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Pre-Hospital Care of the Neonate Objectives Care of The Neonate Presented by: MedicEd.com, Inc. Louis Durkin, MD FACEP, Richard A. Craven Jr., NREMT-P, CCEMT-P, EMT I/C Pre-hospital Care of the Neonate July 2010 Objectives Objective #1 – Discuss the Neonate Objective #2 – Assist the Birth of the Neonate Objective #3 -- Observe Neonatal Distress Objective #4 – Assess Risk Factors for the Neonate Objective #5 – Evaluate the Neonatal Infant Objective #6 -- Stabilize the Neonatal Infant Objective #7 – Appraise the Jaundice Factor in the Neonate Objective #8 – Examine the Neonate Infant in a Major Catastrophe Objective #9 -- Recognize Neonatal Injuries in Child Abuse Page 1 MedicEd..com, Inc. 46 Pilgrim Road, Springfield, MA 01118 tel: 877.781.1173 fax: 877.781.6055 [email protected] www.MedicEd.com Care of The Neonate Objective #1 Discussing the Neonate Neonatal care refers to the care of an infant in the first 28 days of life vs. a newborn which embraces the period of the first few hours of life after birth. Approximately 90% of newborn neonate babies begin life without any difficulty. However, the remaining 10% will require varying degrees of assistance with breathing. 1% to 6% of this 10% just referred to will require invasive resuscitation measures in order to survive. The Premature Neonate A baby born before 34 weeks is considered to be a premature neonate. The weight of a premature baby is normally between 1.5 pounds to 5 pounds. The routine newborn assessment should include an examination for size, macrocephaly or microcephaly, changes in skin color, signs of birth trauma, malformations, evidence of respiratory distress, level of arousal, posture, tone, presence of spontaneous movements, and symmetry of movements. 8 A premature infant’s health at birth is influenced by many factors, including: • Gestational age; • Weight; • Maternal illness and medical treatment during pregnancy; • Congenital birth defects. 6 Most infants born at 36 and 37 weeks’ gestation do not need additional medical intervention. But many premature infants are too immature to survive without medical care in the neonatal intensive care unit (NICU). Symptoms of prematurity that require extensive emergency medical intervention include: • Inability to breathe continuously; • Inability to feed orally; • Inability to maintain body heat; • Underdeveloped lungs. 1 Physical Assessment A thorough physical examination should be done within 24 hours of birth. The following are the areas of the body which the EMS Personnel should evaluate in any environment where a neonatal baby is involved. Cardio-Respiratory System Page 2 MedicEd..com, Inc. 46 Pilgrim Road, Springfield, MA 01118 tel: 877.781.1173 fax: 877.781.6055 [email protected] www.MedicEd.com Care of The Neonate Skin color is considered the single most important index of cardio-respiratory function in the neonate. Good color in white infants means an overall reddish pink hue. The only exception to this color is for possible cyanosis of the hands, feet, and perhaps the lips. In the dark-skinned neonate, the mucous membranes are a more reliable indicator of cyanosis than the skin. The post-mature neonate baby skin is paler than full term. The neonate infant respiratory rate is normally 40 to 60 breaths per minute. However, the neonate infant often is a periodic breather rather than a regular breather. 7 Head and Neck It is important to note the head and neck area of the neonatal newborn because there is a lot of pressure on this area of the body during the birthing process. The head of the infant born by vaginal delivery often shows some degree of molding unless they deliver by cesarean section or breech . Molding is when the skull bones shift and overlap, making the top of the infant’s head look elongated, stretched out, or even pointed at birth. The newborn’s skull is made up of several separate bones that will eventually fuse together. Normal term newborn head circumference is 33 to 38 cm. The technique to take this measure is to place a measuring tape around frontal forehead and occiput. 9 Abdomen and Pelvis The abdomen should be round and symmetric for the healthy neonatal infant. 