9. The newborn infant. Morphological and functional characteristics. Routine delivery room and initial care for the newborn.

Question 1

what are the steps for immediate care of the newborn ?

Answer 1

1) clear airway
2) dry the newborn
3) clamp the cord
4) ensure onset of respiration
5) correct surfactant defficiency
6) APGAR SCORE
8) asses for gross abnormalities
9) obtain footprints
10) apply identification bans
11) administer vitamin k and eye prophylaxis
12) promote bonding

Question 2

when do we clear the airway ?and with what ?

Answer 2

when the head emerges from vagina with towel

bulb suction to aspirate secretion from oropharynx

Question 3

why should we clear the airway

Answer 3

delivery causes compression of the chest wall resulting discharge of fluid from mouth and nose

Question 4

suction should not be used on nose initially why?

Answer 4

initiate the gasp , cause bradycardia from vagal reflex

Question 5

when clearing the airway if there is moderate meconium present ?

Answer 5

Tracheal tube to suction

Inhaled nitric oxide - reduce the pulmonary hypertension

Continuous positive air way pressure mask

Glucocorticoid for anti inflammatory

Surfactants are given

If serious
Mechanical ventilation
Extracorporeal membrane oxygenation

Question 6

how long does it take for the umbilical arteries usually close spontaneously and umbilical vein ?

Answer 6

45-60 second after birth whereas the umbilical vein remains 3-5 minutes longer.

Question 7

what can happen if there is a delay in clamping the cord ?

Answer 7

neonatal jaundice and tachypnea can occur if there is a delay in clamping

Question 8

what is the ideal time in clamping the cord ?

Answer 8

ideal time 20-30seconds after birth

Question 9

when should the onset of respiration take place ?

Answer 9

within first 30 seconds of birth

Question 10

what if the onset of respiration not commenced after 30 seconds or HR is less than 100

Answer 10

less than 100 percent positive pressure ventilation with oxygen should be started
if no improvement after 90 seconds - oxygen should b increased

Question 11

surfactant deffieicncy is common in what types of babies ?

Answer 11

premature infant

Question 12

surfactant deficiency is responsible for ?

Answer 12

respiratory distress syndrome

Question 13

surfactant deficiency is treated with ?

Answer 13

exogenous surfactant ensured either given by tracheal injection at birth or can be given after the syndrome has developed to reduce its severity and prevent mortality

Question 14

what is the APGAR score ?

Answer 14

A - appearance of skin colour / 0-blue pale all over, 1-blue at extremeties and body is pink , 2 - no cyanosis and extremities pink
P- pulse / 0 - absent , 1- <100bpm , 2 .100bpm
G- grimace - no response to stimulation -0/ grimace on action or aggressive stimulation -1/ cry on stimulation -2
A- activity - no response to stimulation -0/ some flexion -1/ flexed arms and legs that resists extension -2
R- respiration - 0 absent / weak irregular gasping , strong robust cry

normal APGAR score is 7 or greater in one minute after delivery , then 9-10 after 5 minutes of delivery

if the infant scores between 7-10 maintain NTE (normal temp and environment ) and observe

Question 15

If the APGAR score is between 4 -6 this indicates what ? and what should be the response

Answer 15

moderate depression (ex. Meconium
aspiration

O2 by bag and Mask (B/M),

warming and stimulating the infant should

Monitor vital signs reevaluate in 5 minutes.

CPAP - continuous positive
airway pressure

or Mechanical Ventilation (MV) may be necessary.

Question 16

A score of 1-3 indicates? and what is the response ?

Answer 16

probably a cardiac or respiratory arrest
or a condition caused by severe bradycardia, hypo ventilation, or CNS depression

Most low Apgar scores are caused by difficulty in establishing adequate
ventilation

Apgar score of 0 to 3 with asphyxia manifest into 
 fetal acidosis (pH <7) seizures, coma, or
hypotonia; and multiorgan dysfunction often occur.

low Apgar scores respond to assisted ventilation by facemask or by endotracheal intubation

Question 17

What are the causes of a very low apgar score

Answer 17

uterine and placental :

- placenta abruption 
placenta previa 
post maturity of placenta 
velamenouts cord insertion 
uterine rupture 

