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THE NEWBORN Ma. Elena S. Dolor, M.D. FPPS OBJECTIVES I. Clinically recognize the normal newborn infant To recognize the context of a normal pregnancy outcome To describe the process of transition from intrauterine to extra uterine existence To perform a complete physical examination of the newborn infant To perform a concise neurodevelopment assessment of the newborn infant OBJECTIVES II. Provide comprehensive newborn care Formulate a risk assessment list Perform basic steps in neonatal resuscitation Provide immediate care for the newborn Continuing care Discharge procedure with adequate instruction

Fetus and extrauterine life form a continuum during which human growth and development are affected by genetic, environmental and social factors.
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INTRAUTERINE LIFE: Embryonic period - first 8 weeks of - differentiation of tissues Fetal period - 9th to 40th week of - rapid growth and
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gestation organs and gestation elaboration of function

EXTRAUTERINE LIFE: Neonatal period birth to 1 month of age very early birth to less than 24 early birth to less than 7 days late 7 days to less than 28 days hours

PERINATAL PERIOD period from the 28th week of gestation through the 7th day after birth (20th week of gestation to birth until 28th day of life)
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Perinatology Awareness of adverse factors in the intrauterine environment which may affect the growth, development, well-being and birth of the fetus allowing appropriate preparations for the delivery of the potentially compromised fetus Identify the high risk pregnancy Aims to decrease neonatal mortality Perinatal History 1. Demographic and social data socioeconomic status, age, race 2. Past Medical Illnesses in the family cardiopulmonary disease, infection, genetic disorder

3. Prior maternal reproductive problems stillbirths, prematurity


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Perinatal History 4. Events occurring in the present pregnancy vaginal bleeding, medications, acute illness, duration of pregnancy 5. Description of Labor duration, fetal presentation, fetal distress, presence of fever 6. Delivery normal, c-section, anesthesia of sedation, forceps Pregnancy Risk Classification Class A: Low risk mother with Low risk newborn - normal uncomplicated pregnancies and normal labor pattern Class B: High risk mother with low-risk newborn - mothers who are sick but in stable condition and therefore presents a minimal risk to the baby eg. Gravidocardiac, primigravida >35 years or < 16 years, malignant disease not receiving therapy, pulmonary disorder, hematologic disorder Pregnancy Risk Classification Class C: Low risk mother with high risk newborn e.g. history of habitual abortion and stillbirth, abnormal ultrasonographic findings, abnormal biophysical profile, prolonged or early gestation, evidence if IUGR, multiple gestation, rupture of membranes, abnormal fetal heart rate or pattern, meconium staining of amniotic fluid,etc. Pregnancy Risk Classification Class D: High risk mother with high risk newborn - fetus and newborns are compromised because of maternal illness e.g. chronic hypertension, pre-eclampsia/eclampsia, diabetes mellitus (uncontrolled), renal/cardiac failure, viral or bacterial infections, chorioamnionitis, 2nd or 3rd trimester bleeding, etc.

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The neonatal period is highly vulnerable for an infant who is completing many of the physiologic adjustments required for extrauterine existence. Fetal Physiology Circulatory system: - normally complete by 40th week of gestation - fetal circulation with 3 shunts: 1. ductus venosus 2. foramen ovale 3. ductus arteriosus Fetal Circulation Placenta umbilical vein ductus venosus inferior vena cava right atrium foramen ovale left atrium left ventricle ascending aorta head and upper part of the body Fetal Circulation Superior vena cava right atrium right ventricle pulmonary artery ductus arteriosus descending aorta lower half of the body Fetal Circulation Blood flows in parallel rather than in series Mainly affected by high pulmonary resistance brought about by non-expansion of the lungs Fetal Physiology RESPIRATORY SYSTEM - formation starts from the airways proceeding to alveolation - alveolar epithelium excretes lung fluid that fills the alveoli

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- surfactant produced by type ll alveolar cells by 20th week of gestation Fetal Physiology RESPIRATORY SYSTEM - adequate surfactant lowers surface tension of the alveolar epithelium preventing alveolar collapse - respiratory movements occur as early as 18th week of gestation but ceases as fetus approaches term - at term, fetus breathes ONLY if a hypoxic stimulus is applied

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The Transition passage of the fetus through the birth canal chest wall is compressed lung fluid is expelled elastic chest wall recoils back high negative intrathoracic pressure The Transition infants FIRST CRY replaces lung fluid with air

