Time-efficient, cost-effective perinatal education and training

PCEP PCEP

PCEP Book 4: Specialized Newborn Care, 4th Edition

4

BOOK
Perinatal Continuing Education Program, 4th Edition Perinatal Continuing Education Program
4TH EDITION
EDITOR IN CHIEF, NEONATOLOGY

Specialized
Robert A. Sinkin, MD, MPH, FAAP

EDITOR IN CHIEF, OBSTETRICS EARN UP TO PCEP Workbook Contents

Christian A. Chisholm, MD, FACOG 56.5 CME MATERNAL AND FETAL EVALUATION AND IMMEDIATE
CREDITS O
R
For more than 35 years, the Perinatal
NEWBORN CARE (BOOK 1)
CONTACT • Is the Mother Sick? Is the Fetus Sick?
Continuing Education Program (PCEP) HOURS! • Fetal Age, Growth, and Maturity

Newborn Care
• Fetal Well-being
has enhanced the knowledge and skills • Is the Baby Sick? Recognizing and Preventing Problems in
of physicians, nurses, nurse midwives the Newborn
• Resuscitating the Newborn
and practitioners, respiratory therapists, • Gestational Age and Size and Associated Risk Factors
and other providers of care for pregnant women and newborns. • Thermal Environment
• Hypoglycemia
The fourth edition PCEP workbooks have been completely updated
MATERNAL AND FETAL CARE (BOOK 2)
with cutting-edge procedures and techniques developed by leading • Hypertension in Pregnancy

Earn
experts in perinatal care. These information-rich volumes provide • Obstetric Hemorrhage
concise information, step-by-step perinatal skill instruction, and • Infectious Diseases in Pregnancy

CME credits
• Other Medical Risk Factors in Pregnancy
practice-focused exercises. They offer time-saving, low-cost solutions • Obstetric Risk Factors: Prior or Current Pregnancy

or contact
for self-paced learning or as adjuncts to instructor-led skills teaching. • Psychosocial Risk Factors in Pregnancy
• Gestational Diabetes

hours!
PCEP IS A COMPREHENSIVE EDUCATION TOOL FOR • Prelabor Rupture of Membranes and Intra-amniotic
• Improving perinatal care techniques, practices, policies, and Infection
• Preterm Labor
procedures. • Inducing and Augmenting Labor
• Teaching both practical skills and core knowledge. • Abnormal Labor Progress and Difficult Deliveries
• Encouraging cooperation and communication among diverse • Imminent Delivery and Preparation for Maternal/Fetal
Transport
health care teams.
• Simplifying education planning and budgeting. NEONATAL CARE (BOOK 3)
• Oxygen
• Saving time—self-paced study approach streamlines the • Respiratory Distress
learning process. • Umbilical Catheters
• Saving money—providing top-notch education at low • Low Blood Pressure (Hypotension)
• Intravenous Therapy
per-participant costs. • Feeding
• Hyperbilirubinemia
• Infections
• Identifying and Caring for Sick and At-Risk Babies
CONVENIENT, HASSLE-FREE CME CREDITS AND
• Preparation for Neonatal Transport
CONTACT HOURS
• Neonatal Abstinence Syndrome (Neonatal Opioid
AMA PRA Category 1 Credit(s)™, AAPA Category 1 CME credits, and Withdrawal Syndrome)
ANCC contact hours are available from the University of Virginia. Visit
www.cmevillage.com for more information. SPECIALIZED NEWBORN CARE (BOOK 4)
• Direct Blood Pressure Measurement
The University of Virginia School of Medicine and School of Nursing is • Exchange, Reduction, and Direct Transfusions
jointly accredited by the Accreditation Council for Continuing Medical • Continuous Positive Airway Pressure
Education (ACCME), the Accreditation Council for Pharmacy Education • Assisted Ventilation With Mechanical Ventilators
(ACPE), and the American Nurses Credentialing Center (ANCC) to • Surfactant Therapy
provide continuing education for the health care team. • Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic
Encephalopathy
• Continuing Care for At-Risk Babies
FOR OTHER PEDIATRIC RESOURCES, VISIT THE AMERICAN ACADEMY • Biomedical Ethics and Perinatology
OF PEDIATRICS AT SHOP.AAP.ORG.

AAP
 PCEP
Perinatal Continuing Education Program

Specialized
Newborn Care
4th Edition

BOOK 4

00_FM_BKIV_PCEP_i-viii.indd 1 5/29/21 8:13 AM

 American Academy of Pediatrics Publishing Staff
Mary Lou White, Chief Product and Services Officer/SVP, Linda Smessaert, Director, Marketing
Membership, Marketing, and Publishing Published by the American Academy of
Mark Grimes, Vice President, Publishing Pediatrics
Heather Babiar, MS, Senior Editor, Professional/Clinical Publishing 345 Park Blvd
Jason Crase, Senior Manager, Production and Editorial Services Itasca, IL 60143
Theresa Wiener, Production Manager, Clinical and Telephone: 630/626-6000
Professional Publications Facsimile: 847/434-8000
Peg Mulcahy, Manager, Art Direction and Production www.aap.org

Information about obtaining continuing medical education and continuing education credit for book study may be
obtained by visiting www.cmevillage.com.
Several different approaches to specific perinatal problems may be acceptable. The PCEP books have been written to
present specific recommendations rather than to include all currently acceptable options. The recommendations in
these books should not be considered the only accepted standard of care. We encourage development of local
standards in consultation with your regional perinatal center staff.
The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical
subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of all infants, children,
adolescents, and young adults.
While every effort has been made to ensure the accuracy of this publication, the American Academy of Pediatrics does
not guarantee that it is accurate, complete, or without error.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of
medical care. Variations, taking into account individual circumstances, may be appropriate.
Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics.
Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes
only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for
the content of external resources. Information was current at the time of publication.
The publishers have made every effort to trace the copyright holders for borrowed materials. If they have
inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity.
This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities
in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of
the content of this publication.
Every effort has been made to ensure that the drug selection and dosages set forth in this publication are in
accordance with the current recommendations and practice at the time of publication. It is the responsibility of the
health care professional to check the package insert of each drug for any change in indications or dosage and for
added warnings and precautions.
Every effort is made to keep Perinatal Continuing Education Program consistent with the most recent advice and
information available from the American Academy of Pediatrics.
Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication.
Special discounts are available for bulk purchases of this publication. Email Special Sales at [email protected]
for more information.
© 2022 University of Virginia Patent Foundation
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any
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fax the permissions editor at 847/434-8780 or email [email protected]). First American Academy of Pediatrics
edition published 2007; second, 2012; third, 2017. Original edition © 1978 University of Virginia.
Printed in the United States of America
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PC0029
ISBN: 978-1-61002-500-3
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Cover design by Peg Mulcahy
Publication design by Peg Mulcahy
Library of Congress Control Number: 2020943714

00_FM_BKIV_PCEP_i-viii.indd 2 5/29/21 8:13 AM

 Perinatal Continuing Education Program (PCEP), 4th Edition
Textbook Editorial Board

Editors
Editor in Chief, Neonatology Editor in Chief, Obstetrics
Robert A. Sinkin, MD, MPH, FAAP Christian A. Chisholm, MD, FACOG
Charles Fuller Professor of Neonatology Medical Director for Outpatient Clinics, Labor,
Department of Pediatrics and Delivery
University of Virginia Children’s Hospital Vice Chair for Medical Education
Vice Chair for Academic Affairs Professor of Obstetrics and Gynecology
Division Head, Neonatology Division of Maternal-Fetal Medicine
Charlottesville, VA Department of Obstetrics and Gynecology
University of Virginia School of Medicine
Charlottesville, VA

PCEP Editorial Board Members

Melissa F. Carmen, MD Peter D. Murray, MD, MSM, FAAP
Associate Professor of Pediatrics Assistant Professor of Pediatrics
Division of Neonatology Division of Neonatology
University of Rochester University of Virginia Children’s Hospital
Rochester, NY Charlottesville, VA

Susan B. Clarke, MS, NPD-BC, RNC-NIC, CNS Susan Niermeyer, MD, MPH, FAAP
NRP Instructor Mentor Professor of Pediatrics
Master Trainer, Helping Babies Survive Section of Neonatology
Affiliate Faculty, Center for Global Health University of Colorado School of Medicine
Colorado School of Public Health Colorado School of Public Health
University of Colorado Anschutz Medical Campus Aurora, CO
Aurora, CO
Barbara O’Brien, MS, RN
Robert R. Fuller, MD, PhD Director, Oklahoma Perinatal Quality Improvement
Associate Professor Collaborative
Division of Maternal-Fetal Medicine University of Oklahoma Health Sciences Center
Department of Obstetrics and Gynecology Oklahoma City, OK
University of Virginia School of Medicine
Charlottesville, VA Chad Michael Smith, MD, FACOG
Medical Director, Oklahoma Perinatal Quality
Ann Kellams, MD, FAAP Improvement Collaborative
Professor, Department of Pediatrics Vice President, Medical Affairs, Mercy Hospital
Vice Chair for Clinical Affairs and Director of Oklahoma City
Breastfeeding Medicine Services Oklahoma City, OK
University of Virginia
Charlottesville, VA Jonathan R. Swanson, MD, MSc, FAAP
Professor of Pediatrics
Sarah Lepore, MSN, APRN, NNP-BC Chief Quality Officer for Children’s Services
University of Virginia Children’s Hospital Medical Director, Neonatal Intensive Care Unit
Neonatal Intensive Care Unit University of Virginia Children’s Hospital
Charlottesville, VA Charlottesville, VA

iii

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 Sharon Veith, MSN, RN Santina Zanelli, MD
Assistant Professor of Nursing Associate Professor of Pediatrics
School of Nursing Division of Neonatology
University of Virginia University of Virginia Children’s Hospital
Charlottesville, VA Charlottesville, VA

iv

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 Continuing Education Credit

Accreditation and Designation Statements

In support of improving patient care, this activity has been planned and implemented by the
American Academy of Pediatrics and the University of Virginia School of Medicine and School of
Nursing, which is jointly accredited by the Accreditation Council for Continuing Medical Educa-
tion (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American
Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.

AMA PRA Category 1 Credit

The University of Virginia School of Medicine and School of Nursing designates this enduring
material (PI CME) for a maximum of 56.5 AMA PRA Category 1 Credits.TM Physicians should
claim only the credit commensurate with the extent of their participation in the activity.

ANCC Contact Hours

The University of Virginia School of Medicine and School of Nursing awards 56.5 contact
hours for nurses who participate in this educational activity and complete the post-activity
evaluation.

AAPA Category 1 CME Credit

This activity is designated for 56.5 AAPA Category 1 CME credits. Approval is valid for 3 years.
PAs should only claim credit commensurate with the extent of their participation.

Credit is awarded upon passing book exams, not individual educational unit posttests. Possible
credits: Book 1, 14.5; Book 2, 16; Book 3, 17; Book 4, 9. To obtain credit, register online at
www.cmevillage.com, choose Courses & Programs, then E-Learning, and scroll down to the
PCEP program. Click on the PCEP program link and navigate to https://med.virginia.edu/cme/
learning/pcep/pcep-book-exam-certificate/ and pass the book exams.

Disclosure of Faculty Financial Affiliations

The University of Virginia School of Medicine and School of Nursing as a Joint Accreditation
Provider adheres to the ACCME Standards for Integrity and Independence in Accredited Con-
tinuing Education, released in December 2020, as well as Commonwealth of Virginia statutes,
University of Virginia policies and procedures, and associated federal and private regulations
and guidelines. As the accredited provider for this CE/IPCE activity, we are responsible for
ensuring that health care professionals have access to professional development activities that
are based on best practices and scientific integrity that ultimately supports the care of patients
and the public.