PROM = delivery must occur in 24 hrs to prevent infection

umbilicals cord prolapse or compression

eryhtoblastis fetalis - haemolytic anema of newborn

diabetes mellitus in pregnancy

cardiopulmonary problems of the mother

trauma during deliver
cephalopelvic diproportion
fetal presentation - breech , brow or face

drugs administered to mother during labor or delivery :
inhaled anaesthetics
local anaesthetic
substance abuse

Question 18

how goes the resuscitation of the newborn

Answer 18

ABCD

A - airway
clearing the airway by suctioning
endotracheal tubing - esp if there is hiatal hernia - if bag and valve used the oxygen also goes into the stomach
fetal hydrop - bilateral thoracocentosis

b - breathing
- mask and bag with manometer

c - circulation
external cardiac massages - no pulse , asystole
120 compression per minute compression and breaths given at a ratio of 3:1

D - drugs
unresponsive to ventilation and systole and no pulse
epinephrine should be given -IV through umbilical vein
or injected through the endotracheal tube

pneumothorax should be thought of before medication with poor pulse
illumination of the thorax through each side of the thorax and over the sternm - if one sid transmits are light then the other suggest pneumothorax
breath sounds diminishes
shift f heart tones away from the side of tension

CNS depression due to narcotics - naloxone intravenously or through endotracheal tubing
= DO NOT GIVE IF IT IS A MOTHER ADDICTED TO DRUGS or is on methadone maintencae
= experience severe withdrawal seizures

Question 19

what is the definition of perinatal period ?

Answer 19

29th gestational week to 7th day of extrauterine life

Question 20

what does it mean by large for gestational age

Answer 20

newborn is heaver than the 90 th percentile

Question 21

what does it mean small for gestational age

Answer 21

new-borns lighter than the 10th percentile

Question 22

what is normal birthweight in a full term baby ?

Answer 22

2500-4000g

Question 23

in new born assessment what is the optimal length of full term baby ?

Answer 23

45-60cm

Question 24

newborns can loose up to how much of the birth weight fr it still to be normal ?

Answer 24

10 percent

Question 25

what is the normal head circumference of a new born

Answer 25

33-38 cm | about half the baby's body length in cm plus 10 cm

Question 26

what is the normal chest cirucumferenfc of a new born?

Answer 26

31-36 cm

Question 27

Normal axillary temperature

Answer 27

36-37°C

Question 28

Normal heart rate of new born

Answer 28

110–160 bpm

Question 29

normal resp rate for new born ?

Answer 29

30–60/minute

Question 30

what are the head morphological features we look for in a new born ?

Answer 30

Fontanels need to be open and soft Depressed fontanel indicates dehydration Bulging fontanel may indicate increased intracranial pressure Molding result of fetal pressure from passage through birth canal ( resolves in 24-48hrs) Cephalhematoma result from trauma (resolves in few weeks hemorrhage between skull and periosteum cause prolonged second stage of labour or instrumental delivery - forceps lead to damage of subperiosteal vessels because swelling is subperiosteal the boundaries are limited to the individual bones as in contrast to caput succedaneum Caput succedaneum pressure from delivery resolves in 1-2 weeks edema between periosteum and overlying skin during labour venous drainage of the blood from the head can be stopped due to the high pressure - resulting in edema

Question 31

what should we look ou for in inspection of face ?

Answer 31

Inspect face for symmetry of eyes, nose, lips, mouth and ears Eyes usually blue or gray, permanent color established in 3- 12 months Nose midline with patent nares Red reflex present cornea intact Can see up to 2 1⁄2 feet clearest vision is 8 to 12 inches Subconjunctive hemorrhages may be present due to the pressure from delivery Ears aligned with outer canthus of eyes; pinna well formed, open auditory canal ( low set ears associated with chromosomal abnormalities) Mouth mucosa pink and moist; tongue mobile, strong suck, hard/soft palate intact

Question 32

what should the morphology check of the baby's neck be?

Answer 32

deep folds of skin webbing associated with down syndrome assess for full range of motion palpate for abnormal masses note the position of trachea

Question 33

what should morphology check of the baby's chest be?

Answer 33

shape should be cylindrical bellshapped chest - underdeveloped lungs evaluate respiratory effort and movement osculate the lung fields and heart sounds unequal breath sounds - penumothorax

Question 34

what's should the morphology check of the abdomen be ?

Answer 34

umbilical cord with two arteries and one vein flat abdomen - diaphragmatic hernia ausculate for bowel sounds suprapubic area palpated for bladder distention femoral pulse palpated if unable to locate -coractaton of aorta

Question 35

female genital and anal assessment ?