8 It’s normal for a baby’s abdomen to appear somewhat full and rounded. When the baby cries or strains, the skin over the central area of the abdomen may protrude between the strips of muscle tissue making up the abdominal wall on either side. This almost always disappears during the next several months as the infant grows. Musculoskeletal System The musculoskeletal system includes the muscles; connective tissue; cartilage and bones in the body. The musculoskeletal system provides structure and movement. Abnormalities of the neonatal musculoskeletal system range from a subtle brachydactyly to a fatal form of osteogenesis. Assessment of the musculoskeletal system can have multiple normal variants so the knowledge of pathogenesis, treatment, and prognoses for deformities of the musculoskeletal system is imperative. Neurologic System A careful examination at delivery helps detect anomalies, birth injuries, and cardio-respiratory disorders that may compromise a newborn’s successful adaptation to extra-uterine life. A detailed examination should also be performed after the newborn has completed the transition from fetal to neonatal life. The examination may begin with an evaluation of neonatal size Page 3 MedicEd..com, Inc. 46 Pilgrim Road, Springfield, MA 01118 tel: 877.781.1173 fax: 877.781.6055 [email protected] www.MedicEd.com Care of The Neonate Objective #2 Assisting the Birth of the Neonate Most births progress through a predictable set of steps without incident. In most incidents the newborn does not need much help because the breathing process begins at the moment of birth. However, should there be an issue with the infant, resuscitative efforts can save precious time and make a critical difference for a variety of complications. APGAR Score The Apgar score has been used for many years in evaluating the prognosis of a newborn. Recent studies have used the pH in the umbilical-artery as a more accurate assessment of newborn prognosis. The APGAR score has weathered the storm and still remains a viable way to assess newborn prognosis. This is especially true in the pre-hospital delivery, when lab testing is unavailable Inverted Triangle Guide There is a reference to an inverted triangle which will guide the EMS Personnel in caring for the neonatal newborn. The points to observe and prioritize from the top of the inverted triangle downward are as follows: • Dry, Warm, Position, Suction, Stimulate; • Supplemental Oxygen; • Establish Effective Ventilation; • Chest Compressions; • Advanced Life Support Intervention. 55 As the head emerges from the birth canal there are three particular things that the EMS Personnel must be observing. Here are three areas that need tending to immediately: • Umbilical Cord; • Mouth; • Nose. Umbilical Cord If the umbilical cord is not around the infant’s neck, the normal procedures to follow are to tightly clam or tie the cord in two places and make the cut between. The first clamp can be Page 4 MedicEd..com, Inc. 46 Pilgrim Road, Springfield, MA 01118 tel: 877.781.1173 fax: 877.781.6055 [email protected] www.MedicEd.com Care of The Neonate placed 8” to10” from the baby and the second clamp should be placed four finger widths from the baby. Then the next procedure is to cut between when pulsations cease. When the umbilical cord is wrapped around the neck of the infant, observe if it is possible to unwrap the cord and then clamp it according to procedures above. If the cord cannot be unwrapped, it may be necessary to cut the cord quickly in order to release the airways. 55 Mouth Following birth, for the lungs to operate as a functional respiratory unit providing adequate gas exchange, the airways and the alveoli must be cleared of fetal lung fluid; pulmonary blood flow must increase, and spontaneous respirations must be established. 57 So the mouth must be suctioned with a bulb syringe, 2 to 3 times. Nose Follow the mouth suctioning with suctioning of the nose. For most births, it is a routine procedure to suction the baby’s mouth and nose as soon as the head emerges on the perineum, in advance of its full birth. Either a deep suction hose will be used or a bulb syringe to extract any mucus or meconium that may be present. While it may seem wise to suction as soon as possible, the reality is that the baby is not at great risk of breathing difficulties until it takes its first breath after the umbilical cord has been cut. If the cord is still pulsating and is not clamped the baby will continue to receive oxygen via the placenta until after it has been fully birthed. 59 Cardiovascular Adaption from Fetal to Neonatal For successful fetal circulation to take place many changes occur in the neonate’s body. What we see in the normal adult circulation is dramatically different in the fetal circulation The fetal circulation allows the baby to get all its nutrients and oxygen from the mother. Since the baby cannot eat or breathe inside the uterus, all the essential elements for growth need to come through maternal circulation. The cardiovascular fetal circulation could be explained as follows. The more highly oxygenated blood bypasses the liver, streams into the inferior vena cava to pass through the foramen ovale into the left atrium. The desaturated blood streams into the inferior vena cava to the right atrium. In the right atrium, it mixes with blood returning from the coronary sinus and superior vena cava and flows into the right ventricle. The more highly oxygenated blood crossing the foramen ovale mixes with the small amount of pulmonary venous return to cross the mitral valve into the left ventricle.
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