a neonatológus szerepe a perinatalis gondozásban · 3 newborn terminology cliv. act of care 1997...
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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
ATTENTION
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