Answer 35

newborn labia majora covers labia minora and clitoris Mucoid vaginal discharge due to maternal hormones Hymenal tag may be present anus patent

Question 36

what is the male genital and anal assessment ?

Answer 36

rugae present on scrotum scrotal edema may be present due to maternal hormones testes descended check for placement if meatus anus should be patent

Question 37

what is the assessment of the extremities ?

Answer 37

assess full range of motion symmetry assess muscle tone hyper flexibility of joints = down syndrome hips assessed for dislocation nail beds pink - persistent cyanosis associated with hypoxia palms should have normal creases - simian crease - down syndrome no signs of polydactyly

Question 38

what is the morphological assemsemt of the spine ?

Answer 38

spine should be straight flat shoulders scapular and iliac crest line up int he same plane evaluate dimpling - associated with spinabifida or fissures

Question 39

what is the morphological assessment of the skin ?

Answer 39

asses the colour trauma rashes birth marks : mongolian spots stork bites/ angel kisses - temporary birth marks caused by dilations (or stretching) in your baby's capillaries (tiny blood vessels) visible through the skin milia - are small, bump-like cysts found under the skin. They are usually 1 to 2 millimeters (mm) in size. They form when skin flakes or keratin, a protein, become trapped under the skin. Milia most often appear on the face, commonly around the eyelids and cheeks lanugo = fine soft hair texture - soft or peeling turgor elasticity Vernix caseosa, also known as vernix, is the waxy or cheese-like white substance found coating the skin of newborn human babies

Question 40

what is the assessment of the neurological reflexes in newborns ?

Answer 40

infant alert and responsive reflexes should be present - the indicate the maturity of the baby and the CNS system

Question 41

what are the neurological reflexes that needs to be looked at in a new born baby

Answer 41

sucking - by 4 months it becomes voluntary rooting grasping - 4-6 month disappear extrusion - 4-6 months after birth causes your baby's tongue to move forward as soon as his lips are touched asymmetrical tonic neck - should disappear in 4-6 months When the face is turned to one side, the arm and leg on the side to which the face is turned extend and the arm and leg on the opposite side flex symmetrical tonic neck reflex should go in 9-11 months more than 2-3 years it is a problem placing the child in quadruped position on the floor and passively flexing the head forward and then extend it backwards. The expected response would be forward head flexion producing flexion of the upper extremities and extension of the lower extremities while extension of the head will produce extension of the upper extremities and flexion of the lower extremities tonic labyrinth reflex - 31/2 years of age when the head is tilted back, the back arches, the legs straighten, and the arms bend. persistant non physiological TLS the child cannot roll over however if the start t roll over before 3 months strong tl suspected and high likely of motor impairment moro - spreading out the arms , pulling the arms in and then crying - asymmetry is almost always a nerve disease stepping babinski - disappear around 12 months of age persistence beyond 2-3 years is a problem truncal incurvation / galant reflex = 4th month holding the newborn in ventral suspension (face down) and stroking along the one side of the spine. The normal reaction is for the newborn to laterally flex toward the stimulated side. blinking majority of reflex diasspaera 4-6 months

Question 42

the moro reflex is in its incomplete form when ?

Answer 42

during preterm after the 25th weeks incomplete form | and in complete form in 30 th week

Question 43

what is exaggerated moro reflex indicate

Answer 43

severe brain damage which occurred in utero - microcephaly and hydrocephaly moderate hypoxemic ischemic encephalopathy

Question 44

when does the rooting reflex disappear ?

Answer 44

four months

Question 45

when does the moro reflex disappear ?

Answer 45

3-6 months

Question 46

if the palmar grasp reflex persists what is the clinical significance

Answer 46

delays motor function the hands Palmar grasp reflex in adults is pathologicamay signify frontal lobe damage, or may be a sign of anterior cerebral artery syndrome.

Question 47

what is the clinical significance if it has passed 6 months for the asymmetrical tonic neck reflex and tonic labyrinth reflex to disappear ?

Answer 47

child has developmental delays, children with cerebral palsy, the reflexes may persist and even be more pronounce hinder functional activities such as rolling, bringing the hands together, or even bringing the hands to the mouth. causing the head of the femur to partially slip out of the acetabulum (subluxation) or completely move out of the acetabulum (dislocation).

Question 48

what is the significance of symmetrical tonic neck reflex ?

