Ágnes Harmath M.D. Ph.D.

NEONATOLOGYHealthy newborn. Neonatal sequelaes

13. December 2019.

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Tasks of the neonatologist

Prenatal diagnosed condition

Inform parents, preparation of necessary intervention

Labor Ward

Handling healthy

newborns

Neonatal sequalae treatment

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Newborn terminology

CLIV. Act of Care 1997 Chapter XII. section 216. d.

„Perinatal Death:

a) Mortality occurs intra uterus post the 24th gestational week or after the

fetus reached 30 cm length or 500 g weight,

b) If the death occurs 168 hours post delivery, irrespective of the growth

parameters of the newborn

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Perinatal Mortality

Fetal Death Infant Death

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Terms of newborns

Mature newborn: 37. – 41 6/7. gestational weekweight: 3500-4500 gramm

length: 45-55 cm

head circumference 32-37 cm

Over-carried newborn: post 42 . week

SGA (small for gestational age) newborn - weight below the 10th percentile

- weight below the average by 2 SD

LGA (large for gestational age) newborn:- weight above the 90th percentile

- weight above the average by 2 SD

Premature birth : age <37 gestational week,

weight <2500 gramms

VLBW (very low birth weight) newborn - <1000 gramms

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Neonatologist is required in the

labor ward

Conditions of the mother

toxaemia, chronic disorders, dependency (drug, alcohol, smoking)

Fetal Conditionmultiples, age of fetus (premature or postmature), IUGR (intrauterin growth retardation),

fetal development condition, diagnosed fetal disorder (e.g.: hydrops-syndroma)

Labour and birth factors:distochia, meconium stained fluid,early membrane rupture/noticeable odor, bleeding,

umbilical chord disorder, cesarean section

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Known anamnesis may result in resuscitation in cases of:

Post the normal pregnancy Newborn shows symptoms of

changing respiratory rate, cyanosis, meconium stained fluid, hydrops syndrome

Apgar test tube can’t get through, development disorders

Healthy newborn’s condition deteriorates

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Labor ward treatment

Newborn resuscitation

Apgar test and score

Umbilical cord clamp

Treatment of eyes

First informative test of newborn

Development control

- Dubowitz-score – 1977

- New Ballard-score – 1991

Sterility/Hygienic norms

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Equipment needed for resuscitation

Open incubator (radiant warmer), phonendoscop, „Apgar clock”

Oxygen and breathing space with tube outlets

Suction and catheters(both throat and tube suction)

Equipments for ventilation(Neopuff, balloon, masks, laryngoscope, tubes)

Equipments for vein punctions

Drugs

Scissors, tape

Resuscitation 2015; 95: 249-263

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APGAR score

0 1 2

Pulse absent <100/min >100/min

Respiratory effort absent Irregular Intensive cry

Grimace

(reflex irritability)Non-responsive Grimace Sneeze or cough

Activity

(Muscle tone)Absent , limp

Some flexion of

extremitiesStrong movement

Appearence

(skin colour) Pale, blue Acrocyanosis Rosy

Assessment:

8-10 – good outcome

6-7 – endangered condition, NICU observation required

4-5 – average condition, NICU observation required

< 3 – serious asphyxia, life threatening condition

Injuries during delivery

Prevalence – 1-2%

Predetermining factors:

macrosomia, premature birth, distochia,

long birth period, breach position

Cephalhaematoma – most common

Other injuries: suffusion, skin injury

Clavicula fracture

Bone fracture

Nerve injury: Erb-Duchenne (C5-6), Klumpke (C7-8, Th1)

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Healthy newborn care on ward

First day of lifeDetailed physical examinationVitamin. K prophylaxisHBsAg test result – if necessary injection

Observation timesucking and feedingjaundicecare of the umbilical region

Day of dischargeMetabolic disease screening testHearing test screeningBCG injection

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Conditions of early discharge

Normal single pregnancy

37- 42. gestational week

Spontaneous vaginal delivery

Normal prae-,intra- and postpartum period

12 hours prior to discharge normal and stable parameters

At least two successful feeds

No condition that would justify hospitalization

Metabolic test results

Suitable home conditions (home assessment)