All individuals involved in the development and delivery of content for an accredited CE/IPCE
activity are expected to disclose relevant financial relationships with ineligible companies
occurring within the past 24 months (such as grants or research support, employee, consultant,
stock holder, member of speakers bureau, etc). The University of Virginia School of Medicine
and School of Nursing employ appropriate mechanisms to resolve potential conflicts of inter-
est and ensure the educational design reflects content validity, scientific rigor, and balance for
participants. Questions about specific strategies can be directed to the University of Virginia

00_FM_BKIV_PCEP_i-viii.indd 5 5/29/21 8:13 AM

 School of Medicine and School of Nursing of the University of Virginia, Charlottesville,
Virginia.

The faculty, staff, and planning committee engaged in the development of this CE/IPCE activ-
ity in the Joint Accreditation CE Office of the School of Medicine and School of Nursing have
no financial affiliations to disclose.

Disclosure of Discussion of Non-FDA-Approved Uses for Pharmaceutical Products

and/or Medical Devices
As a Joint Accreditation provider, the University of Virginia School of Medicine and School of
Nursing, requires that all faculty presenters identify and disclose any off-label or experimental
uses for pharmaceutical and medical device products.

It is recommended that each clinician fully review all the available data on new products or
procedures prior to clinical use.

vi

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 4
BOOK Specialized Newborn Care
UNIT 1: Direct Blood Pressure Measurement����������������������������� 1

Skill Unit: Transducer Blood Pressure Monitoring

UNIT 2: Exchange, Reduction, and Direct Transfusions����������� 19

Skill Unit: Exchange Transfusions

UNIT 3: Continuous Positive Airway Pressure�������������������������� 57

Skill Unit: Delivery of Continuous Positive

Airway Pressure
UNIT 4: Assisted Ventilation With Mechanical
Ventilators������������������������������������������������������������������ 71
Skill Unit: Endotracheal Tubes

UNIT 5: Surfactant Therapy����������������������������������������������������� 99

Skill Unit: Surfactant Administration

UNIT 6: Therapeutic Hypothermia for Neonatal

Hypoxic-Ischemic Encephalopathy����������������������������115
Skill Unit: Passive Cooling

UNIT 7: Continuing Care for At-Risk Babies�������������������������� 137

UNIT 8: Biomedical Ethics and Perinatology�������������������������� 181

PRETEST ANSWER KEY��������������������������������������������������������������������207

GLOSSARY���������������������������������������������������������������������������������������� 211

INDEX�������������������������������������������������������������������������������������������������245

vii

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 For more information, see the other books in the Perinatal Continuing Education Program
(PCEP) series
Book 1. Maternal and Fetal Evaluation and Immediate Newborn Care
Unit 1: Is the Mother Sick? Is the Fetus Sick? Unit 6: Gestational Age and Size and Associated Risk Factors
Skill Unit: Determining Fetal Presentation Skill Unit: Estimating Gestational Age by Examination
With Leopold Maneuvers of a Newborn
Unit 2: Fetal Age, Growth, and Maturity Unit 7: Thermal Environment
Unit 3: Fetal Well-being Skill Unit: Radiant Warmers
Skill Unit: Electronic Fetal Monitoring Skill Unit: Incubators and Neutral Thermal Environment
Unit 4: Is the Baby Sick? Recognizing and Preventing Problems Unit 8: Hypoglycemia
in the Newborn Skill Unit: Blood Glucose Screenings
Skill Unit: Electronic Cardiorespiratory Monitoring Pretest Answer Key
Skill Unit: Pulse Oximetry Glossary
Unit 5: Resuscitating the Newborn Index
Skill Unit: Suctioning
Skill Unit: Management of Oxygen in the Delivery Setting
Skill Unit: Free-Flow Oxygen and Positive-Pressure
Ventilation
Skill Unit: Endotracheal Intubation
Skill Unit: Chest Compressions
Skill Unit: Emergency Medications
Skill Unit: Apgar Score

Book 2. Maternal and Fetal Care

Unit 1: Hypertension in Pregnancy Unit 9: Preterm Labor
Unit 2: Obstetric Hemorrhage Unit 10: Inducing and Augmenting Labor
Unit 3: Infectious Diseases in Pregnancy Unit 11: Abnormal Labor Progress and Difficult Deliveries
Unit 4: Other Medical Risk Factors in Pregnancy Unit 12: Imminent Delivery and Preparation for Maternal/Fetal
Unit 5: Obstetric Risk Factors: Prior or Current Pregnancy Transport
Unit 6: Psychosocial Risk Factors in Pregnancy Pretest Answer Key
Unit 7: Gestational Diabetes Glossary
Unit 8: Prelabor Rupture of Membranes and Intra-amniotic Index
Infection
Skill Unit: Sterile Speculum Examination
Skill Unit: Tests for Suspected or Proven Rupture
of Membranes

Book 3. Neonatal Care

Unit 1: Oxygen Unit 6: Feeding
Skill Unit: Administering Oxygen Part 1: Feeding Principles
  Measuring Oxygen Concentration Part 2: Tube Feeding
  Blending Oxygen and Compressed Air Skill Unit: Nasogastric Tube Feedings
 Heating and Humidifying an Oxygen/Air Unit 7: Hyperbilirubinemia
Mixture Appendix: Identification and Treatment of Jaundice
Skill Unit: Monitoring Oxygen During the First Week After Birth
  Peripheral Arterial Blood Gas Sampling Unit 8: Infections
Unit 2: Respiratory Distress Unit 9: Identifying and Caring for Sick and At-Risk Babies
Skill Unit: Detecting a Pneumothorax Subsection: Vital Signs and Observations
  Transillumination Subsection: Tests and Results
  Chest Radiography Unit 10: Preparation for Neonatal Transport
Skill Unit: Treating a Pneumothorax Subsection: Caring for Parents of Transported Babies
  Needle Aspiration Unit 11: Neonatal Abstinence Syndrome (Neonatal Opioid
  Chest Tube Insertion Withdrawal Syndrome)
Unit 3: Umbilical Catheters Pretest Answer Key
Skill Unit: Inserting and Managing Umbilical Catheters Glossary
Unit 4: Low Blood Pressure (Hypotension) Index
Skill Unit: Measuring Blood Pressure
Unit 5: Intravenous Therapy
Skill Unit: Peripheral Intravenous Infusions
 Inserting and Managing Peripheral
Intravenous Infusions

viii

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 Unit 1: D
 irect Blood Pressure
Measurement
Objectives................................................................................................................................ 2
1. What are the 2 general types of blood pressure monitoring?..................................... 4
2. How are direct blood pressure measurements obtained?........................................... 4
3. Why is direct blood pressure measurement used?...................................................... 4
4. What equipment is needed for direct blood pressure monitoring?............................ 4

UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

5. What are reference neonatal blood pressure ranges?.................................................. 6
6. How do you interpret blood pressure waveforms?...................................................... 8
Figures
Figure 1.1. Systolic and Diastolic Blood Pressure During the First Day After Birth........... 6
Figure 1.2. Systolic and Diastolic Blood Pressure for Babies of Different Gestational
Ages During the First 5 Days After Birth......................................................... 7
Figure 1.3. Systolic Blood Pressure for Babies of Different Postmenstrual Ages................. 7
Figure 1.4. Arterial Waveform........................................................................................... 8
Skill Unit: Transducer Blood Pressure Monitoring........................................................... 13

01_Unit1_BKIV_PCEP_001-018.indd 1 5/29/21 8:12 AM

 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Objectives
In this unit you will learn the
A. Difference between direct and indirect blood pressure monitoring
B. Reasons for direct blood pressure monitoring
C. Equipment needed for direct blood pressure monitoring
D. Interpretation of blood pressure waveforms

01_Unit1_BKIV_PCEP_001-018.indd 2 5/29/21 8:12 AM

 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

Unit 1 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on the
test and check them with the answers at the end of the book.
1. A damped pressure tracing may be caused by each of the following findings except
A. Air bubbles in the tubing
B. Hypotension
C. Severe anemia
D. A clot at the tip of the umbilical catheter
2. True False Special intravenous tubing is needed for direct blood pressure
monitoring.
3. True False A narrowed pulse pressure may suggest certain congenital heart
defects.
4. True False The reference range for direct blood pressure measurements
is different than the reference range for indirect blood pressure
measurements.
5. True False When a direct blood pressure monitoring waveform shows slow
decrease in pressure during diastole, it may indicate increased
systemic vascular resistance.
6. The transducer for direct blood pressure measurement should be level with the
A. Baby’s heart
B. Electronic monitor
C. Umbilical catheter
D. Intravenous infusion pump
7. Direct blood pressure measurement is used for each of the following reasons except
A. Continuous blood pressure monitoring
B. Increased accuracy of the measurements
C. Obtaining information about a baby’s cardiac status
D. Measurement of acid-base balance

01_Unit1_BKIV_PCEP_001-018.indd 3 5/29/21 8:12 AM

 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

1. What are the 2 general types of blood pressure monitoring?

A. Indirect blood pressure measurement
Indirect measurement is the typical way in which blood pressure is measured. An
inflatable cuff is wrapped around an arm or a leg. The cuff is then inflated to a pressure
somewhat higher than the anticipated blood pressure. Manual palpation or a mechanical
device (oscillometric measurement) is used to detect changes in arterial flow as the cuff
is deflated. (See Book 3: Neonatal Care, Unit 4, Low Blood Pressure [Hypotension].)
B. Direct blood pressure measurement
Direct blood pressure measurement occurs when the measuring device is connected to a
catheter inserted directly into an artery, commonly the umbilical artery or a peripheral
(eg, radial) artery.

2. How are direct blood pressure measurements obtained?

An arterial catheter is connected to special tubing that resists changes in pressure. This “high
pressure” tubing is used to transmit the arterial pressure at the catheter tip to a transducer.
The transducer converts the mechanical pressure of blood in an artery into an electrical signal.
The electrical signal is displayed as a waveform on a screen. The resulting pattern is the blood
pressure waveform.

3. Why is direct blood pressure measurement used?

Direct monitoring is used in sick babies who have an arterial catheter in place. It is especially
important for unstable babies. The 3 primary advantages of direct monitoring are
• It allows continuous blood pressure monitoring.
• It gives the most accurate form of blood pressure measurement.
• The waveform shape may suggest certain clinical conditions.

4. What equipment is needed for direct blood pressure monitoring?

General points about direct blood pressure monitoring are presented here; details of the
technique are covered in the Skill Unit: Transducer Blood Pressure Monitoring. The following
equipment is needed for direct blood pressure monitoring:
A. Arterial catheter
In babies, an umbilical arterial catheter is most commonly used. When it is not possible
to use the umbilical artery, a small catheter is placed in one of the peripheral arteries—
usually a radial artery—and then connected to the appropriate monitoring equipment.
B. Electronic monitor with waveform display
This monitor has one channel that allows continuous cardiac (electrocardiographic)
monitoring and another channel for blood pressure monitoring. It has a calibrated
screen where the blood pressure waveform is displayed, as well as a digital readout of
the systolic, diastolic, and mean blood pressures.
C. Non-distensible tubing
This connects the arterial catheter and transducer. It is made of stiff plastic and is
sometimes called high-pressure tubing.
D. Transducer
Several brands of disposable transducers are available.

01_Unit1_BKIV_PCEP_001-018.indd 4 5/29/21 8:12 AM

 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

E. Transducer cable
This connects the transducer with the electronic monitor. Sometimes the transducer and
cable are a single unit.
F. Intravenous pump
This pump should be able to deliver a low volume of fluid (,1 mL/h). It should also be
able to deliver fluid continuously, rather than in pulses. With advanced technology of
intravenous (IV) pumps, many are able to deliver low volumes with a syringe option to
enable monitoring indirect arterial pressure. If this is not an option, a syringe pump can
be used. Follow your hospital’s protocol for use of the appropriate device.
G. Intravenous solution
To obtain continuous blood pressure readings, the system must remain open between
the catheter and transducer. This significantly increases the risk of clot formation
within the catheter unless a continuous infusion of IV fluid is maintained.
Physiological (normal) saline will cause less sludging of blood in a catheter than a
glucose solution will; however, small babies may receive excessive sodium and insuffi-
cient glucose if normal saline is used to help keep the catheter patent. Calculate the
requirements of your patient. (See Book 1: Maternal and Fetal Evaluation and
Immediate Newborn Care, Unit 8, Hypoglycemia, and Book 3: Neonatal Care, Unit 5,
Intravenous Therapy.) Heparin should be added to the IV solution. Most experts rec-
ommend using an IV solution with 0.5 to 1.0 U of heparin per milliliter and infusing it
at a rate of at least 0.5 mL/h.
H. Mechanism to hold the transducer at the level of the baby’s heart
Sometimes the transducer is mounted on an IV pole with a holder that may be raised
or lowered as the baby’s position is changed. Most commonly, however, transducers
are designed to rest on the bed alongside the baby.