Answer 48

It is a bridging or transitional brainstem reflex that is an important developmental stage and is necessary for a baby to transition from lying on the floor to quadruped crawling or walking In order to progress beyond this development stage, the baby needs to have been successful in unlinking the automatic movement of the head from the automatic movement of the arms and legs

Question 49

The presence of the Babinski sign in adults indicate what

Answer 49

upper motor neurone lesion damage to corticospinal tract disease of the spinal cord and brain in adults,

Question 50

how is there a behavioural assessment taken ?

Answer 50

sleep wake cycles activity social interactions response to stimuli

Question 51

what are the ways we can assess neonatal gestational age ?

Answer 51

BALLARD SCORE ``` neuromuscular maturity -posture -square window -arm recoil -popliteal angle -scarf sign - heel to ear sign each given -1 - 4 except popliteal angle to 5 ``` and physical maturity - skin - lanugo - plantar surface - breasts - eye and ear - genetelia scored -1 - 4 except skin and lanugo

Question 52

Ballard score can be used up to ?

Answer 52

4 days after birth usually used in the first 24 hours accurate only within plus or minus 2 weeks, it should be used to assign gestational age only when there is no reliable obstetrical information

Question 53

how do you asses posture to gestational age ?

Answer 53

As maturation progresses, the foetus gradually assumes increasing passive flexor tone at rest that precedes in a centripetal direction with lower extremities slightly ahead of upper extremities. Term newborn (flexed posture) and preterm newborn (extended posture).

Question 54

how do you assess square window ?

Answer 54

Wrist flexibility and resistance to extension of wrist as the baby matures is responsible for the resulting angle of flexion at the wrist. The examiner applies gentle pressure on the dorsum of the hand, close to the fingers. From extremely preterm to post term, the resulting angle between the palm of the infant's hand and forearm is gradually diminished

Question 55

how do you asses arm recoil

Answer 55

Arm recoil examines the passive flexor tone of the biceps . With the infant lying supine, the examiner places one hand beneath the infant's elbow for support taking the infant's hand, the examiner briefly sets the elbow in flexion, then momentarily extents the arm before releasing it. The angle of recoil, to which the forearm springs back into flexion is noted the angle or recoil decreases as gestational age increases

Question 56

how do you assess the popliteal angle ?

Answer 56

This maneuver assesses the maturation of passive flexor tone of the knee extensor muscles . With the neonate lying supine, the thigh is placed gently on the abdomen of the knee fully flexed. The examiner gently grasps the foot at the sides with one hand while supporting the side of the thigh with the other. Care is taken not to exert pressure on the hamstrings. The leg is extended until a definite resistance to extension is appreciated. At this point the angle formed at the knee by the upper and lower leg is measured decreases with age

Question 57

how do you assess the scarf sign ?

Answer 57

It is tests the passive tone of the flexors about the shoulder girdle. With infant lying supine, the examiner adjusts the infant's head to the midline and supports the infant's hand across the upper chest with one hand. The thumb of the examiner's other hand is placed on the infant's elbow. The examiner tries to pull the elbow gently across the chest, feeling for the resistance more resistance as grow older

Question 58

how do you assess the hteel to ear sign ?

Answer 58

This measures the passive flexor tone of the posterior hip / girdle flexor muscles. The infant is placed supine and the flexed lower extremity is brought to rest on the cot. The examiner supports the infant's thigh laterally alongside the body with the palm of one hand. The other hand is used to grasp the infant's foot at the sides and to pull it towards the ipsilateral ear. The examiner feels for the resistance to extension of the posterior pelvic girdle flexors and notes the location of the heel where significant resistance is appreciated heel becomes less closer to ear when aeging

Question 59

how can we asses the skin in ballard score

Answer 59

sticky, friable, transparent -1 gelatinous, red, translucent = 0 smooth pink visible veins = 1 superficial peeling &/or rash, few veins cracking, pale areas, rare veins parchment, deep cracking, no vessels leathery, cracked, wrinkled

