newborn assessment

NEWBORN ASSESSMENT

MIHAI CRAIU MD PhD

INITIAL EVALUATION• Physical assessment in neonates

serves to describe anatomic NORMALITY.

• The improved techniques for fetal diagnosis help in predicting major malformations, but the neonatal examination carries a primary purpose of identifying more subtle anomalies.

Neonatal examination

• First examination immediately at birth

• Recurrent evaluations at 5 minutes interval

• The evaluation tool is Apgar score

APGAR SCORE 1• The mnemonic was introduced in 1963 by

the pediatrician Dr. Joseph Butterfield. • Same acronym is used in German

(Atmung, Puls, Grundtonus, Aussehen, Reflexe),

• Spanish (Apariencia, Pulso, Gesticulación, Actividad, Respiración)

• French (Apparence, Pouls, Grimace, Activité et Respiration) although the letters have different meanings.

APGAR SCORE*Score of 0 Score of 1 Score of 2 Component of

acronym

Skin color blue all over blue at extremitiesbody pink(acrocyanosis)

no cyanosis body

and extremities pink

Appearance

Pulse rate absent <100 >100Pulse

Reflex irritability

no response to stimulation

grimace/feeble cry when stimulated

sneeze/cough/pulls away when stimulated

Grimace

Muscle tone none some flexion active movement Activity

Breathing absent weak or irregular strong Respiration

* Apgar Virginia. A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg. 1953. 32 (4): 260–267

APGAR SCORE

APGAR SCORE 2• The test is generally done at one and

five minutes after birth, and may be repeated later if the score is and remains low.

• Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.

APGAR SCORE 3• A low score on the one-minute test

may show that the neonate requires medical attention, but is not necessarily an indication that there will be long-term problems, particularly if there is an improvement by the stage of the five-minute test.

APGAR SCORE 4• Apgar score remains below 3 at later

times such as 10, 15, or 30 minutes, there is a risk that the child will suffer longer-term neurological damage.

• There is also a small but significant increase of the risk of cerebral palsy.

APGAR SCORE 5• The purpose of the Apgar test is to

determine quickly whether a newborn needs immediate medical care

• It was not designed to make long-term predictions on a child's health.

APGAR SCORE 6• Apgar score is no longer used to

decide if a neonate requires resuscitation.

• That decision is based on emergency assessment of airway, breathing, and circulation ("ABC").

APGAR SCORE 7• The test has also been reformulated

with a different mnemonic, How Ready Is This Child - HRITC

• The criteria are essentially the same:– Heart rate, – Respiratory effort, – Irritabililty, – Tone, – Color.

COMPLETE EXAMINATION• Is complete after the 24 h after birth• If any part of an assessment is

abnormal at that time, discharge will de delayed > 48 h

• Reevaluation should focus on :– Eyes– Cardiovascular system– Hepatobiliary system

FIRST SECOND

10 SECONDS

100 SECONDS

1000 SECONDS

IN THE DELIVERY ROOM

• Delivery room resuscitation should be available in all maternities, regardless of level and staff size and knowledge.

RESPONSABILITIES OF THE NEONATAL MEDICAL TEAM

• Ensure that all medical and nursing staff are familial with neonatal resuscitation.

• Ensure that a roster of trained staff immediately available for resuscitation is posted in a visible space of the ER

• Ensure that delivery room staff are able to mobilize timely qualified people for any anticipated problem.

• Ensure that the resuscitation equipment is available and working.

IN THE DELIVERY ROOMTransitional pathophysiology 1• Acute severe peripartum hypoxia

results in primary apnoea (in-utero)• This is compensated by

– Fetal bradycardia– Rise in fetal BP

• Redistribution of blood flow occurs– Increase in blood flow in brain & heart– Decrease in skin & kidneys

IN THE DELIVERY ROOMTransitional pathophysiology• More severe and prolonged hypoxia

results in secondary apnoea (in-utero)• This is difficult to differentiate primary and

secondary apnoea.• It has practical consequences

– Secondary apnoea does not respond to stimulat.

– Primary apnoea responds to tactile stimulation

IN THE DELIVERY ROOM• Anticipation• It is possible to anticipate many

babies that may require resuscitation• 20% of children in poor condition at

birth can not be predicted• This is why all attending staff in

delivery room should master basic resuscitation procedures.

IN THE DELIVERY ROOM• Min 0 – General care (Thermal

care)• Min 0 – 1 - Airway and breathing• Min 2 – 3 - Circulation• Min 3 – 4 - Consider

– Fluid – Inotrope infusion– Sodium bicarbonate