Self-test A
Now answer these questions to test yourself on the information in the last section.
A1. Indirect blood pressure measurement uses an __________ __________ wrapped around the baby’s arm
or leg, while direct blood pressure measurement uses a __________ inserted into an __________.
A2. What are the 3 primary reasons for using direct blood pressure monitoring?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A3. True False A continuous infusion should be given through an umbilical arterial catheter when it
is being used for continuous blood pressure monitoring.
A4. True False Non-distensible tubing is an optional piece of equipment for continuous direct blood
pressure monitoring.
A5. True False An intravenous pump that delivers fluid in regular, tiny pulses is the preferred type
of pump to use with a direct blood pressure monitoring arterial catheter.

Check your answers with the list near the end of the unit. Correct any incorrect answers and review
the appropriate section in the unit.

01_Unit1_BKIV_PCEP_001-018.indd 5 5/29/21 8:12 AM

 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

5. What are reference neonatal blood pressure ranges?

Figures 1.1, 1.2, and 1.3 show the reference ranges of blood pressure for babies of different
birth weights and at different gestational and postmenstrual ages.

110

100
Systolic Blood Pressure (mm Hg)

90
Upper limit
80
of normal
70

60

50

40

30 Lower limit
20 of normal

10

0
750 1,000 1,250 1,500 1,750 2,000 2,250 2,500 2,750 3,000 3,250 3,500 3,750 4,000

Birth Weight (g)

70
Diastolic Blood Pressure (mm Hg)

60 Upper limit
of normal
50

40

30

20

10 Lower limit
of normal
0
750 1,000 1,250 1,500 1,750 2,000 2,250 2,500 2,750 3,000 3,250 3,500 3,750 4,000

Birth Weight (g)

Figure 1.1. Systolic and Diastolic Blood Pressure During the First Day After Birth
Adapted with permission from Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal
intensive care units: a prospective multicenter study. J Perinatol. 1995;15(6):470–479.

01_Unit1_BKIV_PCEP_001-018.indd 6 5/29/21 8:12 AM

 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

80 55
37 weeks
75 50
37 weeks
33–36 weeks
70

Diastolic Blood Pressure (mm Hg)

Systolic Blood Pressure (mm Hg)
45
33–36 weeks
65 29–32 weeks
40
29–32 weeks
60
28 weeks 28 weeks
35
55

30
50

45 25

40 20
1 2 3 3 4 5 1 2 3 3 4 5
Days Since Birth Days Since Birth

Figure 1.2. Systolic and Diastolic Blood Pressure for Babies of Different Gestational Ages During the First 5 Days After Birth
Adapted with permission from Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal
intensive care units: a prospective multicenter study. J Perinatol. 1995;15(6):470–479.

Figure 1.3. Systolic Blood Pressure for Babies of Different Postmenstrual Ages
Adapted with permission from Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal
intensive care units: a prospective multicenter study. J Perinatol. 1995;15(6):470–479.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

6. How do you interpret blood pressure waveforms?

A. Blood pressure waveform: normal configuration
Figure 1.4 shows a normal newborn blood pressure waveform, as it appears in relation
to a cardiac monitor (electrocardiogram) tracing.

Peak Pressure

Dicrotic Notch
100

Aortic
Pressure 50
(mm Hg) Minimum Pressure

0
Systolic Phase Diastolic Phase

Electrocardiogram

0 0.5 1

Time (seconds)

Figure 1.4. Arterial Waveform

The shape of the pattern corresponds with events happening within the heart. These
are described as follows:
• Systolic phase: Time during which the heart is ejecting blood
• Peak pressure: The highest point during systole (systolic pressure)
• Dicrotic notch: Point of closure of the aortic valve
• Diastolic phase: Time during which the heart is filling with blood
• Minimum pressure: The lowest point during diastole (diastolic pressure)
• Pulse pressure: The difference between peak and minimum pressures
• Mean pressure: The average pressure of the complete cardiac cycle
The key segments to recognize are the sharp increase during systole, the dicrotic notch,
and the slower decrease in pressure during diastole.
In addition to displaying the blood pressure waveform, nearly all monitors digitally
display continuous readings of systolic, diastolic, or mean arterial pressure (or any
combination of those).
B. Blood pressure waveform: abnormal configuration
1. Damped waveform
The most common cause of an abnormal pressure waveform is a damped tracing
in which the waveform “flattens out.” Usually, the systolic pressure will seem to be
decreased and the diastolic pressure will seem to be increased, causing little change

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 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

in the mean arterial pressure. These changes may be subtle or more dramatic, lead-
ing to an almost flat line for a pressure tracing. A damped waveform with subtle
changes can be recognized by the disappearance of the dicrotic notch.
A damped tracing may be caused by
• Air bubbles within the tubing or at the transducer: These air bubbles may be
very tiny. Careful inspection of the full length of the tubing and all connections
is required. If air bubbles are found, they should be flushed from the system while
taking care not to infuse any into the baby. Flush the tubing and transducer by
– Turning the stopcock off to the baby
– Opening the transducer to air
– Flushing the IV fluid through the transducer and out the port that is open to air
• Kink in the tubing: This is a rare occurrence but should be considered whenever a
waveform is damped.
• Hypotension: A baby in shock may also seem to have a damped waveform.
Always be sure to check the blood pressure values by indirect means and assess
the baby’s clinical condition.
• Clot at the tip or within the lumen of the catheter: This is the most common
reason for a damped tracing. If this is the suspected cause of a damped waveform,
aspirate blood from the catheter. Then slowly flush the catheter with 0.5 to 1.0 mL
of flush solution. Reopen the system between the catheter and the transducer. If
the waveform remains damped, and no other cause for a damped tracing can be
found, the catheter needs to be removed.

If a waveform is damped because of a suspected clot at the tip or

within the lumen, the catheter needs to be removed and replaced with
a new one.

2. Abnormally shaped waveform

Waveforms of a particular shape, or changes in a baby’s waveform, may suggest
abnormal findings in cardiac status. These findings are usually subtle and should be
considered only suggestive of the corresponding problem.

Finding Possible Cause

• Slow pressure increase during • Poor left ventricular contractility
early systole • Aortic stenosis
• Slow pressure decrease during • Increased systemic vascular
diastole resistance
• Rapid pressure decrease during • Left-to-right shunting, such as
diastole from a patent ductus arteriosus

C. Abnormally wide or narrow pulse pressure

Pulse pressure is the difference between peak systolic and minimum diastolic pressures.
Wide or narrow pulse pressure may suggest certain cardiac abnormalities. A change in
pulse pressure may suggest the development of certain problems, such as a pneumotho-
rax or pneumopericardium, which may affect cardiac function.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Reliable normal values of pulse pressure in newborns have not been defined. A pulse
pressure less than 10 mm Hg, however, is generally considered too narrow.
A pulse pressure significantly greater than the value of the diastolic pressure is
generally considered too wide. For example, a systolic pressure of 60 mm Hg and
a diastolic pressure of 20 mm Hg give a pulse pressure of 40 mm Hg, which is
significantly greater than the diastolic pressure.

Pulse Pressure Possible Cause

Narrowed • Coarctation of the aorta
• Pneumothorax
• Pneumopericardium or hemopericardium
• Aortic stenosis
• Hypoplastic left side of the heart
• Shock (cardiogenic, septic, or hemorrhagic)
• Heart failure
Widened • Patent ductus arteriosus
• Aortopulmonary window
• Arteriovenous fistula
• Truncus arteriosus
• Hyperthyroidism
• Aortic regurgitation

These waveform findings are only suggestive of the abnormalities listed and must be considered
together with other clinical and diagnostic findings. Consult your regional perinatal center if
you have any questions about a baby’s cardiac status.

Self-test B
Now answer these questions to test yourself on the information in the last section.
B1. A damped waveform may be caused by
Yes No
____ ____ Hypotension
____ ____ Air bubbles in the tubing
____ ____ Patent ductus arteriosus
____ ____ Clot at the catheter tip
B2. True False The pulse pressure is the same as the mean pressure.
B3. True False The lowest point of the waveform indicates the diastolic pressure.
B4. List 2 possible causes of a narrowed pulse pressure.
________________________________________________________________________________________
________________________________________________________________________________________
B5. List 2 possible causes of a widened pulse pressure.
________________________________________________________________________________________
________________________________________________________________________________________
Check your answers with the list near the end of the unit. Correct any incorrect answers and review
the appropriate section in the unit.

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 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.
Self-test A
A1. Indirect blood pressure measurement uses an inflatable cuff wrapped around the baby’s arm
or leg, while direct blood pressure measurement uses a catheter inserted into an artery.
A2. Provides most accurate form of blood pressure measurement
Allows continuous measurement of blood pressure
Produces waveform shape that may aid in the diagnosis of certain clinical conditions
A3. True
A4. False. 
Reason: Only non-distensible tubing allows accurate transmission of pressure
between the catheter and transducer without being “lost” in the elasticity of regular
intravenous tubing.
A5. False. 
Reason: An intravenous pump that delivers a low volume of fluid continuously,
rather than in pulses, is the preferred type of pump for direct blood pressure
monitoring.
Self-test B
B1. Yes No
  X         Hypotension
  X         Air bubbles in the tubing
        X   Patent ductus arteriosus
  X         Clot at the catheter tip
B2. False. 
Reason: The pulse pressure is the difference between peak (systolic) and minimum
(diastolic) pressures. Mean blood pressure is the average pressure of the complete
cardiac cycle.
B3. True
B4. Any 2 of the following causes:
• Coarctation of the aorta
• Pneumothorax
• Pneumopericardium or hemopericardium
• Aortic stenosis
• Hypoplastic left side of the heart
• Shock (cardiogenic, septic, or hemorrhagic)
• Heart failure
B5. Any 2 of the following causes:
• Patent ductus arteriosus
• Aortopulmonary window
• Arteriovenous fistula
• Truncus arteriosus
• Hyperthyroidism
• Aortic regurgitation

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 1 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf
file and save it to print later or return to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits; Book 2:
16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

SKILL UNIT

Transducer Blood Pressure Monitoring

This skill unit will teach you the principles of continuous electronic blood pressure monitoring.
Study this skill unit, and then attend a skill practice and demonstration session. You will learn
how to apply the principles studied in this unit to the specific equipment used in your hospital.
To master the skill, you will need to demonstrate each of the following steps correctly, using
the specific equipment available in your hospital:

SKILL UNIT: TRANSDUCER BLOOD PRESSURE MONITORING

1. Assemble the equipment.
2. Set up continuous infusion.
3. Flush tubing and transducer with infusion fluid.
4. Connect tubing to “baby’s” (mannequin’s) arterial catheter.
5. Level the transducer with the baby’s heart.
6. Zero the monitor.
7. Set alarms.
8. Measure the baby’s blood pressure.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

PERINATAL PERFORMANCE GUIDE

Using Transducer Blood Pressure Monitors

ACTIONS REMARKS

Preparing the Equipment

1. Collect the equipment. The baby should have an arterial catheter
• Electronic monitor already in place with extension tubing
• Non-distensible (high-pressure) tubing and Luer lock attached.
• Transducer with stopcock
• Transducer cable
• Infusion pump that can deliver less than An infusion pump should be used to ensure
1 mL/h in continuous flow that a constant, correct volume is infused.
The use of an infusion pump will prevent
backup of blood into the catheter and possi-
ble obstruction of the line with a thrombus.
• Heparinized intravenous (IV) solution This is usually pharmacy prepared.
• Three-way stopcock
• Adjustable-height clamp to hold Many transducers are designed to rest on
transducer at the level of the baby’s heart the baby’s bed, next to the baby. Know the
(optional) requirements of the transducer you are using.
• Sterile gloves
• Hat and mask
• Sterile field
• Sterile caps to close all open ports
2. Assemble the equipment while Most transducer kits come preassembled; if
maintaining sterile technique. not, connect infusion to tubing ➝ transducer
with stopcock ➝ non-distensible tubing ➝
stopcock ➝ extension tubing ➝ arterial
catheter.