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The Transition aeration of the lungs eliminate the hypoxic state causing vasodilation of lung vessels

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decrease in pulmonary vascular resistance The Transition decrease in pulmonary vascular more blood enter the lungs and return to the heart

resistance and pressure

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left atrial pressure increases causing physiologic closure of the foramen ovale The Transition increase in oxygen content causes the muscular constriction and functional closure of the patent ductus arteriosus APGAR Score practical method of systematically assessing newborn infants immediately after birth to help identify those requiring resuscitation and to predict survival in the neonatal period APGAR Score APGAR Score

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Not designed to predict neurological outcome APGAR Score 1 minute score = signal the need for immediate resuscitation 5 minute score = probability of successfully resuscitating an infant May be extended to 10, 15, 20 minutes until score of 7 is reached NEONATAL RESUSCITATION Neonatal Resuscitation Environment - place infant under a preheated warmer - quickly dry the infant of amniotic fluid - wrap in warm blanket Neonatal Resuscitation Positioning -low risk infants: place head downward after delivery to clear mouth, pharynx and nose of fluid, mucus, blood, amniotic debris by gravity - maybe placed flat on back with neck slightly extended - head turned to one side if with copious secretions Neonatal Resuscitation Suctioning - gentle suctioning with bulb syringe or soft catheter - mouth first, then the nose - should never exceed 10 seconds at a time to prevent vagal response or bradycardia -to prevent hypoxia, time should be allowed in between suctioning Neonatal Resuscitation Suctioning - meconium stained amniotic fluid > require thorough suctioning before initiation of respiration > if depressed infant: do direct tracheal suctioning Neonatal Resuscitation Tactile Stimulation Slapping or flicking of the soles of the feet rubbing the infants back Neonatal Resuscitation Assessment 1) Respiratory effort > breathing rate and depth should increase with brief stimulation > if inappropriate respiratory response (shallow, slow or absent) do immediate PPV or positive airway ventilation Neonatal Resuscitation Assessment 2) Heart Rate > more than 100 beats/minute with spontaneous respiration continue assessment > less than 100 beats/minute do PPV Neonatal Resuscitation Ventilation : Positive Pressure Ventilation > indications: 1) apnea 2) heart rate less than 100/min 3) persistent central cyanosis in a minimal oxygen environment > assisted ventilator rate of 40-60 breaths/minute should provide adequate ventilation Neonatal Resuscitation Endotracheal Intubation

Endotracheal Intubation - bag-mask ventilation is ineffective - tracheal suctioning is required in cases of thick meconium amniotic fluid - prolonged positive pressure ventilation necessary
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Neonatal Resuscitation Chest Compressions - heart rate less than 60 beats/min and not responding despite adequate ventilation with 100% oxygen x 30 minutes Neonatal Resuscitation Medications and Fluid Management - should be administered if despite adequate ventilation with 100% oxygen and chest compressions, heart rate remains less than 80/minute - epinephrine volume expander Ringers Lactate sodium bicarbonate dopamine Expanded Ballard Score Assessment of gestational age by determining state of maturity Use of physical features and neurological responses Extremely prematures assessed as early as 12 hours, term infants may be assessed even up to 72 hours Expanded Ballard Score Physical Maturity skin lanugo plantar surface breast eyes/ears genitalia Neuromuscular Maturity posture square window arm recoil popliteal angle scarf sign heel to ear Expanded Ballard Score Physical Examination of the Newborn Initial examination performed as soon as possible after delivery > to detect abnormalities and > to establish a baseline for subsequent examinations 2nd examination: within 24 hours after birth 3rd examination: within 24 hours of discharge Physical Examination of the Newborn Tailored to fit both the gestational and postnatal age of an infant Requires patience and procedural flexibility to return to do part of the examination in order to stay within the limits of an infants tolerance Requires gentleness Physical Examination of the Newborn Anthropometric measurements: weight, length, head circumference, chest circumference and abdominal circumference Vital signs: pulse rate = 120-160 beats/min. respiratory rate = 30-60 breaths/min. temperature,