Mother is capable of caring for the newborn

Within 48 hours if pediatrician (GP) undertakes the general practice at home

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Problems at healthy newborns

Managed on normal neonatal ward:

Tremor - Hypoglycemia – blood sugar below 1,8-2 mmol/l

- Hypocalcemia – SeCa level below1,7 mmol/l

Passage disturbances:-regurgisting, vomiting

- Stool (meconium) problems if it within 24-36 hours recover

Omphalitis without feeding problems and deterioration of

general condition

Icterus – physiologic

enough fluid intake supply, blue-light therapy and observation

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Cases of Intensive Care

requirement

Post intubation or resuscitation

Cardiorespiratory disorders

Prior to 34. gestational week or below 2000 grams of birthweight

Symptoms of anemia or shock

Central nervous system disorders

Serious development disorders

Feeding difficulties or reoccurring vomiting

Infection

Serious disturbances of ion homeostasis

Clinical icterus

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Tasks prior to transfer

Stabilization, checking clinical signs and vital

parameters till the ambulance arrive

Inform the staff of ambulance service and the host

hospital before transportation

Parents information

Preparing documentation

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Necessary data:

Data of perinatal period: mode of delivery, time of membrane

rupture, amniotic fluid condition, medicine usage during

delivery, analgesia

Data of newborn: birthweight, Apgar points, invasive

treatments, medicaments, infusions, ventilation support,

laboratory findings

Maternal anamnesis: birthdate, insurance number, blood

group, date of previous pregnancies, acute and chronic

diseases, family anamnesis, regular use of medicine/alcohol/

drug

Data of recent pregnancy: results of laboratory and

ultrasound and screening tests (e.g..: HBsAg !!)

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Intensive Care Placement

I. Infection suspicion

II. Development disorders

III. Respiratory condition

IV. Gastrointestinal condition

V. Icterus

VI. Haematologic disorders

VII. Others- seizures - ion homeostasis disturbances

- injury through delivery - social problems

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Recomendations - some main points

Mothers at high risk of preterm birth <28–30 weeks’

gestation should be transferred to perinatal centers with

experience in management of RDS

Clinicians should offer a single course of prenatal

corticosteroids to all women at risk of preterm delivery

from when pregnancy is considered potentially viable until

34 weeks’ gestation ideally at least 24 h before birth.

A single repeat course of steroids may be given in

threatened

preterm birth before 32 weeks’ gestation if the first course

was administered at least 1–2 weeks earlier .

20Neonatology 2017; 111: 107-125.

If possible delay clamping the umbilical cord for at least 60 s

to promote placentofetal transfusion. Cord milking is a

reasonable alternative if delayed cord clamping is not possible.

In spontaneously breathing babies, stabilise with CPAP of at least

6 cm H2O via mask or nasal prongs.

Gentle positive pressure lung inflations with 20–25 cm H2O peak

inspiratory pressure (PIP) should be used for persistently apnoeic or

bradycardic infants.

Oxygen for resuscitation should be controlled using a blender.

Use an initial FiO2 of 0.30 for babies <28 weeks’ gestation and

0.21–0.30 for those 28–31 weeks, 0.21 for 32 weeks’ gestation and

above. FiO2 adjustments up or down should be guided by pulse

oximetry.

21Neonatology 2017; 111: 107-125.

Recomendations - some main points

Plastic bags or occlusive wrapping under radiant warmers should

be used during stabilization in the delivery suite for babies <28

weeks’ gestation to reduce the risk of hypothermia.

For infants <32 weeks’ gestation, SpO2 of 80% or more (and heart

rate >100/min) should be achieved within 5 min.

LISA is the preferred mode of surfactant administration for

spontaneously breathing babies on CPAP, provided that

clinicians are experienced with this technique.

Intubation should be reserved for babies not responding to

positive pressure ventilation via face mask or nasal prongs.

Babies who require intubation for stabilisation should

be given surfactant.

Enteral feeding with mother’s milk should be started from the

first day if the baby is haemodynamically stable.

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Recomendations - some main points

Neonatology 2017; 111: 107-125.

THANK YOU FOR YOUR KIND

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