Extension
with Luer lock

Stopcock

Fluid
infusion

Non-distensible
tubing

Transducer
with stopcock
Non-
distensible
tubing

Arterial setup.
If your kit is not preassembled, connect
the pieces in this sequence by using sterile
technique.

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 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

ACTIONS REMARKS

Preparing the Equipment (continued)

3. Set up the continuous infusion. A heparinized solution (0.5 to 1.0 U/mL) of
normal saline is most commonly used.
Other heparinized solutions (eg, sodium
acetate or half-normal saline) may be used.
See section 4.G in the unit.
4. Flush the heparinized IV solution through Be sure to clear the tubing of all air bubbles,
the IV tubing, transducer, stopcock, and including very tiny bubbles. Snapping a finger-
non-distensible tubing. nail or tapping gently against the transducer or
tubing can help dislodge stubborn bubbles.
As an additional safeguard, non- If the tubing is flushed slowly, air bubbles are
distensible tubing that has an air-bubble generally less of a problem. Also, hold the
filter incorporated into it is available. transducer so the exit to the non-distensible
Know the features of the tubing used in tubing is uppermost. This will help ensure
your hospital. that the transducer fills completely and no
air bubbles are trapped in a corner of it.
5. Connect the non-distensible tubing with
stopcock to the extension tubing attached
to the baby’s arterial catheter.
6. Use a syringe on the third port of the There is no need to pull blood into the
stopcock (the stopcock that is connected syringe or even fill the catheter with blood.
to the arterial catheter) to draw blood You just need to see a flash of blood in the
into the catheter, to be sure there is a catheter and observe that the catheter can
brisk blood return before beginning to be aspirated easily.
infuse fluid through the catheter.
7. Turn the stopcocks so they are open Double-check to be sure no air bubbles are
between the baby’s arterial catheter and in the tubing.
the IV fluid, as shown in the figure below.
8. Begin infusion of the heparinized IV fluid. Neither this infusion rate nor the IV fluid
Infusion at a rate of at least 0.5 mL/h is used is designed to fulfill a baby’s fluid
generally recommended. requirements, but rather to keep the catheter
patent. Keep track of the volume infused
because even this low infusion rate can
provide a significant volume for small babies.

Extension
Arterial Non-distensible Transducer Non-distensible Fluid
tubing with Stopcock
catheter tubing with stopcock tubing infusion
Luer lock

Third port Third port

(used when blood (used to zero
drawn—closed) transducer—closed)

Configuration During Infusion: System Open Between Intravenous Fluid and Arterial Catheter

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Calibrating the Blood Pressure Monitor

9. With the baby supine, level the transducer In some cases, it may be useful to tape the
with the baby’s heart. Use the baby’s mid- transducer to a small, folded blanket that
axillary point to approximate the level is placed next to the baby. This will keep
of the heart. In most cases, this may be the transducer flat and raise it slightly off
accomplished by simply putting the trans- the bed, to the mid-axillary level of the
ducer flat on the bed next to the baby. baby’s chest.
Sometimes transducers are clamped to However the transducer is positioned, it is
a pole beside the bed. They should be important that the position relative to the
clamped at a point level with the baby’s baby remain constant. Changing the trans-
mid-axillary area. ducer level compared to the baby will result
in false readings.

Extension
Arterial Non-distensible Transducer Non-distensible Fluid
tubing with Stopcock
catheter tubing with stopcock tubing infusion
Luer lock

Third port Third port

(used when blood (used to zero
drawn—closed) transducer—closed)

Configuration During Calibration: System Closed to Arterial Catheter (Baby), Open

Between Transducer and Air

10. Zero the monitor.

• After leveling the transducer, turn the
stopcock on the transducer off to the
patient and open to the air. Remove
the cap to the stopcock port. Zero the
transducer by following the manufac-
turer’s instructions for zeroing.
• Adjust the display so that the blood In most cases, this is accomplished by simply
pressure reads zero. pressing a “zero” button on the monitor
screen.
Note: Some monitors need to be cali- Be sure you know the requirements of the
brated to both zero and a higher specific equipment used in your hospital.
number, usually 100 mm Hg.
11. Begin to monitor the baby.
• Close the system to atmospheric pressure The system should, again, be configured the
and reopen it between the IV infusion same way as shown in the figure after step 8.
and the baby’s arterial catheter.
• Cap the port that was open to atmo-
spheric pressure with a syringe or
sterile cap.

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 UNIT 1: DIRECT BLOOD PRESSURE MEASUREMENT

ACTIONS REMARKS

Calibrating the Blood Pressure Monitor (continued)

• Check again to be sure no air bubbles Sometimes air enters the stopcock, and then
have entered the tubing. the tubing, when the stopcock is opened to
air during calibration.
• Check to be sure the monitor is set for Most monitors have 2 or 3 pressure scales
a scale appropriate to neonatal blood that may be used. Generally, the 0 to 100
pressure values. mm Hg scale is used for babies. If a different
scale is used, the waveform may sometimes,
depending on a baby’s blood pressure,
appear to be off the screen.
Measuring the Baby’s Blood Pressure
12. Set the alarm limits appropriate to the Determine if the alarm limits on your
baby’s blood pressure. monitor can be set for systolic/diastolic or
If the baby is initially hypotensive, mean blood pressure (or both). Then set
readjust the alarm limits as the blood the alarm limits 5 to 10 mm Hg higher and
pressure is corrected. 5 to 10 mm Hg lower than the baby’s blood
pressure reading.
13. Observe the character of the pressure If the waveform is damped, investigate the
waveform. Determine if the waveform cause. Review section 6.B.1 in the unit.
is a damped or an undamped tracing.
14. Read and record the baby’s blood Usually, the baby’s systolic, diastolic, and
pressure. This may be read from the mean arterial pressures (MAPs) are recorded
screen or the digital readout. (eg, 65/45 MAP 53). If a digital readout is
not available, only the systolic and diastolic
pressures can be read from the waveform
tracing on a calibrated monitor screen.
15. Regularly, routinely examine the tubing If any air bubbles are found, remove them
to be sure no air bubbles have entered from the system.
the system.
16. Periodically check the baby’s blood Direct and indirect blood pressure readings
pressure by indirect measurement with should correlate very closely.
an inflatable cuff.
17. Periodically repeat steps 9 through 11 to The transducer setup is commonly
calibrate the monitor. calibrated 2 to 3 times a day, whenever
the disposable transducer and tubing are
changed, and whenever there is a question
about waveform quality.

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01_Unit1_BKIV_PCEP_001-018.indd 18 5/29/21 8:12 AM
 Unit 2: E
 xchange, Reduction, and Direct
Transfusions
Objectives.............................................................................................................................. 20
Exchange Transfusions in the Management of Hyperbilirubinemia................................. 23
1. What is an exchange transfusion?............................................................................... 23

UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

2. Why is an exchange transfusion done?....................................................................... 23
3. What type of donor blood is used?............................................................................. 24
4. How should the blood be preserved?.......................................................................... 24
5. How much blood is used for an exchange transfusion?............................................ 25
6. What else is done to prepare blood for an exchange transfusion?.......................... 25
7. How should I monitor an infant before, during, and after an
exchange transfusion?.................................................................................................. 26
8. How is an exchange transfusion performed?............................................................. 27
9. Will a baby ever need more than one transfusion?................................................... 29
10. What are the potential complications of an exchange transfusion?........................ 29
Partial Exchange Transfusions in the Management of Polycythemia
or Severe Anemia................................................................................................................. 31
1. What is a partial exchange transfusion?..................................................................... 31
2. What is polycythemia?................................................................................................. 32
3. How is a reduction exchange transfusion done for polycythemia?.......................... 33
4. What are the potential complications of a reduction exchange
transfusion for polycythemia?..................................................................................... 34
5. When is a partial exchange transfusion used for severe anemia?............................ 34
6. Why is a partial exchange transfusion done for severe anemia?.............................. 35
7. How is a partial exchange transfusion done for severe anemia?............................. 35
Direct Transfusions in the Management of At-Risk and Sick Babies................................ 36
1. What is a direct transfusion?........................................................................................ 36
2. Why are direct transfusions done?.............................................................................. 36
3. How is a direct transfusion done?............................................................................... 37
4. What are the potential complications of a direct transfusion?................................. 37
Table and Box
Table 2.1. Potential Complications of Exchange Transfusions........................................ 29
Box 2.1. Monitoring an Infant Before, During, and After Exchange Transfusion......... 26
Recommended Routines.................................................................................................... 39
Skill Unit: Exchange Transfusions...................................................................................... 43

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Objectives
In this unit you will learn
A. Why exchange, reduction, and direct transfusions are performed
B. What type of donor blood is used
C. The effects of anticoagulants on donor blood
D. How to prepare donor blood
E. How exchange, reduction, and direct transfusions are performed
F. How to monitor the baby for potential complications

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

Unit 2 Pretest
Before reading the unit, please answer the following questions. Select the
one best answer to each question (unless otherwise instructed). Record your
answers on the test and check them with the answers at the end of the book.
1. True False Blood glucose screening test results should be checked immediately
after any exchange transfusion.
2. True False When an umbilical arterial catheter is used in an exchange
transfusion, it is used only to withdraw blood from the baby.
3. True False No baby should undergo more than one exchange transfusion.
4. True False Packed red blood cells (hematocrit level .70%) of appropriate group
and type should be used for an exchange transfusion.
5. A reduction exchange transfusion is different from an exchange transfusion for
hyperbilirubinemia because
A. A larger volume of blood is exchanged.
B. Infectious complications are more likely to occur.
C. Blood is not given.
D. Rebound hypoglycemia is more likely to occur.
6. What is the preferred age of donor blood used for an exchange transfusion?
A. 1 to 10 days.
B. 10 to 15 days.
C. 15 to 20 days.
D. Age of the blood is not an issue.
7. True False A term, 4,000-g (8 lb 13 oz) baby with tachypnea who has been
treated for hypoglycemia and has a venous hematocrit level of 68%
should be considered for a reduction exchange transfusion.
8. True False Phototherapy lights should be used after every exchange transfusion
for babies with hyperbilirubinemia.
9. True False All preterm babies should be transfused with packed red blood cells
if their hematocrit level is less than or equal to 25%.
10. True False Capillary blood from a heel stick sample is the preferred way to test
a baby’s hematocrit level.
11. Which of the following findings is a possible sign of anemia in a stable, growing,
preterm baby?
A. Rapid weight gain
B. Hypoglycemia
C. Hyperbilirubinemia
D. Tachypnea

(continued )

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 2 Pretest (continued )

12. Which of the following babies is at lowest risk for polycythemia?
A. A 30-weeks’ gestational age (GA) baby who is appropriate for GA
B. A 40-weeks’ GA baby who is small for GA
C. A 43-weeks’ GA baby who is appropriate for GA
D. A 38-weeks’ GA baby of a diabetic mother
13. A 1,800-g (3 lb 151/2 oz), preterm baby is severely anemic and requires a transfusion
of packed red blood cells. How much blood would you give?
A. 10 mL
B. 18 mL
C. 36 mL
D. 162 mL

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

Exchange Transfusions in the Management of Hyperbilirubinemia

Notes
• This section will discuss exchange transfusions only for hyperbilirubinemia. Exchange
transfusions for other purposes (eg, sepsis, disseminated intravascular coagulation, or
metabolic disorders) require other techniques and types of donor blood.
• Prior to the routine maternal administration of Rh immunoglobulin to prevent the devel-
opment of erythroblastosis fetalis, performing an exchange transfusion was a much more
common procedure. It is a procedure associated with significant risk and therefore should
only be performed in a facility with personnel experienced in performing it, particularly if
the baby is preterm.
• Postnatal administration of intravenous immunoglobulin has been shown to reduce the need
for exchange transfusion in infants with hyperbilirubinemia because of blood group incom-
patibility. (Refer to Book 3: Neonatal Care, Unit 7, Hyperbilirubinemia, for further details.)