Question 60

how do you asses lanugo to ballard score

Answer 60

``` none sparse abundant thinning bald areas mostly bald sparse = full term ```

Question 61

plantar surface assessment ?

Answer 61

heel to toe 40–50 mm more than 50 mm no crease Faint red marks Anterior transverse crease only Creases over anterior 2/3 of sole Creases over entire sole

Question 62

breast assessment

Answer 62

Imperceptible Barely perceptible Flat areola no bud Stippled areola 1–2 mm bud Raised areola 3–4 mm bud Full areola 5–10 mm bud = full term

Question 63

eye and ear assessment

Answer 63

Lids fused Loosely: -1 Tightly: -2 Lids open pinna flat stays folded Sl. curved pinna soft; slow recoil Well-curved pinna soft but ready recoil Formed & firm instant recoil Thick cartilage = full term ear stiff

Question 64

genitals male assessment ?

Answer 64

Scrotum flat, smooth Scrotum empty, = 23 wks in abdomen faint rugae Testes in upper canal, rare rugae Testes descending, 26-28 wks pass through inguinal canal few rugae Testes down, good rugae Testes pendulous, = full term deep rugae

Question 65

female genetelia assessment ?

Answer 65

Clitoris prominent & labia flat Prominent clitoris & small labia minora Prominent clitoris & enlarging minora Majora & minora equally prominent Majora large, minora small Majora cover clitoris & minora

Question 66

how does the ballard scoring work ?

Answer 66

A simple formula to come directly to the age from the Ballard Score is Age=((2*score)+120)) / 5 ``` score -10 - 50 from 20(-10) weeks to 44 (50) ```

Question 67

what is apnea ?

Answer 67

cessation of respiration for more than 30 seconds WITH bradycardia and acidosis

Question 68

what are two types of apnea ?

Answer 68

primary - cessation of breathing occurs immediately after birth for 30 with bradycardia and acidosis lasts 1 min followed by gasping lasting several mins = primary apnea responds to pain and cold and oxygen therapy primary apnea can go into normal respiration or secondary apnea secondary paean = dos not respond to pain or cold or touch or oxygen oxygen produces severecyanosisi bradycardia resuscitative efforts must begin immediately

Question 69

how do we treat apnea ?

Answer 69

``` tactile stimuli oxygen theophylline - cns stimulant pap mechanical ventialtion ```

Question 70

what is asphyxia neonatrum ?

Answer 70

all conditions manifesting to hypoxia , hypercapnia and acidosis an all neonates experience asphyxia as a result of delivery

Question 71

what causes asphyxia ?

Answer 71

intrauterine hypoxiemia ischemia = placenta abruption etc intrapartum cephalopelvic disproportion dystocia umbilical cord compression ``` post partum myasthenia graves myopathy pneumonia china atresia laryngeal webs goiter pneumothorax diaphragmatic hernia pneumothorax ```

Question 72

what re the effects of asphyxia

Answer 72

cns - hypoxemic ischemic encephalopathy seizures hypotonia cv - MOCARDAL ICHEMIA , Pulmonary - perisitant pulmonary hypertension , cor pulmonale , respriatory distress syndrome renal - acute tubular or cortical necrosis adrenal - adrenal haemorrhages gastrointestinal - ulceration and necrosis

Question 73

what is the pathophysiology of meconium aspiration occurring after birth ?

Answer 73

decreased placental blood flow or maternal hypoxia = can lead to fetal hypoxia in face of severe fetal hypoxia and acidosis the fetus will respond to peripheral vasoconstriction further decreasing he oxygen status and prolonged anoxia causes the chemoreceptors to trigger breathing and aspirate amniotic fluid if the oxygen saturation drop below 30 the baby will loose consciousness and have bowel movement and pass meconium

Question 74

what is the pathophysiology of meconium aspiration after the birth ?

Answer 74

once he baby's head and chest are delivered the baby starts to breath and pulls the meconium deep into the airway

Question 75

meconium aspiration is particularly common in ?

Answer 75

post term babies fetus less than 34 week old rarely passes meconium small for gestational age , breech birth

Question 76

what are the harmful effect of meconium aspiration ?

Answer 76

ball valve obstruction bacterial infection = sterile before birth but not after chemical pneumonitis

Question 77

what are the signs and symptoms of meconium aspiration baby ?

Answer 77

baby has meconium stains on head and face old meconium = yellow new mecum = black and tar like APGAR score low silverman is high RDS breath sounds = whetting , expiratory grunting xray = air trapping , consolidation and atlelectasisi

Question 78

what s the treatment for meconium aspiration

Answer 78

suction out of oropharynx intubate asses the vita signs and the oxygen = 70 percent to 100 percent administer antibiotics beta 2 agonist = bronchodilators

Question 79

what is complication of meconium aspiration ?

Answer 79

pneumothorax persistent pulmonary hypertension