Care of the Newborn

Provena Regional EMS December 2012 CE

Objectives
Discuss

the components of the APGAR scoring system Describe how the inverted triangle concept is used in the resuscitation of newborns. Review the steps of CPR for the newborn Using scenarios demonstrate the resuscitation of newborn infants in various stages of distress

The APGAR Score

Standard Assigns

scoring system used to assess the status of a newborn

a number value to five areas:
Appearance
Pulse Grimace or irritability Activity or muscle tone Respirations

The APGAR Score

The APGAR Score

Appearance

If the skin of the newborns entire body is blue (cyanotic) or pale, award 0 points. If the newborn has blue hands and feet with pink skin at the core of the body, award 1 point If the skin of the extremities as well as the trunk is pink, award 2 points.

The APGAR Score

Pulse Heart rate is one of the most important signs of whether oxygen is reaching the newborns tissues following birth.

Count the heart rate for at least 30 seconds, preferably with a stethoscope. If you do not have a stethoscope, feel the pulse of the umbilical cord where it joins the abdomen or at the brachial artery.

If no pulse is present, award 0 points. If the heart rate is under 100 (also a serious finding), award 1 point. If the heart rate is over 100, award 2 points.

The APGAR Score

Grimace (reflex irritability)

Gently flick the soles of the newborns feet, or observe the facial expressions during suctioning.

If the newborn displays no reflexive activity to your stimulation, award 0 points. If the newborn displays only some facial grimace, award 1 point If your stimulation causes the newborn to grimace and cough, sneeze, or cry, award 2 points.

Activity

The APGAR Score

This score refers to extremity reflexes/movement, or the degree of flexion of the arms and legs and the resistance to straightening them. The normal newborns elbows, knees, and hips are flexed, and you should encounter some degree of resistance when you try to extend them.

If during your assessment, the newborn is limp and displays no extremity movement, award 0 points. If the newborn only displays some flexion without active movement, award 1 point. If the newborn is actively moving around, award 2 points.

The APGAR Score

Respiration

Another important assessment sign is the newborns breathing effort. The newborn should have regular respirations and a vigorous cry. Distress is indicated by irregular, shallow, gasping, or absent respirations.

If the newborn displays no respiratory effort, award 0 points If the newborn displays only a slow or irregular breathing effort with a weak cry, award 1 point If the newborn displays good respirations and a strong cry, award 2 points.

The APGAR Score

The

total of the five numbers is the Apgar score.

A perfect score is 10.

Calculate the Apgar score at 1 minute and 5 minutes after birth.

The APGAR Score

710

pointsThe newborn should be active and vigorous. Provide routine care. 46 pointsThe newborn is moderately depressed. Provide stimulation and oxygen. 03 pointsThe newborn is severely depressed. You will probably need to provide extensive care including oxygen with bag-valve-mask ventilations and CPR.

Neonatal Assessment and Resuscitation

Follow

standard precautions.

Always

put on gloves before handling a newborn.

Protecting

the newborn against heat loss

is critical!
Also

assure that the airway is clear of all secretion or birth fluids. Perform additional suctioning as needed.

Neonatal Assessment and Resuscitation

Newborn

should begin breathing spontaneously within 15 to 30 seconds after birth Heart rate should be 100 beats/min or higher If you do not observe these responses:

Gently tap or flick the soles of the feet or rub the back. Begin resuscitation efforts.

Neonatal Assessment and Resuscitation

Most

newborns require no resuscitation beyond temperature maintenance, mild stimulation, and suctioning. A minority of the newborns will be so depressed that they also will need chest compressions or resuscitative medications.

Signs of Severely Depressed Newborn

Respiratory rate over 60 per minute Diminished breath sounds Heart rate over 180 per minute or under 100 per minute Obvious signs of trauma from the delivery process Poor or absent skeletal muscle tone Respiratory arrest, or severe distress

Heavy meconium staining of amniotic fluid Weak pulses Cyanotic body (core and extremities) Poor peripheral perfusion Lack of or poor response to stimulation APGAR score under 4

The Inverted Pyramid

Neonatal Assessment and Resuscitation

Observe

the newborn for spontaneous respirations, skin color, and movement of the extremities. the heart rate at the base of the umbilical cord or the brachial artery.