1. What is an exchange transfusion?

An exchange transfusion entails withdrawing blood from a baby in small aliquots and replac-
ing it with an equal amount of donor blood, then repeating this process many times until
most of the baby’s blood has been removed and replaced with donor blood. Usually a double
volume exchange transfusion is performed, by using 160 to 180 mL/kg of a blood product
(assuming a baby’s total blood volume to be approximately 80–90 mL/kg).
Routes of Exchange
• An umbilical venous catheter (UVC) alone may be used to perform an exchange transfusion.
• Umbilical venous and arterial catheters may be used simultaneously, with blood withdrawn
through the arterial catheter and infused through the venous catheter.
• Blood may also be withdrawn through an umbilical arterial catheter (UAC), peripheral
arterial catheter (PAC), or UVC and infused through a peripheral intravenous (PIV) line.

Blood should not be infused through a peripheral arterial catheter. Infusion through
a central arterial catheter is a very high-risk procedure and should be used only as
a last resort.

2. Why is an exchange transfusion done?

There are 3 purposes for an exchange transfusion in the treatment of severe hyperbilirubinemia:
• To remove bilirubin.
• To remove sensitized red blood cells (RBCs) and replace them with non-sensitized RBCs
(for hyperbilirubinemia caused by blood group incompatibility).
• To remove circulating antibodies (for hyperbilirubinemia caused by blood group
incompatibility).
Note: R
 efer to Book 3: Neonatal Care, Unit 7, Hyperbilirubinemia, to determine when
exchange transfusions should be used to treat hyperbilirubinemia.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

3. What type of donor blood is used?

A. For hyperbilirubinemia due to Rh incompatibility
• Rh-negative RBCs of the baby’s blood group (A, B, AB, or O) resuspended in plasma
of an ABO group compatible with the baby
or
• Type O, Rh-negative RBCs resuspended in type AB plasma
B. For hyperbilirubinemia due to ABO incompatibility
• Group O, Rh-compatible RBCs resuspended in plasma of the same ABO group as the
baby, or in group AB plasma
It is recommended that blood for an exchange transfusion be irradiated to reduce the likelihood
of viral contamination and the possibility of sensitization from white blood cell contamina-
tion. While most blood for exchange is reconstituted RBCs and plasma, platelets should not
be added to the product. A platelet count should be checked before and after the exchange
transfusion, and platelets should be transfused, if needed.

4. How should the blood be preserved?

The freshest available and most suitable blood should be used. It is important to know the
anticoagulant used and how that substance may affect the baby. Older blood may have a
higher potassium concentration, leading to hyperkalemia, and the pH level of the blood
may be affected (either increased or decreased), depending on the type of anticoagulant used.
Citrate phosphate dextrose adenine (CPDA-1) is the anticoagulant used most often, and it can
cause any of the following problems:
• Hypocalcemia: Citrate binds the electrolyte calcium; therefore, calcium replacement may
be necessary during or shortly after an exchange transfusion (or at both times). Laboratory
measurement of blood calcium level should be monitored prior to, during, and after an
exchange transfusion. Calcium replacement should be given if the baby shows signs of
hypocalcemia, including jitteriness, seizures, tachycardia, and apnea. Monitoring of the
QT interval with electrocardiography may also alert the provider to a decrease in the baby’s
calcium levels. The QT interval may become prolonged in the setting of hypocalcemia.
If the baby is symptomatic, 1 to 2 mL of calcium gluconate in 10% (100 mg/mL) concentra-
tion is given slowly (over approximately 10 minutes) through a UVC, with the tip located in
the inferior vena cava. Calcium gluconate in 10% concentration may be diluted with sterile
water for injection to 5% and 2 to 4 mL given, as described in the Skill Unit: Exchange
Transfusions.
The baby’s heart rate must be continuously monitored electronically. The calcium infusion is
stopped immediately if the baby’s heart rate begins to slow. (See the skill unit for the details
of calcium administration.)
• Hypoglycemia: Babies with Rh isoimmune disease often have hyperactive insulin-secreting
cells. In addition, any baby may develop “rebound hypoglycemia” once the exchange trans-
fusion has been completed, due to the high concentration of dextrose in CPDA-1–preserved
blood. Any baby receiving an exchange transfusion should have blood glucose screening test
results checked immediately after the exchange and hourly for several more hours.
• Acidosis or alkalosis: CPDA-1–preserved blood has a pH level in the range of 7.5 to 7.6 at
the beginning of storage but may decrease to 7.0 or lower as storage time lengthens. Most
babies can metabolize the preservative without difficulty. With citrate-preserved blood,

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

alkalosis may develop as citrate is metabolized in the liver to form bicarbonate. The resulting
metabolic alkalosis may persist for several days.
• Hyperkalemia: For an exchange transfusion in babies, use of CPDA-1–preserved donor
blood that does not exceed 10 days of age is recommended. Blood stored for more than
10 days may develop potassium levels that are dangerously high for babies. Laboratory
measurement of blood potassium level should be monitored prior to, during, and after an
exchange transfusion.

5. How much blood is used for an exchange transfusion?

Generally, 160 to 180 mL of donor blood for every kilogram (1,000 g) of the baby’s weight is
used for an exchange transfusion, plus an additional volume is needed to fill a blood warmer
(if one is being used). A “double volume” exchange derives its name from the volume being
used because a baby’s average blood volume is 80 to 90 mL/kg. A double volume exchange
transfusion will remove and replace 85% to 90% of a baby’s original blood.
Immediately after a double volume exchange, the baby’s bilirubin level can be expected to be
one-third to one-half the pre-exchange bilirubin level.

6. What else is done to prepare blood for an exchange transfusion?

A. Determine the hematocrit level.
The hematocrit level of blood used for an exchange transfusion should generally be
higher than the hematocrit level of adult blood because
• Newborn hematocrit levels are generally higher than adult hematocrit levels.
• Babies with Rh or ABO incompatibility may be anemic because of the rapid
breakdown of their RBCs.
Blood used for neonatal exchange transfusions should have a hematocrit level of 45%
to 55%. Most blood banks can prepare blood with appropriate hematocrit levels by
mixing packed RBCs and plasma in the necessary ratio.
B. Warm the blood.
The blood should be warmed by using a commercially available blood warmer with
• A constant temperature readout
• An adjustable thermostat
• An alarm system to prevent overheating the blood
Note: Radiant warming devices or older immersion warmers without the characteristics
listed here are dangerous and should not be used.
Summary of Preparation Steps
The following 5 steps should be taken to prepare donor blood for an exchange transfusion:
1. Select the appropriate blood group and Rh type.
2. Know the anticoagulant used and the age of the blood.
3. Calculate the volume of blood to be exchanged.
4. Know the hematocrit level of the blood prepared by the blood bank.
5. Warm the blood with a commercial device that has the necessary safety features.
Do not add platelets to the blood constituted for exchange. Check platelet count after the
procedure and transfuse platelets if indicated.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

7. How should I monitor an infant before, during, and after an

exchange transfusion?
Continuous cardiopulmonary monitoring and pulse oximetry should be used throughout the
exchange transfusion. Consider these additional tests, because infants undergoing exchange
transfusion are at increased risk for electrolyte imbalances and coagulopathies (Box 2.1).

Box 2.1. Monitoring an Infant Before, During, and After Exchange Transfusion
1. Pre-exchange 2. Mid-exchange 3. Post-exchange

Hemoglobin/hematocrit Blood gas to check pH level Hemoglobin/hematocrit level

level, reticulocyte count, (includes hemoglobin); glucose Platelets, reticulocyte count
platelets, bilirubin, every 30 min
Bilirubin
calcium, electrolytes, Calcium
pH level Calcium
Extra tubes as indicated Electrolytes
Test blood for possible: Blood gas analysis upon
completion of exchange and
• RBC enzymes
hourly until stable
• Chromosomes
• TORCH titers

Other specific tests

• Glucose-6-phosphate
dehydrogenase,
phenylketonuria
• Hemoglobin electro-
phoresis if unclear
etiology for
hyperbilirubinemia

Abbreviations: RBC, red blood cell; TORCH, toxoplasmosis, rubella cytomegalovirus, herpes simplex, and HIV.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

Self-test A
Now answer these questions to test yourself on the information in the last section.
A1. What are 4 possible problems with the use of citrate phosphate dextrose adenine–preserved blood?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A2. The hematocrit level of donor blood used in an exchange transfusion should be _________% to
_________%.
A3. True False Blood is best warmed under a radiant warmer.
A4. Immediately after a double volume exchange transfusion, the baby’s bilirubin level will be _________
to _________ the level it was before the exchange.
A5. Identify whether each of the following methods may be used to withdraw or infuse blood
(or do both).
Withdraw Infuse
Yes No Yes No
Umbilical arterial catheter (unless route of last resort) ____ ____ ____ ____
Peripheral arterial catheter ____ ____ ____ ____
Umbilical venous catheter ____ ____ ____ ____
Peripheral intravenous line ____ ____ ____ ____

Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

8. How is an exchange transfusion performed?

Although the precise details of the techniques for exchange transfusion are given in the skill
unit, several points are especially important and are therefore mentioned here.
A. Methods of exchange
• Pull-push method: The method in which a small volume of the baby’s blood is with-
drawn (pulled) through a UVC, followed by an equal volume of donor blood infused
(pushed) through the UVC to the baby. This pull-push cycle is repeated until the
exchange transfusion is completed.
• Continuous method: The method in which the baby’s blood is withdrawn through
one line and, simultaneously, an equal amount of donor blood is infused through a
second line.
Blood may be withdrawn from a UVC or an arterial catheter and given in equal
volume through a PIV line. The baby’s blood may also be withdrawn through an
arterial catheter, and donor blood may be infused simultaneously through a UVC.
Although the continuous method has the advantage that it can be performed more
quickly, it has the disadvantage that catheters and syringes are more likely to become
clotted with blood. If clots develop, the UVC, PIV line, or syringes (or any combination
of those) need to be replaced.
Regardless of the exchange method, blood should not be infused through a peripheral
artery, and infusion through a central arterial catheter, which is extremely risky, should
be done only as a last resort. The risk of tissue damage from the unintentional infusion

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

of emboli due to air bubbles or tiny blood clots is much greater when blood is infused
through an artery rather than a vein.
For either exchange method, withdrawal and infusion should be done slowly and steadily
to avoid sudden shifts in the baby’s blood pressure. Sudden shifts in blood pressure have
been associated with intraventricular bleeding in newborns, particularly in preterm
babies. Withdrawal and infusion rates no faster than 2 to 3 mL/kg/min are recommended.

Withdrawal and infusion rates no faster than 2 to 3 mL/kg/min are

recommended.

Summary of Exchange Routes

• Pull-push method: Blood is alternately withdrawn and infused in small
increments through a UVC.
• Continuous method: Blood is withdrawn through one line and simultaneously
infused through another. Appropriate withdrawal and infu-
sion routes are:
Withdrawal Route   Infusion Route
UAC UVC or PIV line
PAC UVC or PIV line
UVC PIV line
B. Catheter position
Ideally, the tip of a UVC should be above the diaphragm, in the junction of the inferior
vena cava and the right atrium, as confirmed with radiography.
If this position cannot be achieved and bilirubin levels are considered to be dangerously
high, an exchange transfusion can be performed through a UVC when the catheter tip is
still in the umbilical vein and has not yet entered the vena cava—but there is a some-
what greater risk of liver damage. This so-called low UV line should be inserted until
there is a free flow of blood (“to-and-fro flow”), which is usually achieved when the
catheter is inserted at only about 3 to 4 cm (1.2–1.6 in) in a term neonate. Sclerosing
agents, such as calcium, should not be infused through a catheter in this position.

Regardless of umbilical venous catheter location, blood flow should

be obtained easily from the catheter before starting any exchange
transfusion.
If a UAC is used to withdraw blood, it should be inserted and positioned as outlined in
Book 3: Neonatal Care, Unit 3, Umbilical Catheters. A PIV line in any location may be
used to infuse blood. Both lines should be periodically flushed with heparinized saline to
avoid clotting, as described in the skill unit.
C. Keeping blood mixed
The actual process of exchanging the baby’s blood for donor blood takes approximately
1 to 2 hours to complete, depending on the volume of blood and the exchange method
used. During this time, it is important to mix the donor blood several times to prevent
further separation of the RBCs from the plasma. Mixing the blood is done by gently
agitating the donor blood bag by hand every 10 to 15 minutes.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

If the blood is allowed to settle during the procedure, the baby will receive mostly
plasma at the end of the exchange transfusion. This may cause the baby to have a low
post-exchange hematocrit level.
D. Record keeping
• At least 2 people are required for a pull-push exchange transfusion. After the UVC is
inserted, the second person is required to keep precise records of the blood exchanged
and the medications given to the baby, if any.
• Three people are generally required for a continuous exchange: one to withdraw the
baby’s blood, one to infuse the donor blood, and one to keep records.
With either method, each small increment of blood withdrawn and given is recorded, as
well as a “running total” of all blood removed from and given to the baby.
Keeping precise, detailed records is extremely important for avoiding unintentionally
overloading the baby with fluid or leaving the baby in a hypovolemic state at the end of
the exchange.

9. Will a baby ever need more than one transfusion?

Most babies with hyperbilirubinemia do not require an exchange transfusion. Refer to
Book 3: Neonatal Care, Unit 7, Hyperbilirubinemia, to determine if and when a particular
baby needs an exchange transfusion.
In a baby, hyperbilirubinemia severe enough to require one exchange may require more than
one exchange. An exchange transfusion will not remove all of the baby’s circulating bilirubin.
In addition, rebound hyperbilirubinemia may occur after an exchange is completed. The
baby’s bilirubin level should be checked every 4 to 6 hours after an exchange.

Phototherapy lights should always be used after every exchange transfusion

for hyperbilirubinemia.

10. What are the potential complications of an exchange transfusion?

An exchange transfusion is an important, but invasive, therapeutic measure for a baby with
severe hyperbilirubinemia. With careful preparation and monitoring of the baby’s cardiac and
metabolic status, the following complications can be minimized or avoided (Table 2.1).

Table 2.1. Potential Complications of Exchange Transfusions

Possible Complications Means to Monitor/Prevent Complications
Vascular
• Formation of air or blood • Use careful technique when infusing through an umbilical venous
emboli catheter, as shunts to the arterial side are common in newborns.
• Thrombosis • Do not infuse through a peripheral arterial catheter. Avoid infusing
through an umbilical arterial catheter unless absolutely necessary.
• Be sure there is adequate blood return from the catheter, and do
not leave the catheter in place longer than necessary. Flush the
lines periodically with heparinized saline.

(continued )

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Table 2.1. Potential Complications of Exchange Transfusions (continued )

Possible Complications Means to Monitor/Prevent Complications
Vascular (continued)
• Intravenous infiltration • If a peripheral intravenous line is used to infuse donor blood,
observe the site carefully throughout the infusion for signs of
infiltration, including swelling at the site and difficulty in flushing
the line or infusing blood.
Cardiac
• Arrhythmias • Monitor continuously with an electronic heart rate monitor.
• Check electrolyte levels if the heart rate pattern changes.
• Volume overload, volume • Keep precise records of blood given to and taken from the baby.
depletion
• Cardiorespiratory arrest • Obtain blood pressure measurements at least every 15 minutes
during the exchange.
• Continuously monitor the baby with an electronic heart rate
monitor.
• Keep resuscitation equipment at the bedside.
Clotting
Catheter clotted Be aware that this is more likely to happen when an arterial catheter
is used to withdraw blood during a continuous exchange. Periodi-
cally flush the umbilical or peripheral arterial catheter with a small
volume of heparinized saline.
Metabolic
• Hypocalcemia (low blood Obtain blood studies for glucose, calcium, potassium, sodium, and
calcium level) bilirubin levels after the exchange transfusion and as indicated by
• Hypoglycemia (low blood the baby’s condition.
glucose level)
• Hyperkalemia (high blood
potassium level)
• Rebound hyperbilirubinemia
• Acidosis or alkalosis
Infectious
• Sepsis • Maintain sterile technique throughout the exchange transfusion.
• Serum hepatitis • Blood banks screen blood donors carefully and test the blood.
• Cytomegalovirus • Blood banks screen blood donors carefully and test the blood.
• Use blood that has undergone leukoreduction when available.
• HIV • Blood banks screen blood donors carefully and test the blood.
Miscellaneous
• Mechanical injury to donor • Use only a commercial blood warmer that has passed quality
cells inspection for temperature control and an alarm system.
• Perforation of the inferior • This is rare, but if resistance is met when an umbilical venous
vena cava catheter is inserted, it should not be forced further.
• Hypothermia • Warm the blood to 37.0°C (98.6°F).
• Maintain temperature control of the baby during the procedure.
(continued )

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Table 2.1. Potential Complications of Exchange Transfusions (continued )

Possible Complications Means to Monitor/Prevent Complications
Miscellaneous (continued)
• Tanning (injury from • Do not warm the blood under a radiant warmer. Be sure the
overheating) of the red temperature of a commercial blood warmer does not go above
blood cells 38.0°C (100.4°F).
• Anemia • Be sure the blood bank measures the hematocrit level of the donor
blood.
• Mix the blood frequently during the procedure.
• Thrombocytopenia • Check a post-exchange platelet count. Reconstituted red blood cell
products do not contain viable platelets.

Self-test B
Now answer these questions to test yourself on the information in the last section.
B1. True False If an umbilical venous catheter is used to withdraw a baby’s blood for an
exchange transfusion, the donor blood can be infused through an arterial
catheter.
B2. List at least 2 possible cardiac complications of an exchange transfusion.
________________________________________________________________________________________
________________________________________________________________________________________
B3. After an exchange transfusion for hyperbilirubinemia, a baby’s bilirubin level should be checked every
_______ to _______ hours.
B4. List at least 3 possible metabolic complications of an exchange transfusion.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

Partial Exchange Transfusions in the Management of Polycythemia or

Severe Anemia

1. What is a partial exchange transfusion?

A partial exchange transfusion is the process of withdrawing a calculated amount of the
baby’s blood and replacing it with an equal amount of packed RBCs or physiological (normal)
saline, depending on whether the baby is being treated for too many RBCs (polycythemia)
or too few (severe anemia). In either condition, the baby’s initial total blood volume may be
normal or even excessive, resulting in varying degrees of heart failure.

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2. What is polycythemia?
Polycythemia is a condition in which a baby has more RBCs than normal, with a resulting
increase in hematocrit level. When the hematocrit level of blood drawn from a free-flowing
large vessel is higher than approximately 65%, blood flow may become sluggish.
Sluggish blood flow may, in turn, cause poor tissue perfusion. The organs most affected by
sluggish flow may vary from baby to baby, leading to a wide range of possible problems.
Some babies with hematocrit levels between 65% and 70% will not show any of the follow-
ing signs, but almost all babies with hematocrit levels of 70% and above will show one or
more of them:
• Plethora (ruddy appearance) • Seizures
• Congestive heart failure • Poor feeding
• Cyanosis • Hypoglycemia
• Tremors • Respiratory distress
• Lethargy • Hyperbilirubinemia
A. How is polycythemia diagnosed?
Blood drawn from a vein or an artery should be used to measure a baby’s hematocrit
level. A baby’s capillary blood, or blood obtained when a heel stick is done, should not
be used. While capillary blood from a finger stick will provide accurate results in adults,
this is not true for babies.
Blood obtained from heel sticks in babies can give falsely high hematocrit values due
to venous stasis. Alternatively, if the heel is squeezed excessively to collect the blood
sample, interstitial fluid may dilute the sample and give falsely low hematocrit values.

Polycythemia should not be diagnosed on the basis of a baby’s capillary

(heel stick) blood sample. Only blood drawn from a free-flowing vein or
artery should be used.

B. Which babies are at risk for polycythemia?

1. Babies who experience chronically low in utero oxygen concentrations
Fetuses who were exposed to somewhat lower oxygen concentrations over a relatively
long period will increase the number of RBCs they produce to help improve their
oxygenation. These include
• Small-for-gestational-age babies or babies who experienced fetal growth
restriction
• Post-term babies
2. Babies who received extra blood from the placenta
• In utero fetal-fetal transfusion (during a twin or multiple gestation) resulting from
an abnormal connection between placentas (generally, the donor fetus is anemic,
while the recipient fetus is polycythemic)
• In utero maternal-fetal transfusion resulting from abnormal connections within the
placenta, causing the fetus to receive blood directly from the mother
• Delayed cord clamping at the time of delivery

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3. Babies who are large for gestational age, especially babies of diabetic mothers
The reasons for this are not entirely clear.
4. Babies with certain chromosomal abnormalities, such as Down syndrome
C. Which babies with polycythemia need to be treated?
Complications of untreated polycythemia may include thromboembolic events, such
as cerebral artery thrombosis, necrotizing enterocolitis, and acute tubular necrosis.
Long-term motor and mental disabilities have also been associated with untreated
polycythemia.
Currently, there is some controversy over which babies should be treated. In general,
however, most experts agree that the following babies need treatment:
• Babies with venous or arterial hematocrit levels of at least 70%
• Babies with venous or arterial hematocrit levels between 65% and 70% who have
signs or symptoms of polycythemia

3. How is a reduction exchange transfusion done for polycythemia?

The procedure for performing a reduction exchange transfusion is similar to that of an exchange
transfusion; however, the solutions used for each differ, as do the goals of the procedures. A
double volume exchange transfusion is used to reduce toxic bilirubin levels, while a reduction
exchange transfusion is conducted to reduce the baby’s RBC mass. In a reduction exchange
transfusion, some of the thick (polycythemic) blood is removed, and a solution that will dilute
the baby’s blood is infused. Saline, plasma, or 5% albumin may be used, but, for a variety of
reasons, saline is recommended. In addition, a full exchange is not performed. Only enough
blood to lower the baby’s hematocrit level to an acceptable range is exchanged.
A. How do you calculate the amount of blood to exchange?
Use the following formula to determine the amount of blood that should be withdrawn
from a baby. The amount of blood withdrawn is also the amount of diluent (normal
saline) that should be given to the baby.
Blood to Withdraw (in small aliquots)
baby’s blood volume 3 (actual hematocrit 2 desired hematocrit) 5 amount of blood to withdraw
actual hematocrit
Normal Saline to Infuse (in small aliquots)
calculated amount of blood to be withdrawn 5 amount of saline to infuse
Example: A 3,000-g (6 lb 10 oz) baby has a hematocrit level of 75%. The baby’s
blood volume is 90 mL/kg (Book 3: Neonatal Care, Unit 4, Low Blood
Pressure [Hypotension]). The baby’s total blood volume is therefore 270 mL
(90 mL 3 3 kg 5 270 mL). You wish to reduce the hematocrit level to 55%.
(75% 2 55%)
270 mL 3
75%
20%
270 mL 3
75%
4
270 mL 3 5 72 mL of blood to withdraw from the baby and
15
72 mL of normal saline to infuse

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

B. What methods are used to perform a reduction exchange transfusion?

• Pull-push technique: 5 to 10 mL of the baby’s blood is withdrawn (pulled) through
a UVC and discarded, followed by normal saline infused (pushed) through the UVC.
This pull-push cycle is repeated until the desired volume of blood has been exchanged
(see the previous calculation).
• Continuous method: Withdrawal of blood from one line and simultaneous infusion of
normal saline through a second line.
Blood may be withdrawn through a UAC, UVC, or PAC. Saline may be given through a
PIV line or UVC. Some experts consider the preferred routes to be withdrawal through a
PAC and replacement infusion through a PIV line.
Withdrawal of blood and infusion of normal saline need to be done slowly to avoid sud-
den shifts in the baby’s blood pressure. Sudden shifts in blood pressure have been associ-
ated with intraventricular bleeding in newborns, particularly in preterm babies.

