: 1. Immediate postpartum mother –infant contact with suckling rooming-in. 2. Demand feeding.
3. Inclusion of fathers in prenatal breast feeding education and support from experienced women. 4. Avoiding of pacifiers and supplemental formulas (unless medically indicated). Nursing should be at least 5min at each breast, using both breasts, to allow a baby to obtain most of the available breast milk and to provide effective stimulation for increasing milk supply.
Indications that the baby is ready for feeding are: 1. Alertness and vigor. 2. Absence of abdominal distention. 3. Good bowel sounds. 4. Normal hunger cry. All of these signs are present within 3-6 hr after birth in healthy term newborns, but are delayed in depressed and sick newborns.
Mechanism of first breath after delivery The initiation of the first breath after delivery depend on two major factors, which are removal of the lungs fluid and the presence of surfactant in the lungs.
Methods of removal of lungs fluid: 1. By pulmonary circulation which increased many times at birth because of all the Rt. ventricular output now perfuses the pulmonary vascular bed. 2.By intermittent compressions of the chest during vaginal delivery. 3.By the pulmonary lymphatic. 4. Expelled by the infants. 5. Swallowed by the infants. 6. By aspiration from the orophyranx.
Factors impaired removal of lung fluids: 1. Cesarean section delivery. 2. Endothelial cells damage. 3. Hypoalbuminemia. 4. High pulmonary venous pressure. 5. Neonatal sedation.
Surfactant: Is lipoprotein synthesized and stored in type II alveolar cells composed of phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins (surfactant proteins (SP)-A, B, C, D) and cholesterol. Surfactant lining the alveoli enhances aeration of gas-free lungs by reducing surface tension, so it's lowering the pressure required to open alveoli
The opening pressure required to inflate the airless lungs are higher than those needed at any other period of life, they range from 10-50cm H2O compared with about 4cm H2O for normal breathing in term infants and adults
This higher pressure to initiate respiration is required to: 1. To overcome the opposing forces of surface tension (especially in small airways). 2. To overcome the viscosity of liquid remaining in the airways 3. To introduce about 50ml of air in to the lungs, 20-30ml of which remains in the lungs after the 1st breathe to establish the functional residual capacity (FRC).
Stimulation factors of the 1st breathe: 1. Decreased Po2 and pH and increased Pco2 due to lack of placental circulation. 2. Redistribution of COP after umbilical cord clamping. 3. Decreased body temperature. 4. Various tactile stimuli.
Hypoxic-Ischemic encephalopathy Anoxia: refer to consequences of complete lack of oxygen. Hypoxia: refer to an arterial concentration of oxygen that is less than normal. Ischemia: refer to blood flow to cells or organs that is insufficient to maintain Their normal functions
Hypoxic-Ischemic encephalopathy (HIE): is a syndrome resulting from the effects of the hypoxia and ischemia on the brain cells. Its important cause of permanent damage to CNS cells, which may results in neonatal death (15-20% of patients) or may be manifested latter as cerebral palsy or mental retardation (25-30% of patients). HIE, passing clinically in 3 stages:
