Introduction

Dr. Miada Mahmoud Rady

EMS/481

Neonatal emergencies lecture 1

Introduction

Newborn : babies within the first few hours after birth.

Neonates : within the first month after birth.

Paramedic is usually called to take care of newborn in two

cases :

1. For transport in case hospital delivery.

2. In case of unscheduled either ( home or in the field

delivery ).

Introduction

Unscheduled delivery means two patient , at least , the mother

and the baby.

Most of new born will need minimal stimulation .

The need for further intervention is affected by several factors.

Neonatal resuscitation

Factors that may indicate the need for further intervention

include :

1. Antepartum Factors.

2. Intrapartum Factors.

Factors that may indicate the need for resuscitation :

Antepartum Factors

1. Multiple gestations

2. Inadequate prenatal care

3. Mother’s age (<16 or >35)

4. History of prenatal morbidity or mortality.

5. Post term gestation.

6. Drugs or medications.

Intrapartum Factors

1. Premature labour

2. Meconium stained amniotic

fluid

3. Ruptured membranes more

than 24 hours prior to

delivery

4. Narcotics within 4 hour of

delivery

5. Abnormal presentations.

Transition From Fetal To Neonatal Circulation

Dramatic changes occurs as the newborn prepares for

extra uterine life :

1. Fluid in the fetal lungs is forced out through chest

compression during delivery.

2. Newborn usually takes first breath within seconds of

delivery independent of cutting cord.

Transition from Fetal to Neonatal Circulation

3. Stimulant of the First Breath include :

a. Mild acidosis.

b. Initiation of stretch reflexes in the lungs.

c. Hypoxia.

d. Hypothermia .

Transition from Fetal to Neonatal Circulation

4. Changes that occur with the first breath:

At birth , the lung expand as become filled with air and alveolar

fluid gradually leaves the lungs .

At the same time , lung arterioles open allowing considerable

amount of blood to enter the lung.

As result , the blood that was passing through the ductus arteriosus

enter the lung where it pick up oxygen and then this blood is carried

to supply the newborn tissue , so the ductus starts to close.

Circulation to the lungs increases left atrium flow,

increased pressure causes the foremen ovale to close and

blood circulates normally.

During the first breath , pulmonary vascular resistance

drops .

Transition from Fetal to Neonatal Circulation

4. Delay in drop pulmonary pressure leads to:

a. Delayed transition.

b. Hypoxia.

c. Brain injury.

d. Death.

Assessment

of

the newborn

Assessment general guidelines

1. Assess the newborn immediately after birth.

2. Ideally, one paramedic attends the mother while the other

attends the newborn.

3. Newborns will be slippery and require both hands.

4. Use the following parameters to assess newborn : heart rate ,

respiratory rate , skin color and APGAR score.

General parameters

1. Normal heart rate 150–180/min :

Slowing to 130–140 thereafter.

A pulse less than 100 indicates distress.

2. Normal respiratory rate 40–60/min.

Normal appearance

Head : shows molding which is the irregular shape of a baby's

head from the birth process. Normal shape usually returns by the

end of the first week.

Vernix : This is a white, greasy, cheese-like substance on the

skin of many babies at birth. It protects the baby's skin during

pregnancy.

Lanugo : This is soft, downy hair on a baby's body , It's more

prominent in premature babies , gradually disappear.

Normal appearance

Color : A baby's skin coloring can vary greatly .

1. When first born, the skin is a dark red to purple color. As the

baby begins to breathe air, the color changes to red.

2. This redness normally begins to fade in the first day.

3. A baby's hands and feet may stay bluish in color for several

days , due to underdeveloped blood circulation.

4. Blue coloring of other parts of the body, however, isn't

normal.

Normal appearance

Milia : are tiny, white, bumps on a newborn's nose, cheeks,

chin and forehead, milia form from oil glands and disappear

on their own.

APGAR test

Definition :

1. A quick test performed on a baby at 1 and 5 minutes after

birth :

The 1-minute score : determines how well the baby

tolerated the birthing process.

The 5-minute score : determines how well the baby is

doing outside the mother's womb.

How the test is done?.............

You will examine the baby's:

1. Breathing effort

2. Heart rate

3. Muscle tone

4. Reflexes

5. Skin color

Each category is

scored with 0, 1, or

2, depending on the

observed condition

Why the test is done??

This test is done to determine whether a newborn needs help

breathing or is having heart trouble.

Normal Results

1. The APGAR rating is based on a total score of 1 to 10.

2.  The higher the score, the better the baby is doing after

birth.

3. A score of 7, 8, or 9 is normal and is a sign that the

newborn is in good health.

APGAR score

A for appearance

1. Appearance (Skin color):

• If the skin color is pale blue, the infant scores 0 for color.

• If the body is pink and the extremities are blue, the infant

scores 1 for color.

• If the entire body is pink, the infant scores 2 for color.

P for pulse

2. Pulse (Heart rate) :

is evaluated by stethoscope ,this is the most important

assessment:

If there is No Heartbeat, the infant scores 0 for heart rate.

If heart rate is Less Than 100 Beats per minute, the infant

scores 1 for heart rate.

If heart rate is Greater Than 100 Beats per minute, the

infant scores 2 for heart rate.

G for grimace

3. Grimace response ( reflex irritability ):

• It is a term describing response to stimulation such as a mild

pinch :

– If there is no reaction, the infant scores 0 for reflex irritability.

– If there is grimacing, the infant scores 1 for reflex irritability.

– If there is grimacing and a cough, sneeze, or vigorous cry, the

infant scores 2 for reflex irritability.

A for activity

3. Activity ( Muscle tone):

– If muscles are loose and floppy, the infant scores 0 for

muscle tone.

– If there is some muscle tone, the infant scores 1.

– If there is active motion, the infant scores 2 for muscle

tone.

R for respiration

1. Respiration ( Breathing )effort:

– If the infant is not breathing, the respiratory score is 0.

– If the respirations are slow or irregular, the infant scores 1

for respiratory effort.

– If the infant cries well, the respiratory score is 2

Neonatal

resuscitation

Neonatal resuscitation

1. Initial steps of neonatal resuscitation include:

I. Airway (position and clear)

II. Breathing (stimulate to breathe)

III. Circulation (assess heart rate and oxygenation)

2. Additional resuscitation steps :

• They are used based on need and include →

Additional Resuscitation Steps

1. Supplemental Oxygen.

2. Positive Pressure Ventilation.

3. Intubation.

4. Chest Compressions.

5. Medications.

Initial steps of stabilizing a newborn

I. Warming the newborn to prevent hypothermia.

II. Positioning the newborn

III. Clearing the airway if necessary

IV. Drying and stimulating breathing

Warming the newborn to prevent hypothermia

1. Place on prewarmed towels or blankets and dry.

2. Replace wet towels with dry, prewarmed ones.

3. When resuscitation is complete, place the newborn on the

mother’s chest or abdomen, another heat source, or under a

radiant warmer.

Four mechanisms of heat loss in newborn and corresponding

interventions

Evaporation : Dry infant immediately.

Conduction : Place on mothers body skin to skin.

Convection : Cover with a blanket, wear a cap.

Radiation : Keep away from cold windows and cold objects.

Mechanisms of heat loss

So why warming the newborn is so important???

Effect of Cold Stress

1. Increased oxygen need.

2. Decreased surfactant production.

3. Respiratory distress.

4. Hypoglycemia.

5. Metabolic acidosis.

6. Jaundice.

7. Vasoconstriction can cause a return to fetal circulation

patterns.

Warming the newborn to prevent hypothermia

Neutral thermal environment which helps prevent heat loss

and help the infant to maintain stable body temperature.

Thermoneutral zone should be 32° to 35° C.

Elevated temperature causes increased need for oxygen

and glucose and vasodilation leads to increased insensible

fluid loss.

So Closely monitor warming equipment to prevent

overheating of infant.

Any question????