A withdrawal rate no faster than 2 to 3 mL/kg/min and an infusion rate no

faster than 2 to 3 mL/kg/min are recommended.

4. What are the potential complications of a reduction exchange

transfusion for polycythemia?
Complications of a reduction exchange transfusion are similar to those outlined earlier for
exchange transfusions for hyperbilirubinemia but do not include complications directly
related to the use of blood products. For example, the risk of viral infections associated with
the transfusion of blood is not a possible complication of a reduction exchange transfusion
because blood is not given to the baby.
Some experts suggest waiting to feed a baby for 24 to 72 hours after a reduction exchange
transfusion. Polycythemia, by itself, may be associated with intestinal injury and has been
reported to increase the risk for developing necrotizing enterocolitis. While the baby is fed
nothing by mouth, the baby will need to receive intravenous fluids to maintain hydration and
adequate blood glucose levels.

5. When is a partial exchange transfusion used for severe anemia?

In the case of severe anemia, the goal is to increase, rather than decrease, the RBC mass.
A. Why might severe anemia develop during gestation?
Rarely, a fetus may become extremely anemic for the following reasons:
• Chronic hemolysis from blood group incompatibility with the mother or from an in
utero viral infection
• When the fetus is the donor of a fetal-fetal or fetal-maternal in utero transfusion
• From causes unknown
B. How may the fetus be affected by severe in utero anemia?
If the anemia is very severe, the fetus may die in utero or may develop edema (hydrops
fetalis), which may or may not be detectable with antenatal ultrasonography. The low
oxygen-carrying capacity created by the paucity of RBCs will often result in these
fetuses not tolerating labor well and requiring resuscitation at birth.

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6. Why is a partial exchange transfusion done for severe anemia?

The purpose of a partial exchange transfusion in the case of severe anemia is to increase,
rather than decrease, the concentration of RBCs in the blood, so as to increase the oxygen-
carrying capacity and reverse heart failure. If the anemia has been developing over weeks or
months, the fetus will have retained sufficient plasma so that the blood volume is normal or
even increased. In such cases, a direct transfusion of packed RBCs may result in worsening of
the heart failure. If a partial exchange for hydrops becomes necessary, it may be needed at
birth, so you should have appropriately matched packed RBCs available in the delivery room.

7. How is a partial exchange transfusion done for severe anemia?

The process for performing a partial transfusion for anemia is the same as the process
described previously for polycythemia, except for the product used for infusion. In the case
of severe anemia, the goal is to increase the concentration of RBCs without increasing the
total blood volume. Therefore, instead of infusing normal saline and removing blood that is
too thick, you will be removing the thin, anemic blood and transfusing packed RBCs.
For a case of severe anemia, you can use a mathematic method similar to that described previ-
ously for polycythemia to calculate the total amount of blood to be exchanged for normal saline.
volume exchanged (milliliters) 5
   (hematocrit desired 2 hematocrit initial)
baby’s blood volume 3
(hematocrit donor RBCs 2 hematocrit initial)

However, clinicians generally exchange a total volume of 20 mL/kg, repeat the hematocrit test
and assess the baby’s condition, and then may perform a second partial exchange if judged to
be necessary. Either the pull-push or the continuous method may be used.

Self-test C
Now answer these questions to test yourself on the information in the last section.
C1. True False Untreated polycythemia has been associated with permanent intellectual
disability.
C2. Blood for determining a baby’s hematocrit level should be drawn from an __________________
or a __________________.
C3. List at least 5 possible signs of polycythemia.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
C4. In general, babies with hematocrit levels equal to or greater than _________% need to be treated for
polycythemia.
C5. A 1,980-g (4 lb 6 oz) 38-weeks’ gestational age baby that is small for gestational age is tachypneic
with a hematocrit level of 66%. You rule out other causes for her respiratory distress and determine
she needs a reduction exchange transfusion. How much blood would you exchange if her desired
hematocrit value is 50%?
______________ mL blood withdrawn
______________ mL physiological (normal) saline given
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

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Direct Transfusions in the Management of At-Risk and Sick Babies

1. What is a direct transfusion?

A direct transfusion is the process of infusing packed RBCs into a baby through a PIV line.

2. Why are direct transfusions done?

Several studies, designed to decrease the exposure to donor blood, recommend transfusion
standards for certain hematocrit levels and disease severity categories (Pediatrics. 2005;115[6]:
1685–1691; J Pediatr. 2006;149[3]:301–307). There continues to be ongoing research in the
optimal timing and degree of anemia at which to transfuse babies, especially preterm babies.
Much of this research is focused on neonatal morbidities related to transfusion, as well as
long-term neurodevelopmental outcomes.
A. Sick babies who require ventilatory support
Often, sick or at-risk babies undergo numerous laboratory studies, which cumulatively
result in a large quantity of blood being withdrawn. The specific quantity of blood
drawn before a transfusion is indicated is controversial. However, in a sick baby
who requires assisted ventilation, packed RBCs may be transfused when the baby’s
hematocrit value drops below the standard set for that facility.
B. Babies who are hypovolemic
Babies who are, or are suspected of being, hypovolemic because of blood loss may be
given direct transfusions to increase their blood volume. The management of babies
with hypovolemia is discussed in greater detail in Book 1: Maternal and Fetal Evalua-
tion and Immediate Newborn Care, Unit 5, Resuscitating the Newborn, and Book 3:
Neonatal Care, Unit 4, Low Blood Pressure (Hypotension).
C. Babies who have signs of anemia
Normally, even without any blood being withdrawn for laboratory studies, healthy
term babies will become anemic during the first 6 to 8 weeks after birth. Preterm
babies or babies who have had blood withdrawn for laboratory studies usually develop
anemia sooner, and with a greater drop in hematocrit values, than healthy term babies.
Stable preterm babies often continue to grow well and have normal vital signs, even
though they may become quite anemic with hematocrit values of 25% or lower.
Some anemic babies, however, will demonstrate signs of anemia that may require one
or more direct transfusions to resolve the problems. Signs of anemia include
• Tachycardia
• Tachypnea
• Apnea
• Failure to gain weight
The decision of when to transfuse a baby who is anemic is controversial. Most experts
recommend not transfusing babies who are anemic but have no signs or symptoms of
anemia. When a baby develops signs such as tachycardia, tachypnea, or apnea, you
should evaluate the baby for all the possible causes of these problems. (See Book 3:
Neonatal Care, Unit 9, Identifying and Caring for Sick and At-Risk Babies, Subsection:
Vital Signs and Observations.)

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

If the most likely cause of the baby’s problems is anemia, you need to weigh the risks
of transfusion against the risks of problems the baby is demonstrating. When signs of
anemia are significant, and the baby’s hospitalization is being prolonged because of
these problems, a transfusion of packed RBCs may be necessary.

3. How is a direct transfusion done?

• Packed RBCs should be compatible with the baby’s blood type.
• Usually a volume of 10 to 15 mL/kg is transfused.
• Example: A sick, 1,500-g (3 lb 5 oz), preterm baby who requires ventilator support has a
hematocrit value of 34%. You elect to transfuse the baby with 10 mL/kg.
10 mL 3 1.5 kg 5 15 mL of packed RBCs to be transfused
• Packed RBCs are given through a PIV or UVC.
• Follow your hospital’s protocol for acquiring parental consent and for the filtering,
identification, and disposal of blood.
• A transfusion is usually given over approximately 2 to 4 hours. A transfusion that is
given too quickly may cause volume overload, which may lead to increased respiratory
distress in the baby.
• In a sick baby, consider checking the hematocrit level 12 to 24 hours after transfu-
sion. This allows time for the transfused blood to equilibrate in the baby’s circulation.
However, many critically ill infants undergo serial hemoglobin testing, such as often
occurs with blood gas analysis. This may be adequate to monitor levels of anemia, with
intermittent hematocrit checks. In a stable baby, you can generally wait to check the
hematocrit value until the next time blood is drawn for laboratory studies. It may also
be useful to follow serial reticulocyte counts to determine if the baby is mounting a
recovery response to the anemia, in which case it may be prudent to hold off on further
transfusions.

4. What are the potential complications of a direct transfusion?

A. Infection
Serious infections, such as HIV or hepatitis, can occur after blood transfusion.
Currently, blood banks extensively test blood before it is used. Despite these efforts, a
very small number of individuals who receive blood may develop an infection.
B. Emboli
Small blood clots can pass through an intravenous line. Blood is usually filtered by the
blood bank before it is sent to the nursery. If this is not done, a filter should be inserted
between the blood being transfused and the baby before the transfusion is given.
C. Increased potassium levels
Older blood can have high levels of potassium. In general, this is not dangerous
because the total amount of potassium that will be given to the baby is small. In
very small, sick babies, however, an added potassium load can result in an increase of
potassium to a level that can cause heart arrhythmias. Therefore, you should always
use the freshest blood available.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Self-test D
Now answer these questions to test yourself on the information in the last section.
D1. True False Some babies will require a transfusion of packed red blood cells when their
hematocrit values fall below 40%, while other babies with hematocrit values
of 25% or lower will not require a transfusion.
D2. List 4 reasons transfusions of packed red blood cells are used.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
D3. True False Certain viral infections may occur as a result of a blood transfusion.
D4. Blood should be filtered before it is transfused to prevent the infusion of ________________.
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

Recommended Routines
All the routines listed here are based on the principles of perinatal care presented in the unit
you have just finished. They are recommended as part of routine perinatal care.
Read each routine carefully and decide whether it is standard operating procedure in your
hospital. Check the appropriate blank next to each routine.

Procedure Standard Needs Discussion Recommended Routine

in My Hospital by Our Staff
________________ ________________ 1. Establish a policy of obtaining a radiograph
for umbilical catheter placement before an
elective exchange transfusion.
________________ ________________ 2. Establish a policy of providing continuous
electronic cardiac monitoring for all babies
undergoing an exchange transfusion.
________________ ________________ 3. Establish a policy of monitoring blood
pressure at least every 15 minutes during an
exchange transfusion.
________________ ________________ 4. Establish a routine of determining hematocrit
values, as well as serum glucose, calcium,
potassium, sodium, and bilirubin levels, after
every exchange transfusion.
________________ ________________ 5. Establish a routine of warming blood before
an exchange transfusion, by using a commer-
cial blood warmer with appropriate tempera-
ture control and alarm features.
________________ ________________ 6. Establish a policy of using phototherapy after
any exchange transfusion for hyperbilirubinemia.
________________ ________________ 7. Establish a policy of checking the hematocrit
values of all babies at risk for polycythemia.
________________ ________________ 8. Establish a policy of using only venous or arterial
(not capillary) blood to determine the hematocrit
value of a newborn at risk for polycythemia.
________________ ________________ 9. Establish a policy of monitoring all babies
with hematocrit values greater than 65% for
signs of polycythemia.
________________ ________________ 10. Establish a policy for the hematocrit level
below which a baby who is critically ill
(ventilated, unstable) will be transfused.
________________ ________________ 11. Establish a policy of monitoring the hemato-
crit values of sick babies and stable, growing
preterm babies.
________________ ________________ 12. Establish a policy of monitoring babies with
low hematocrit values for signs of anemia.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.
Self-test A
A1. Hypocalcemia
Hypoglycemia
Acidosis/alkalosis
Hyperkalemia
A2. The hematocrit level of donor blood used in an exchange transfusion should be
45% to 55%.
A3. False. Reason: Blood should be warmed only with a commercial blood warmer that has
the appropriate temperature control and alarm features.
A4. Immediately after a double volume exchange transfusion, the baby’s bilirubin level will be
one-third to one-half the level it was before the exchange.
A5. Withdraw Infuse
Yes No Yes No
Umbilical arterial catheter   X                   X*
Peripheral arterial catheter   X                   X
Umbilical venous catheter   X            X         
Peripheral intravenous line          X     X         

*Unless route of last resort.

