PENGENALAN

KEGAWATAN
PADA
NEONATUS

Dr. Aris Primadi, Sp.A(K)

RSHS/ FK UNPAD BANDUNG

Danger signs
  Asphyxia Abdominal distension
  Lethargy
Yellow palms/soles
Bleeding
  Hypothermia
Excessive weight loss
  Respiratory distress
VomiAng
  Cyanosis Diarrhea
  Convulsion
 APGAR Scores

Sign Score = 0 Score = 1 Score = 2

---------------------------------------------------------------------------------------------------
APPEARANCE Blue all over, Acrocyanosis Pink all over
(color) or pale
PULSE Absent Below 100 Above 100
(heart rate)
GRIMACE No response Grimace or Good cry
(reflex irritability) weak cry
ACTIVITY Flaccid Some flexion of Well flexed, or active
(muscle tone) extremities movements of extremities
RESPIRATIONS Absent Weak, irregular, Good crying
or gasping
============================================
The APGAR score should be assigned at one minute and five minutes, finding the total score (0-10)
at each time by adding up points from the table above.
Continue to assign scores every five minutes thereafter as long as the APGAR score is less than 7.

Bernapas atau menangis? Ya Perawatan rutin:

DIAGRAM ALUR
Tonus baik? • Pastikan bayi tetap hangat
• Keringkan bayi
Tidak
PADA!SETIAP!LANGKAH!TANYAKAN:!APAKAH!ANDA!MEMBUTUHKAN!BANTUAN?!

• Lanjutkan observasi pernapasan,

!
laju denyut jantung, dan tonus
RESUSITASI NEONATUS
30!detik!

Langkah awal: (nyalakan pencatat waktu)

• ! Pastikan bayi tetap hangat
• Atur posisi dan bersihkan jalan napas Keterangan:
• ! Keringkan dan stimulasi
DI
Pada bayi dengan berat
• Posisikan kembali
! ≤ 1500 gram, bayi langsung
dibungkus plastik bening
!
Observasi usaha napas, laju denyut jantung (LDJ), dan tonus otot tanpa dikeringkan terlebih

!
dahulu kecuali wajahnya,
kemudian dipasang topi.
FASILITAS
Tidak bernapas/ Bernapas spontan
Bayi tetap dapat distimulasi
!
megap-megap, dan atau
atau LDJ < 100x/ menit
!
walaupun dibungkus plastik
PELAYANAN
Distres napas Sianosis sentral
30!detik!

KESEHATAN
! (Takipnu, retraksi, atau persisten
merintih) Tanpa distres
`! Ventilasi napas
tekanan positif Pertimbangkan

RUJUKAN
! Continuous positive
(VTP) suplementasi oksigen
airway pressure (CPAP)
! PEEP 5-8 cmH2O
Pemantauan SpO2 Pemantauan SpO2
Pemantauan SpO2

!
!

Gagal CPAP
Keterangan: à FASILITAS LENGKAP
Bila!LDJ!tetap!! PEEP 8 cmH2O Apabila LDJ > 100 kali per
<!100!kali/!menit! FiO2 > 40% menit dan target saturasi
! Dengan distres napas oksigen tercapai:
Setiap 30 detik sekali nilai laju denyut jantung, usaha napas dan tonus

Pertimbangkan intubasi • Tanpa alat ! Lanjutkan ke

!
perawatan observasi
! • Dengan alat ! Lanjutkan ke
Pengembangan dada adekuat? perawatan paska-resusitasi
!
Ya! Tidak Waktu dari Target SpO2
! Lahir Preduktal

! mengembang adekuat
Dada Bila dada tidak 1 menit 60-70%
namun LDJ < 60x/ menit mengembang adekuat
! 2 menit 65-85%
VTP (O2 100%) +
kompresi dada
(3 kompresi tiap 1 napas)
Evaluasi:
• Posisi kepala bayi 3 menit 70-90%
!
UKK Neonatologi IDAI
• Obstruksi jalan napas
2014
4 menit 75-90%
• Kebocoran sungkup
!Pertimbangkan Intubasi
• Tekanan puncak 5 menit 80-90%
Observasi LDJ dan usaha inspirasi cukup atau
tidak 10 menit 85-90% !
napas tiap 30 detik
!
Keterangan:
Intubasi endotrakea dapat !
dipertimbangkan pada
LDJ < 60/ menit?
langkah ini apabila VTP tidak!
efektif atau telah dilakukan
Pertimbangkan pemberian obat dan cairan intravena selama 2 menit
 Lethargy and poor sucking

v  In a term baby who was feeding earlier

→ indicates neonatal illness (as perceived by mother)

v  In a preterm baby
→ needs careful assessment
because it may be due to cold stress or immaturity

VOLPE, 2008
Level of Penampilan Respon Respon Motorik
Alertness Bayi Bangun KuanAtas Kualitas

Normal Bangun Normal Normal High Level

Stupor
Ringan Mengantuk Berkurang Berkurang High Level
(slight) (slight)