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color, activity * monitored every 30 minutes after birth for 2 hours or until stabilized General Appearance Physical activity: absent, decreased, vigorous crying Muscle tone: active or passive Take note of unusual posture Coarse tremulous movements vs. convulsive twitchings Edema: generalized or localized Skin Vasomotor instability and peripheral circulatory sluggishness = deep redness or purple lividity during crying Acrocyanosis of the hands and feet Mottling = associated with severe illness or related to transient fluctuation of skin temerature Skin Harlequin color change extraordinary division of the body from the forehead to the pubis into red and pale halves; transient and harmless condition Pallor represents asphyxia, anemia, shock or edema

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Skin Vernix caseosa Plethora = polycythemia Skin Lanugo fine, soft immature hair on scalp, brow and face; especially among prematures

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Skin Mongolian spots slate blue, well-demarcated areas of pigmentation seen over the buttocks, back - tend to disappear within the 1st year of life

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Skin Erythema toxicum small white occasionally vesiculopustular papules on an erythematous base seen on the face, trunk and extremities - appears 1-3 days after birth and persists for as long as 1 week Skin Milia small whitish papules made up of distended sebaceous glands, usually covering the nose Head

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Head Molding: usually among first born, parietal bones tend to override the occipital and frontal bones Suture lines: check for premature fusion = craniosynostosis Anterior and posterior fontanels: check for abnormal size Craniotabes: soft area in the parietal bones at the vertex near sagittal suture Head Caput succedeneum edematous swelling of the soft tissue of the scalp Head Cephalhematoma subperiosteal hemorrrhage Face Dysmorphic features: epicanthal folds, widely spaced eyes, microphthalmia, low set ears Asymmetry: abnormal fetal posture, 7th nerve palsy Face Eyes Conjuctival and retinal hemorrhages usually benign Check for bilateral red reflex Leukocoria: white pupillary reflex = cataracts, tumors, chorioretinitis, ROP Ears Deformities of the pinnae Preauricular skin tags Nose Patency and symmetry of the nares Assymetry: dislocation of nasal cartilage from the vomerian groove Choanal atresia may lead to respiratory distress Mouth Precocious dentition: natal present at birth neonatal eruption after birth Mouth Soft and hard palate: check for complete or submucosal cleft, check for contour Mouth Epstein pearls: retention epithelial cells cysts seen on the hard palate and gums Mouth Tongue: short frenulum

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Neck Relatively short Abnormalities not common: goiter, cystic hygroma, brachial cleft vestiges, sternocleidomastoid hematomas Neck Redundant skin or webbing: Turner syndrome

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Clavicular fracture Chest Breast hypertrophy common Supernumerary nipples occasionally seen Milk may be present (witchs milk) Retractions (intercostal/subcostal): respiratory distress Lungs Variation in rate and rhythm of breathing according to infants physical activity RR > 60/min : respiratory, cardiac or metabolic disease Breathing is diaphragmatic paradoxical movement Prematures: Cheyne-Stokes rhythm = periodic breathing Lungs Breath sounds bronchovesicular Expiratory grunting: respiratory distress Heart Determine location: dextrocardia Transitory benign murmur are common Congenital heart disease may not initially produce the murmur that will appear later Palpation of pulses in the upper and lower extremities: coarctation of the aorta Abdomen Prominent, globular but not distended Liver usually palpable 2 cm below the rib margin Tip of the spleen may be felt less commonly Abnormal masses: renal pathology most common Scaphoid abdomen: diaphragmatic hernia Abdomen Abdominal wall defects: omphalocoele vs gastroschisis Abdomen Air in the GIT vary, present in the rectum by radiograph by 24 hours of age Umbilicus: 2 arteries and 1 vein Genitalia Maternal hormones = enlargement and secretion of breasts, prominent female genitalia with non-purulent discharge Testes may not be fully descended but are palpable in the canals Prepuce normally tight and adherent Genitalia Ambiguity in external genitalia requires further investigation Anus Check for patency Passage of meconium by 48 hours of life Extremities Check of effect of fetal posture Poly or syndactyly Clubfoot Abnormal dermatoglyphic pattern: simian crease Congenital hip dislocation: Ortolanis maneuver Extremities Neurological Examination A. POSTURE > resting, unrestrained posture:

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flexion and adduction of the hips, flexion of the knees arms adducted and flexed at the elbow fists often clenched Neurological Examination B. STATE OF WAKEFULNESS 1. Deep sleep - no movement, regular 2. Light sleep - with eye movements, breathing 3. Quiet, awake - eyes closed or halfbreathing hypotonic and irregular open, with slight activity

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Neurological Examination B. STATE OF WAKEFULNESS 4. Fully awake - eyes open, alert with 5. Fully awake, active - with plenty of 6. Fully awake, crying some movement movements

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Neurological Examination B.STATE OF WAKEFULNESS >The neurodevelopmental exam is >Rooting, licking, sucking reflexes >observe eye opening, yawning, facial Neurological Examination C. TONE >Observe for posture >Frog leg position suggests flaccidity >Passive tone: observe by performing suspension >Active tone: pull-to-sit maneuver

most reliably done in states 3 or 4. reflect level of responsiveness expressions and stretching

vertical suspension and horizontal

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Neurological Examination C. TONE >Ankle clonus of >10 beats probably >Differentiate tremulousness from

abnormal seizures

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Neurological Examination D. REFLEXES >Deep tendon: patellar reflex test (L2>Less easy to elicit: biceps, ankle, >Primitive: assessed for presence or completeness, persistence Neurological Examination D. REFLEXES >Moro, palmar and plantar grasp, at birth > tonic neck reflex at later days Neurological Examination

L4) truncal innervation absence, symmetry,

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rooting, sucking, placing reflexes

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Neurological Examination Neurological Examination E. HIGHER FUNCTION AND CRANIAL NERVES > Observe response to breast-feeding, human voice (particularly mothers voice) > Capable of visual fixation and limited tracking during alert periods > Especially responsive to the human face Immediate Care for the Newborn Thermoregulation - relative to body weight, body surface area of a newborn infant is approximately 3x that of an adult - estimated rate of heat loss in a newborn is approximately 4x that of an adult - maintain 36.6 37.2 C Immediate Care for the Newborn Thermoregulation Mechanisms of heat loss: - convection: from infant to the surrounding air - conduction: from infant to the surface with which he is in direct contact - radiation: from infant to the nearby cooler solid object - evaporation: from moist skin of the infant and the lungs Immediate Care for the Newborn Thermoregulation Consequences of excessive heat loss: 1) insufficient oxygen supply and hypoxia from increase oxygen consumption 2) hypoglycemia secondary to depletion of glycogen stores 3) metabolic acidosis caused by hypoxia and peripheral vasoconstriction Immediate Care for the Newborn Thermoregulation Skin to skin contact with the mother is the optimal method to maintain temperature in the stable newborn. Immediate Care for the Newborn Skin and Cord care - once infants temperature has stabilized, entire skin and cord should be cleaned with warm water and mild non- medicated soap - careful removal of blood and meconium, do not remove vernix - cord may be treated daily with bactericidal or anti-microbial; agents such as triple dye or bacitracin Immediate Care for the Newborn Skin and Cord care - 2x daily alcohol soaking until cord falls off reduces colonization, exudates and odor of the umbilicus - hand washing of nursery personnel is mandatory Immediate Care for the Newborn Eye Care - instillation of 1% silver nitrate drops or erythromycin 0.5% or tetracycline ophthalmic ointment - to prevent gonococcal eye infections Immediate Care for the Newborn Vitamin K administration - water-soluble vitamin K (phytonadione) given by intramuscular injection - 0.5 mg for premature infants 1.0 mg for term infants - to prevent hemorrhagic disease of the newborn Immediate Care for the Newborn

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Immediate Care for the Newborn Immunization - Hepatitis B and BCG - babies of mothers with reactive HBsAg should receive both Hepatitis B immune globulin and vaccine Continuing Care Rooming-in - within 2 hours after birth or as soon as possible - clear bassinet to allow easy monitoring and care - advise on thermoregulation and hand washing - mother directly responsible for the routine care of the infant during roomingin Continuing Care Breastfeeding - latch-on within 30-45 minutes after birth or as soon as he infant shows signs of readiness - proper technique in breastfeeding - no pacifiers or other artificial forms of feeding - on demand feeding preferred Continuing Care Newborn Screening - collection of blood samples from the sole of the feet of newborn infants, placed on filter paper - for detection of: Congenital Hypothyroidism Congenital Adrenal Hyperplasia Phenylketonuria Galactosemia Glucose 6 Phosphate Dehydrogenase Deficiency Continuing Care Discharge Procedure - continue exclusive breastfeeding - cord care - bathing - signs of illness contact numbers, emergency room - well baby visit schedule

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