Module 7 Unit B Flashcards
What are the 5 Cardinal signs of respiratory distress in the new born?
Tachypnea Grunting Nasal flaring Retractions Cyanosis
How does each Cardinal sign of respiratory distress in the newborn assist the newborn breathing?
Tachypnea
Most efficient way to temporarily ↑ventilation and compensate for hypoxia and hypercarbia
Grunting
Normally - vocal cords silently abduct during inspiration and adduct during expiration
Expiration through partially closed vocal cords produces the audible grunt sound
By closing the glottis over the cords during expiration, the infant holds in air, maintaining lung expansion and preserving oxygenation for a few extra seconds
Expiratory grunting elevates the pressure at the end of respiration
Attempt to clear fluid from lungs, sounds created by exhaling against a partially closed glottis in an attempt to increase functional residual capacity in lungs and stabilize alveoli
The maneuver helps keep the lungs expanded and preserves oxygen
Nasal flaring
Attempt to decrease resistance to airflow by ↑size of nostrils
Flaring enlarges the nostrils, decreasing nasal resistance to airflow, and because the infant is obliged to breathe through its nose, any ↓in resistance will ↓total work of breathing
Retractions
Attempts to ↑lung compliance
Retracting assists the diaphragm as it mechanically expands the lung during inspiration
Cyanosis
Central cyanosis is necessary to asses and distinguishes from normal physiologic peripheral cyanosis. Look at the mucous membranes more than the skin.
Cyanotic skin may result from peripheral constriction for any number of reasons - not necessarily hypoxia
Worse hypoxia = more extensive central cyanosis as oxygenated blood is shunted to the heart, brain, lungs, and adrenals
Remember that central cyanosis is not visible until the sPO2 decreases to 80-85% and may be a sign of respiratory or cardiac problems
What is does periodic breathing in the newborn?
How does periodic breathing differ from apnea?
breathing alternating w/ a pause of up to 20 seconds
More common in preterm
Considered benign and normal in full-term
Can be induced by hypoxemia and respiratory depression
Can be relieved w/ respiratory stimulants like caffeine
lapse of 20 seconds or more in breathing w/color changes or bradycardia
Changes in heart rate - often to less than 80 bpm
Common in preterm infants
More frequent for infants w/ chronic lung disease or other respiratory problems
Abnormal finding in full-term infants - may indicate an underlying problem, like sepsis, hypoglycemia, CNS injury or abnormality, or seizures, can also be d/t maternal drug use
What are the 3 categories of apnea?
Central ~ no airflow or breathing efforts
Obstructive ~ no airflow WITH breathing efforts
Mixed ~ begins as central and ends as obstructive
What causes maconium stained fluid?
Elimination of meconium into amniotic fluid
May represent normal GI tract maturation under neural control
Can be associated w/ some form of fetal distress
Theory that mec passage follows vagal stim from common but transient umbilical cord entrapment w/resultant increased bowel peristalsis
What are the maternal implications of maconium stained fluid?
Increased risk for intrauterine infection
What are the fetal implications of maconium stained fluid?
Fetal implications
Irritating to fetal skin → ↑risk for erythema toxicum
Mec aspiration - aspiration induces hypoxia via 4 major pulmonary effects ~
Airway obstruction
Surfactant dysfunction
Chemical pneumonitis
Pulmonary hypertension
Current belief is that Meconium aspiration occurs when infant compromised by a chronic event like chronic metabolic acidosis, infection, or other comorbidities rather than only an acute event in labor
How should the nurse midwife manage meconium stained fluid during birth/delivery?
