Week 2 Neonatal Assessment and Resuscitation (everything)

Question 1

There are some similarities between the initial assessment of the neonate and the initial assessment of an adult who requires resuscitation. In both situations, the physician should give immediate attention to

Answer 1

ABCs of resuscitation (i.e., airway, breathing, circulation).

Question 2

what is the normal neonatal respiratory rate

Answer 2

30-60 Breaths per minute

Question 3

neonatal breathing should begin at ____seconds and be regular by ____ seconds of age

Answer 3

30

regular at 90

Question 4

if a neonate does not breath by 90 seconds of age this may indicate ____ or ____ apnea

Answer 4

primary or secondary apnea

Question 5

what helps initiate breathing efforts during primary apnea

Answer 5

tactile stimulation can initiate breathing efforts

Question 6

low heart rate is presented which apneas

Answer 6

primary and secondary

Question 7

reduction of blood pressure is presented during which apneas

Answer 7

secondary apnea

Question 8

if tactile stimulation does not result in the initiated of spontaneous breathing what is the next step

Answer 8

aggressive resuscitation must be initiated promptly if tactile stimulation does not initiate spontaneous breathing

Question 9

how many weeks gestation is the fetus for meconium to be present in the intentional tract

Answer 9

31 weeks

Question 10

which type of pregnancy has the higher incidence of meconium stained amniotic fluid

Answer 10

post term pregnancies

Question 11

meconium stained amniotic fluid is present in

Answer 11

10-15% of all pregnancies

Question 12

the preterm neonate- especially the VLBW infant is at higher risk for what problems

Answer 12

Multiple organ system problems simply because of immaturity

Question 13

what is the treatment for meconium aspiration syndrome?

Answer 13

PPV and is associated with a 5-20% incidence of pneumothorax from pulmonary ark leaks.

Question 14

what is meconium aspiration syndrome

Answer 14

respiratory distress in a neonate whose airway was exposed to meconium and whose chest radiograph exhibits characteristic findings (pulmonary consolidation and atelectasis)

Question 15

what was the common practice for meconium aspiration syndrome- no longer done, but may still see it in practice

Answer 15

In an attempt to reduce inhalation of meconium from the pharynx and thus prevent or reduce the severity of MAS the practice of suctioning the mouth and pharynx after delivery of the head, and subsequent intubation to remove meconium from the trachea , was common practice. However, studies have documented that airway suctioning at birth does not prevent MAS

Question 16

Congenital Anomalies can cause special issues related to what

Answer 16

special resuscitation issues.

Question 17

congenital abnormalities that cause upper airway obstruction include

Answer 17

micrognathia, macroglossia,laryngeal webs, laryngeal atresia, stenosis , subglottic webs, tracheal agenesis, tracheal rings

Question 18

what is Exit Procedure - ex utero intrapartum treatment procedure

Answer 18

delivers the fetal head and shoulders, but keeps the lower torso and umbilical cord intact within the uterus. allows surgeon to perform direct laryngoscopy, rigid bronch, tracheostomy. allowing establishment of an airways prior to completing delivery.

Question 19

what is the benefit of the exit procedure

Answer 19

thereby maintaining placental perfusion and oxygenation

Question 20

Congenital high airway obstruction syndrome (CHAOS)

Answer 20

Intrinsic airway obstruction of the larynx or upper trachea (e.g., laryngeal web, subglottic cyst, tracheal atresia) can lead to retention of bronchial secretions and subsequent pulmonary distention; this constellation of findings is often classified as

Question 21

long term survival of children with congenital high airway obstruction syndrome long term survival results when “”” this procedure is used

Answer 21

exit procedure

Question 22

talk to me about ethical considerations of non initiating resuscitating in the delivery room

Answer 22

extremes of prematurity < 23 weeks. (although massey said we can save down to 20) severe congenital anomalies (anencephaly, confirmed trisomy 13, 18)

Question 23

talk to me about ethical considerations when stopping resuscitation is appropriate

Answer 23

once further information has been obtained and discussion with family has occurred.

-remember a trial of therapy may be appropriate

Question 24

for those situation with a poor prognosis- unlikely survival or high morbidity (23-25 weekS) how to we handle the parents desires to initiation of resuscitation

Answer 24

should be supported

Question 25

the fetus is connected by the

Answer 25

umbilical cord to the placenta

Question 26

the fetus gets all needed nutrition and oxygen via

Answer 26

the blood vessels in the umbilical cord "Life support"

Question 27

Wast products and CO2 from the fetus are sent back through the umbilical cord and

Answer 27

placenta to the mother's ciruculation to be removed

Question 28

**the fetal circulatory system uses how many shunts?

Answer 28

3 shunts

Question 29

**The purpose of these shunts in fetal circulation is to

Answer 29

bypass the lungs and liver

Question 30

**The shut that bypasses the lungs

Answer 30

Foramen Ovale *** | -moves blood from the RA to the LA

Question 31

This moves blood from the pulmonary artery to the aorta:

Answer 31

the Ductus arteriosus

Question 32

enriched blood flows through the umbilical cord to the liver and

Answer 32

splits into 3 branches

Question 33

The major vein connected to the heart

Answer 33

Inferior vena cava

Question 34

Most blood is sent through the

Answer 34

ductus venosus

Question 35

What is the role of the ductus venosus?

Answer 35

also a shunt | -lets highly oxygenated blood bypass the liver to the IVC and then to the RA of the heart.

Question 36

Does any blood go to the fetal liver?

Answer 36

yes, a small amount of blood goes straight to the liver to give it oxygen and nutrients

Question 37

**Blood enters the fetal heart via the

Answer 37

RA

Question 38

* from the RA blood flows through

Answer 38

the foramen ovale to the LA

Question 39

*From the LA blood passes into

Answer 39

the LV

Question 40

*From the LV blood passes to the

Answer 40

aorta

Question 41

*From the aorta, blood is sent to

Answer 41

the heart muscle itself , the brain, and arms

Question 42

*after blood circulates in the heart,brain, and arms, the blood (core circulation)

Answer 42

returns to the RA via the SVC

Question 43

*When blood returns to the RA from the core circulation, is it oxygenated or not?

Answer 43

less oxygenated blood In the RA it mixes with the oxygenated blood.

Question 44

*After the core circulated blood has returned to the RA, instead of going back through the foramen ovale, it goes

Answer 44

to the RV

Question 45

*This less oxygenated blood is pumpned from the RV into the

Answer 45

pulmonary artery | - a small amount of blood continues to the lungs

Question 46

*From the lungs, the blood is shunted through the

Answer 46

ductus arteriosus to the descending aorta

Question 47

*From the descending aorta, this blood enters the

Answer 47

umbilical arteries and flows into the placenta.

Question 48

At birth, the umbilical cord is clamped and the baby no longer receives what from the mother

Answer 48

oxygen and nutrients

Question 49

with the first breaths of life the lungs start to

Answer 49

expand and the alveoli are cleared of fluid

Question 50

** an increase in the baby's blood pressure and a major reduction in the pulmonary pressures reduce the need for the:

Answer 50

Ductus arteriosus to shut blood; so it helps the shunt close

Question 51

The closing of the Ductus Arteriosus raises the pressure in the ____ and lowers the pressure in the ____.

Answer 51

left atrium ; right atrium

Question 52

** The shift in pressure b/w RA and LA, stimulates what to occur?

Answer 52

the foramen ovale to close

Question 53

*** What three things must happen to complete the change of fetal to newborn circulation?

Answer 53

the closure of the: 1. ductus arteriosus 2. ductus venosus 3. foramen ovale

Question 54

Preterm infants and infants requiring cesarean delivery without labor may have what difference to their lungs compared to a baby delivered vaginally?

Answer 54

residual liquid in the lungs.

Question 55

The residual liquid that is in an infants lungs is far more in a C section baby compared to a vaginal baby, why is this (tell me the process)

Answer 55

If delivered by C section the infant may have greater amount of residual liquid after delivery owing to a reduced catecholamine surge at delivery that promotes sodium channel transport. (I had always heard it was bc without vaginal delivery it could not be squeezed out lol)

Question 56

*** The residual lung liquid in the infants lungs (more in there if C section) can cause what kind of issues?

Answer 56

leads to difficulty in initiation and maintenance of normal breathing patterns, and is the cause of transient tachypnea of the newborn. ***

Question 57

What is Transient tachypnea of the newborn? (TTN)

Answer 57

benign, self limited condition that can present in infants of any gestational age, shortly after birth caused by delay of fluid clearance from the lungs.

Question 58

Why is the neonate's first breath important and how long after delivery does it occur typically?

Answer 58

This first breath is important because it establishes the neonate’s functional residual capacity. (FRC) 9 sec after delivery for first breath.

Question 59

Why do preterm infants have more liquid in their lungs? (we already know why C -section babies do)

Answer 59

2/3 of the liquid is expelled from the lungs of the term neonate by the time of delivery. (so if pre-term more in the lungs and if pre-term c-section then even more!)

Question 60

Tell me a major physiologic stimulus for the release of lung surfactant into the alveoli? (bold in ppt)

Answer 60

Lung inflation

Question 61

WHY is surfactant important?

Answer 61

Surfactant is the liquid in alveoli that decreases surface tension, without it the alveoli would not stay open, they would collapse and no oxygen could make it's way down to them and no exchange of CO2 and O2 would occur. (collapse lungs)

Question 62

``` When is surfactant present within the: alveolar lining cells? lumen of the airways? terminal airways? (it shows up in each place at different weeks of gestation) ```

Answer 62

alveolar lining cells = 20 weeks lumen of the airways = 28-32 weeks terminal airways = 34-38 weeks. (surfactant can show up in the terminal airways sooner IF stimulated by chronic stress or maternal corticosteroid administration.)

Question 63

What negative thing can occur (for the fetus) if there is stress during labor and delivery? (what can get into the babies lungs?)

Answer 63

Stress during labor and delivery can lead to the passage of meconium into the amniotic fluid and gasping efforts by the fetus, which may result in the aspiration of amniotic fluid into the lungs.

Question 64

What time period of pregnancy is associated with a surge of catecholamines?

Answer 64

Transition to extrauterine life! | hours before delivery and at delivery

Question 65

**** Catecholamines have an important role in the following areas: (four answers)

Answer 65

(1) the production and release of surfactant, (2) the transition to active sodium transport for absorption of lung fluid, (3) the mediation of preferential blood flow to vital organs during the period of stress that occurs during every delivery, and (4) thermoregulation of the neonate. * ***

Question 66

What is the major mechanism for neonatal heat regulation?

Answer 66

nonshivering thermogenesis

Question 67

What two things does the neonate do in response to cold? | what do said responses cause?

Answer 67

raise their metabolic rate and release norepinephrine. these responses above facilitates the oxidation of brown fat, which contains numerous mitochondria.

Question 68

Thermal stress (cold) can be a big issue for what type of infants?

Answer 68

infants with low fat stores, such as preterm infants or infants who are small for gestational age. (they do not have as much brown fat and thus can not warm themselves as well)

Question 69

For most infants, right after they are born, what do we do in order to try and keep them warmer?

Answer 69

dry them and place them in in an appropriate thermoneutral environment, for example with a radiant warmer.

Question 70

True or false | nonshivering thermogenesis does not consume any oxygen bc no actual shivering is occuring?

Answer 70

False This process may lead to significant oxygen consumption, especially if the neonate has not been dried and placed in an appropriate thermoneutral environment

Question 71

What is an alternative method to drying and warming the baby immediately?

Answer 71

An alternative method to eliminate heat loss from evaporation is to provide an occlusive wrap rather than drying the infant.

Question 72

For what infants would NOT drying and using an occlusive wrap be recommended?

Answer 72

For infants born at less than 28 weeks’ gestation, the use of polythene wraps or bags is recommended to minimize heat loss.

Question 73

What is the actual temp. for neutral thermal environment for a newborn baby?

Answer 73

34-35 degrees C

Question 74

Who is the only exception to the "keep warm" after birth rule? You want to keep these infants cool for a while.

Answer 74

the neonate with a perinatal brain injury, mild hypothermia therapy through selective head or whole-body cooling is initiated in the first 6 hours of life and may be neuroprotective in the setting of hypoxia-ischemia.

Question 75

A nonreassuring FHR tracing is considered a predictor of the need for WHAT?

Answer 75

neonatal resuscitation.

Question 76

what percentage of neonates require some level of resuscitation?

Answer 76

10%

Question 77

Infants with congenital anomalies (e.g., tracheoesophageal fistula, diaphragmatic hernia, CNS and cardiac malformations) may need what after they are born?

Answer 77

resuscitation and cardiorespiratory support.

Question 78

True or False | Preterm delivery increases the likelihood that the neonate will require resuscitation?

Answer 78

True

Question 79

Anything that causes neonatal depression at birth can increase the likelihood that the neonate will need resuscitation, can you think of some examples of things that cause neonatal depression? (not bold, but just a knowledge check)

Answer 79

neonatal depression at birth can result from acute or chronic uteroplacental insufficiency or acute umbilical cord compression. Fetal hemorrhage, viral or bacterial infection, meconium aspiration, and exposure to opioids or other CNS depressants also can result in neonatal depression.

Question 80

What are the parameters for the APGAR score? (what do the letters stand for?)

Answer 80

``` A- apperance P- pulse G- grimace A- activity R- respirations ```

Question 81

at what time intervals after birth is the APGAR assessed?

Answer 81

Apgar score done a 1, 5 and 10 minute interval post delivery.

Question 82

What points are you assigned based on the APGAR scale? (slide 12)

Answer 82

0, 1, or 2 points assigned for each parameter. | slide 12

Question 83

APGAR acronym tells you what to look for after birth of an infant but according to the ppt the paramerters are also listed as? (these parameters are the same essentially as the direct APGAR signs to letters stuff, but I guess this was just another way to say it??)

Answer 83

``` Parameters are: Heart Rate Respiratory Rate Muscle Tone Reflex Irritability and color ``` (see it covers the same things as A, P, G, A, R)

Question 84

APGAR was developed by who?

Answer 84

Developed in 1953 by Anesthesiologist Virginia Apgar.

Question 85

fetal lungs contain a liquid composed of an

Answer 85

ultrafiltrate of plasma - that's secreted by the lungs inutero.

Question 86

volume of fetal lung ultrafiltrate plasma?

Answer 86

30 mls

Question 87

at the time of labor and delivery, partial reabsorption of the fetal lung fluid occurs and what happens to the rest?

Answer 87

2/3 is expelled from the lungs of the neonate by the time of delivery