Sedang Tidur Berkurang Berkurang High Level

(sedang) (sedang)


Berat Tidur Berkurang High Level
Tidak ada
(jelas)

Koma Tidur Tidak ada Berkurang (jelas)/ Low Level

tak ada
 Primitive gut formed

Gut rotation

Structure
Villi

Digestive enzymes

Small intestine mature

Swallow
Function

Gastrointestinal motor activity

Organized motility

Nutritive sucking and swallowing

Post-menstrual age (wk)

The ontogenic timetable showing structural and functional gastrointestinal development

Clin Perinatol 2000

Body temperature in newborn infant (oC)

37.5o
Normal range

36.5o
Cold stress
Cause for concern
36.0o
Moderate hypothermia
Danger, warm baby

32.0o
Severe hypothermia Outlook grave, skilled
care urgently needed
Respiratory problems

v  RR > 60 / min*
v  Retractions
v  Grunting
v  Central cyanosis
v  Apnea

* Rate should be counted in a quiet state

and not immediately after feed
 Cyanosis

Peripheral
v  Normal at birth
v  Seen in extremities
due to cold

Central
v  Always needs appropriate referral
v  Seen on lips and mucosa
v  Indicates cardiac or pulmonary disease

Respiratory Distress Evaluation

Silverman Anderson retraction score

Score Upper chest Lower chest Xiphoid Nasal Grunt

restracAon retracAon retracAon dilataAon

0 Synch None None None None

1 Lag on Just visible Just visible Minimal Stethoscope
inspiraWon only
2 See-Saw Marked Marked Marked Naked ear
A score of > 6 is indicative of impending respiratory failure
Silverman WC, Anderson DH. Controlled clinical trial on effects of water mist on obstructive respiratory signs, death rate and
necropsy findings among premature infants. Pediatrics 1956; 17: 1-4.
 Respiratory Distress Evaluation

Classification of breathing difficulty (WHO – Depkes)

Respiratory Distress Evaluation

Downes’ score

Score Respiratory Cyanosis Air entry Grunt RetracAon

rate
0 <60/min Nil Normal None Nil
1 60-80/min In room air Mild ? Ausc Mild
with
stethoscope
2 >80/min In >40% Marked ? Audible with Moderate
naked ear

Score < 3 Minimal respiratory distress

Score 4 – 5 Moderate respiratory distress
Score > 6 Severe respiratory distress

Wood DW, Downes’ JJ, Locks HI. A clinical score for the diagnosis of respiratory failure.
Amer J Dis Child 1972; 123: 227-9.
 Convulsion

17

ABDOMINAL DISTENSION

Feeding Intolerance
Stop enteral feeds and reassess:
v  Bilious (or greenish residuals)
v  Vomiting
v  Acute increase in abdominal girth >2 cm
v  Frankly bloody or very watery stool
v  Increased residuals
v  Other signs of illness
Yellow staining of soles

19

Clinical assessment of severity of jaundice

•  Cephalocaudal progression
–  face 5 mg/dL (approximately)
–  upper chest 10 mg/dL (approximately)
–  abdomen and upper thighs 15 mg/dL (approximately)
–  soles of feet 20 mg/dL (approximately)

•  Visual inspection may be misleading

20
 Kernicterus - Neuropathology

Yellow staining and neuronal

necrosis
•  Basal ganglia:
–  globus pallidus
–  subthalamic nucleus
•  Cranial nerve nuclei:
•  vestibulocochlear
•  oculomotor
•  facial
•  Cerebellar nuclei
21

BLEEDING

Disseminated Intravascular
Coagulation

22
 Bleeding infant

Screening tests
Activated partial thromboplastin time (aPTT)
Thrombin clotting time (TCT)
Prothrombin Time (PT)
Fibrinogen (Fbg)
Platelet Count
Bleeding Time (BT)

All tests aPTT PT prolonged aPTT, PT, Thrombocytopenia BT abnormal,

normal prolonged TCT, Fbg Platelet count
abnormal
normal

CAPILLARY REFILL TIME (CRT)

v  Indicates tissue perfusion
  Normal CRT < 3 seconds
  Prolonged CRT > 3 seconds *
* Hypotension, hypothermia, acidosis
Excessive
weight loss pattern

v  > 10 percent of birth weight in term

v  > 15 percent in preterm
v  > 5 percent acute weight loss

Failure to pass
meconium & urine

Failure to pass meconium

Majority pass within 24 hrs
v  Delayed passage
v  May have passed in –utero
v  Suspect obstruction

Failure to pass urine

Majority pass within 48 hrs
v  Delayed passage
v  Exclude obstructive uropathy or renal
agenesis
 Vomiting*

v  Ingestion of meconium stained amniotic fluid

v  Systemic illness
v  Raised ICP – IVH, asphyxia

•  Persistent, projectile or bile stained

à intestinal obstruction

Diarrhea

v  Infective diarrhea*
(often non breast fed baby)
v  Metabolic disorders
v  Maternal drug addiction

* Infective diarrhea needs

treatment with systemic antibiotics