Intrapartum management
Correcting any risk for fetal insults
Recurrent late decels, prolonged decels, bradycardia, minimal or absent variability → lateral position, maternal O2 admin, IV bolus, ↓ctx freq
Tachysystole w/ cat II or II tracing → d/c oxytocin or prostaglandins, give tocolytics - terbutaline or mag sulfate
Recurrent variable decels, prolonged decels or bradycardia → reposition, amnioinfusion; if there is cord prolapse→ manually elevate presenting part and prepare for immediate delivery
Correct maternal hypotension d/t regional analgesia and d/c oxytocin
SVE to exclude prolapse or impending birth
IV bolus 500-1000mL LR over 20 minutes
Lateral position
Supplemental O2 at 10L per non rebreather
Delivery management
Team measure skilled in endotracheal intubation should be present
Do NOT
Perform amnioinfusion for mec specifically - could be used for variables
Suction mouth and nose on perineum
Intubate and suction vigorous and non vigorous infant
MAS ~
Ventilatory support and intubation as needed
Chest x-ray ~ varies w/ severity, areas of patchy atelectasis, areas of overinflation
Surfactant replacement
Inhaled corticosteroids
What are the indications for newborn endotracheal sectioning?
What are the indications for newborn intubation?
Endotracheal suctioning
If the baby’s condition has not improved and you have not been able to achieve chest movement despite all the ventilation corrective steps and a properly placed endotracheal tube, there may be thick secretions obstructing the airway. Thick secretions may be from blood, cellular debris, vernix, or meconium.
Intubation
Intubation should be considered in the following circumstances:
If PPV with a face mask does not result in clinical improvement, an endotracheal tube or laryngeal mask is strongly recommended to improve ventilation efficacy
If PPV lasts for more than a few minutes, and ET tube or LMA may improve the efficacy and ease of assisted ventilation
Intubation is STRONGLY recommended in the following circumstances:
If chest compressions are necessary, an ET tube will maximize the efficacy of each Positive- pressure breath and allow the compressor to give compressions from the head of the bed. If intubation is not successful or feasible, an LMA is used
And ET tube provides the most reliable airway access in special circumstances, such as
Stabilization of a newborn with a suspected diaphragmatic hernia
For surfactant administration
For direct tracheal suction if the airway is obstructed by thick secretions
What are the adverse effects of newborn intubation/endotracheal sectioning?
Intubation
Pneumothorax
Trauma during insertion to the soft tissues which can cause swelling and closure of the airways
Bradycardia, hypoxemia, systemic hypertension, increased ICP
Endotracheal suctioning
Trauma during insertion to the soft tissues which can cause swelling and closure of the airways
Vigorous suction may injure tissues
Stimulation of the posterior pharynx during the first minutes after birth can produce a vagal-response leading to bradycardia or apnea
Bradycardia, deterioration of pulmonary compliance, oxygenation, and cerebral blood flow
Alter oxygen levels and blood pressure
What are the initial steps of neo natal resuscitation?
First questions after birth
Term?
Tone?
Breathing or crying?
Provide warmth
Position the head and neck
Sniffing position
Dry
Stimulate
How is newborn temperature controlled during neonatal resuscitation?
Baby should be placed under radiant warmer
If you anticipate baby will remain under the warmer for more than a few minutes apply a servo-controlled temp sensor to monitor baby’s temp
Avoid hypothermia and overheating
During resuscitation and stabilization, the baby’s body temp should be between 36.5 and 37.5 c
When is airway clearance indicated with neonatal resuscitation?
Clear secretions from the airway if the baby is not breathing, is gasping, has poor tone, if secretions are obstruction the airway, if the baby is having difficulty clearing their secretions, if there is meconium-stained fluid, or if you anticipate starting PPV
How can airway clearance be achieved within neonatal resuscitation?
Gentle bulb syringe
If baby has copious secretions coming from mouth, turn the head to the side
Suction mouth before nose (Alphabetical M-N)
DO NOT SUCTION VIGOROUSLY OR DEEPLY AS THIS CAN INJURE TISSUES
When is oxygen administration indicated with a neonatal resuscitation?
Supplemental o2 is used when the oximeter reading remains below the target range for the baby’s age.
Free flow o2 can be given spontaneously breathing baby by holding o2 tubing close to the baby’s mouth and nose- NOT effective if the baby is not breathing
A flow rate of 10L/min is used for a free-flow oxygen
Used with PPV if needed
Also if labored breathing or persistent cyanosis but just PRN not standard for all
O2 use is guided by pulse oximetry- adjust the o2 concentration to maintain the baby’s minute specific o2 sat within the target range (Don’t want to much as research is emerging of o2 free radicals and damage)
