NEONATOLOGY Healthy newborn. Neonatal sequelaes Ágnes Harmath M.D. Ph.D. senior lecturer 11. November 2016.
Tasks of the neonatologist Prenatal diagnosed condition Inform parents, preparation of necessary intervention Labor Ward Handling healthy newborns Neonatal sequalae treatment 2
Newborn terminology Perinatal Mortality Fetal Death Infant Death CLIV. Act of Care 1997 Chapter XII. section 216. d. Perinatal Death: a) Mortality occurs intra uterus post the 24 th 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 3
Terms of newborns Mature newborn: 37. 41 6 / 7. gestational week weight: 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 10 th percentile - weight below the average by 2 SD LGA (large for gestational age) newborn: - weight above the 90 th 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 4
Neonatologist is required in the Conditions of the mother labor ward Known anamnesis may result in resuscitation in cases of: toxaemia, chronic disorders, dependency (drug, alcohol, smoking) Fetal Condition multiples, 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 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 condition deteriorates 5
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 6
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 7
Resuscitation 2015; 95: 249-263 8
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Delivery Room Stabilization 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. Oxygen for resuscitation should be controlled using a blender. An initial concentration of 30% oxygen is appropriate for babies <28 weeks gestation, and 21 30% for those of 28 31 weeks, and adjustments up or down should be guided by pulse oximetry from birth. In spontaneously breathing babies, stabilize with CPAP of at least 6 cm H 2 O via mask or nasal prongs. Gentle positive pressure lung inflations using about 20 25 cm H2O peak inspiratory pressure should be used for persistently apnoeic or bradycardic infants. Neonatology 2017;111:107 125 10
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 extremities Strong 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 11
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 (C 5-6 ), Klumpke (C 7-8, Th 1 ) 12
Healthy newborn care on ward First day of life Detailed physical examination Vitamin. K prophylaxis HBsAg test result if necessary injection Observation time sucking and feeding jaundice care of the umbilical region Day of discharge Metabolic disease screening test Hearing test screening BCG injection 13
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 14
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 15
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 16
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 17
Necessary data: 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!!) 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 18
Intensive Care Placement I. Infection suspicion II. III. IV. Development disorders Respiratory condition Gastrointestinal condition V. Icterus VI. VII. Haematologic disorders Others - seizures - ion homeostasis disturbances - injury through delivery - social problems 19
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