Evaluate

The heart rate is the most important measure in determining the need for further resuscitation.

Neonatal Assessment and Resuscitation

Neonatal Assessment and Resuscitation

If

cyanosis is present but breathing and heart rate are adequate, provide blow-by oxygen

Neonatal Assessment and Resuscitation

Provide ventilations by bag-valve-mask with supplemental oxygen at the rate of 4060 per minute if the newborn displays any of the following: The infants breathing is shallow, slow, gasping, or absent following brief stimulation. The infants heart rate is less than 100 beats per minute. The infants core body remains cyanotic (blue) despite provision of blow-by oxygen.

Neonatal Assessment and Resuscitation

Reassess after 30 seconds of ventilation. If the breathing has not improved and the heart rate is less than 100/minute, continue ventilations and reassess every 30 seconds.

Neonatal Assessment and Resuscitation

If,

despite adequate ventilations, the infants heart rate drops to less than 60 beats per minute, continue ventilations and begin chest compressions at a rate of 120/min

Neonatal Assessment and Resuscitation

Use either the handencircling technique or the two-finger technique.

Coordinate chest compressions with ventilations at a ratio of 3:1.

Neonatal Assessment and Resuscitation ALS

If

heart rate is < 60 beats/min after another 30 seconds CPR, consider intubation. Prepare epinephrine dose of 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of the 1:10,000 solution) ET/IV/IO.

Neonatal Assessment and Resuscitation BLS Shock Treatment

Shock

symptoms:

Poor perfusion Weak pulses Poor response to resuscitation.

Shock

treatment:

Rapid transport.

Neonatal Assessment and Resuscitation ALS Shock Treatment

Assure adequate oxygenation and ventilation. Obtain intravenous access: Intravenous: first choice Intraosseous: second choice Umbilical venous: if trained and equipped 1020 mL/kg normal saline or Ringers lactate

Key Concept: The Inverted Pyramid

Review

Answer the following questions as a group. If doing this CE individually, please e-mail your answers to: shelley.peelman@presencehealth.org Use Dec 2012 CE in subject box. You will receive an e-mail confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book.

Review
Scenario: You and your partner are dispatched to the local shopping mall for a 17 year old female with severe abdominal pain. When you arrive you find your patient lying on the floor of the bathroom and discover that she has just given birth. The newborn is face down on the bathroom floor. The mother is stable.

Review
1. 2.

What are your initial treatment priorities for this newborn infant? Calculate the initial APGAR score from the following information.
Cyanosis to hands and feet Crying; non-labored respirations Heart rate is 120 Arms and legs held in flexed position

Review
Scenario: You and your partner deliver a 31 week gestation baby girl . You dry, warm, position, suction and stimulate the infant but despite these interventions the infant remains flaccid with irregular respiratory effort and a weak cry. Central cyanosis is also present and the heart rate is 40.

Review
3. 4. 5.

Calculate the AGPAR score of this newborn infant. What are the BLS treatment priorities for this newborn infant? ALS providers: What, if any, are the ALS treatment priorities for this newborn infant?

Review
6. What is the appropriate rate of compressions and the compressions to ventilations ratio during CPR for the newborn?

Answers
1.

2.

Reposition the infant and suction the mouth first, then the nose. Dry and warm the infant. Stimulate by rubbing the infants back or flicking the soles of the feet. Calculate the APGAR score at 1 and 5 minutes. Complete the initial assessment (ABCs). APGAR score = 9

Answers
4.

APGAR score = 2 Begin bag valve mask ventilations and chest compressions immediately. Reassess heart rate after 30 seconds.

Answers
5.

6.

If despite ventilations and chest compressions the heart rate remains below 60, consider endotracheal intubation and IV/IO access. Administer Epinephrine 1:10,00 0.01-0.03 mg/kg ET/IV/IO if needed. 120 /minute; 3:1 (compressions to ventilations)