Self-test B
B1. False.  Reason: Blood may be withdrawn from an artery but should not be infused into a
peripheral artery or through an umbilical arterial catheter (unless an umbilical arte-
rial catheter is the route of last resort). The risk of tissue damage from unintentional
infusion of air bubbles or tiny clots is much greater with an infusion through an ar-
tery rather than a vein.
B2. Any 2 of the following complications:
• Arrhythmia
• Volume overload or depletion
• Cardiorespiratory arrest
B3. After an exchange transfusion for hyperbilirubinemia, a baby’s bilirubin level should be
checked every 4 to 6 hours.
B4. Any 3 of the following complications:
• Hypocalcemia
• Hypoglycemia
• Hyperkalemia
• Rebound hyperbilirubinemia
• Acidosis or alkalosis

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

Self-test C
C1. True
C2. Blood for determining a baby’s hematocrit level should be drawn from an artery or a vein
(not heel stick).
C3. Any 5 of the following signs:
• Plethora
• Cyanosis
• Lethargy
• Poor feeding
• Respiratory distress
• Congestive heart failure
• Tremors
• Seizures
• Hypoglycemia
• Hyperbilirubinemia
C4. In general, babies with hematocrit levels equal to or greater than 70% need to be treated
for polycythemia.
C5. 44
44
Self-test D
D1. True
D2. Replace blood withdrawn for laboratory tests.
Treat hypovolemic babies.
Treat stable babies who have symptomatic anemia.
Maintain hematocrit levels of approximately 40% in sick babies.
D3. True, although risk is extremely small.
D4. Blood should be filtered before it is transfused to prevent the infusion of tiny blood clots.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 2 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages on
www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf file
and save it to print later or come back to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

SKILL UNIT

Exchange Transfusions
This skill unit will teach you how an exchange transfusion is performed. Not everyone will be
required to learn how to conduct an exchange transfusion; however, all staff members should
read this unit and attend a skill session to learn the equipment and sequence of steps so they
can assist with the preparation for an exchange transfusion.
Although the following steps are the same as the ones used in clinical practice to perform an
exchange transfusion, mannequins and models should be used for demonstration and practice
of this skill.
The staff members who will be asked to master all aspects of this skill will need to demon-
strate each of the following steps correctly:
1. Prepare the “baby” (mannequin) for the exchange transfusion.

SKILL UNIT: EXCHANGE TRANSFUSIONS

2. Prepare the donor “blood.”
3. Insert an umbilical venous catheter, an umbilical or a peripheral arterial catheter, a periph-
eral intravenous line, or a venoarterial catheter, as needed. Identify the proper location of
umbilical venous and arterial catheters on radiographs to indicate appropriate positioning
of the catheter.
4. Demonstrate the pull-push method or the continuous method (or both).
5. Record blood exchanged, vital signs, etc.
6. Monitor the baby during the exchange.
7. Monitor the baby after the exchange.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

PERINATAL PERFORMANCE GUIDE

Performing Exchange Transfusions

Note: While this skill unit describes the procedure for an exchange transfusion for hyperbiliru-
binemia, the same basic techniques are used for a reduction exchange for polycythemia.
As you know, the amount of blood withdrawn and the replacement fluid given are both
different, but the techniques for how the blood is withdrawn and the volume is replaced
are the same.

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion

Several things must be done to prepare a baby
before the actual exchange transfusion begins.
1. Send a sample of the baby’s and the If a baby has a significant risk of needing an
mother’s blood for crossmatching. exchange transfusion, notify the blood bank
and send appropriate samples early. Prepara-
tion of an appropriate blood product may
require several hours.
2. Do not give enteral feedings for 3 to 4 hours This will reduce the chance the baby will
or aspirate stomach contents just prior to vomit (and possibly aspirate) during the
the exchange. procedure.
3. Establish a properly warmed and oxygen- Exchange transfusions can be done with the
ated (if the baby requires supplemental baby inside an incubator or under a radiant
oxygen) environment for the baby during warmer. Wherever care is provided, it must
the exchange. be possible to establish and maintain a
sterile field.
4. Consider establishing a peripheral During the exchange, the amount of blood
intravenous (PIV) line. given will usually be the exact amount with-
drawn. A separate intravenous (IV) line is
helpful to provide a constant infusion of
fluid and glucose during the exchange, and
IV access in case of an emergency.
5. Attach a cardiac monitor to the baby. Continuous cardiac monitoring is important
This monitor should provide a continuous so any change in the baby’s heart rate can be
signal of the baby’s heartbeat. High and instantaneously detected.
low heart rate alarms should be set.
6. Attach a blood pressure cuff to one of Because the baby may get too much or
the baby’s extremities and obtain a too little volume during the procedure,
measurement at least every 15 minutes. or develop a complication, it is important to
monitor blood pressure.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

7. Collect resuscitation equipment and place The mortality rate associated with exchange
it at the baby’s bedside. This equipment transfusions is less than 1%, although
includes it is higher if the baby is preterm or ill.
• Resuscitation bag and mask (assembled Unexpected, unexplained cardiac arrest
and connected to an oxygen source) does occasionally occur.
• Laryngoscope, endotracheal tubes, Fewer and fewer perinatal health profession-
stethoscope, etc als are experienced with exchange transfu-
sions. This makes being prepared for the
• Emergency medications
unexpected increasingly important.
• At least 2 people trained in neonatal
resuscitation present with the baby
throughout the entire procedure
8. Prepare the blood. See section 4 in Exchange Transfusions in the
a. Be sure the blood is antigen-negative Management of Hyperbilirubinemia.
for passively acquired antibodies. For citrate phosphate dextrose adenine anti-
coagulated blood, be especially careful to
observe the baby for signs of hypocalcemia,
and check for the possible development of
hypoglycemia.
b. Know the anticoagulant used and the Donor blood, especially older blood (more
age of the blood. Request blood that is than 10 days old), will need to be washed by
no more than 10 days old. the blood bank to reduce potassium levels.
c. Calculate the volume of blood needed. Generally, double volume exchange transfu-
sions using 180 mL of donor blood for every
kilogram of the baby’s weight are used.
Example: Double volume exchange transfu-
sion for a baby weighing 2,600 g
(5 lb 12 oz) would require
468 mL of donor blood
(180 mL/kg 3 2.6 kg 5 468 mL).
d. Request that the hematocrit level of the Most blood banks can prepare donor blood
blood be between 45% and 55%. so it has an appropriate hematocrit level.
e. If possible, warm the blood to 37.0°C Do not use true packed red blood cells with
(98.6°F) by using a commercial blood high hematocrit values. See section 6.A in
warmer that has Exchange Transfusions in the Management
• Constant temperature readout of Hyperbilirubinemia.
• Adjustable thermostat Do not use blood warmers without precise
• Automatic alarm system to prevent thermostatic control because these may cause
warming the blood above 38.0°C mechanical trauma to the red blood cells.
(100.4°F)
Do not heat the blood under a radiant
warmer or in a water bath warmer because
this may “tan” the surface red blood cells
and produce intravascular hemolysis.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

9. Prepare the fluid lines. Use the sterile procedure and insertion
a. Insert an umbilical venous catheter technique outlined in Unit 3, Continuous
(UVC) if you will use the pull-push Positive Airway Pressure, Skill Unit: Delivery
method. of Continuous Positive Airway Pressure.
• Measure the baby to determine Maintain sterile technique throughout the
the appropriate distance to insert catheterization and exchange transfusion.
the UVC.
Everyone involved should wear sterile gowns
• Use a size 5F catheter for most
and gloves. If the baby is inside an incubator,
babies with a birth weight over
masks are not necessary but should be used
1,000 g (2 lb 3 oz).
if the baby is on a radiant warmer.
b. Insert an umbilical arterial catheter
(UAC), peripheral arterial catheter If the baby does not require a UAC for other
(PAC), UVC, or PIV line (or any reasons (eg, monitoring arterial blood gases,
combination of those) if you are central blood pressure), either the pull-push
using the continuous method. method through the UVC or continuous
method through a UVC and PIV line is
See section 8.A in Exchange Transfusions in
preferable.
the Management of Hyperbilirubinemia.
Some clinicians place a PAC and use it for
withdrawal, with infusion through a UVC
or PIV line.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

10. Determine the placement of the catheters
by using radiographs.
• Ideally, a UVC tip should be at the
junction of the inferior vena cava and
the right atrium.
• On a radiograph, the UVC tip should
be above or at the level of the dia- Heart

phragm (see illustration). Diaphragm

• It is also possible to perform an ex-

change transfusion through a UVC Liver

when the catheter tip is still in the um-

bilical vein and will not pass into the
inferior vena cava. However, there is a
somewhat increased risk of liver dam-
Umbilicus
age. In this case, the catheter should be
inserted only until a free flow of to- Catheter
outside
and-fro flow is achieved, usually at 3–4 baby

cm [1.2–1.6 in]; infusion of sclerosing

agents, such as calcium, should be
avoided.
Wherever the UVC is placed, you
should be able to obtain blood flow
into the catheter very easily.
Optimum Location for Umbilical Venous
• A UAC tip should be between L3 and
Catheter Tip
L4 if using a “low UAC.” Alternatively,
the UAC may be placed as a “high
UAC,” with its tip placed between T6
and T9. (The UAC is not shown in the
illustration. See Book 3: Neonatal Care,
Unit 3, Umbilical Catheters.)
• A PAC is commonly placed in the
radial artery.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

11. Collect the appropriate equipment.
Commercial sterile exchange transfusion
kits are available, or you can make your
own kit with the following equipment:
Pull-Push Method
• One 4-way stopcock
• 6-, 10-, or 12-mL syringe
Continuous Method
• Three 3-way stopcocks
• One 50- to 60-mL syringe for each
150 mL of blood to be withdrawn
• One 50- to 60-mL syringe for blood
infusion
• 5- to 6-mL syringe for heparinized
saline flush
Either Method
• Blood filter (Sometimes blood filters are
incorporated into IV tubing.)
• IV tubing between the donor blood and
stopcock
• Plastic bag or container to collect blood
removed
• IV tubing between stopcock and
collection container
• Two 5-mL syringes to obtain pre-
exchange and post-exchange
laboratory samples

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

12. Assemble the equipment as shown in one
of the diagrams that follow, depending on
whether you will use the pull-push or
continuous method.

Pull-Push Method

Donor blood

Blood filter

Blood warmer

Baby with
umbilical
Syringe 4-way stopcock
venous
catheter

Collection bag for baby’s blood

Continuous Method
Infusion System Removal System

Donor blood Baby with peripheral arterial catheter,

umbilical arterial catheter, or
umbilical venous catheter

Blood filter
Collection
3-way bag for
stopcock #1 baby’s
blood
Blood warmer

Syringe with
50-mL 3-way 3-way
heparinized
syringe stopcock stopcock #2
saline

Baby with umbilical

venous catheter or
peripheral intravenous line 50-mL
syringe

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

13A. Pull-Push Technique See step 13B for a description of the
a. Open the UVC to the 10- or 12-mL continuous method.
syringe.
b. Pull 5 or 10 mL of blood slowly For small babies, only 5-mL volumes should
from the baby, at a rate no faster be withdrawn or given at a time. For larger
than 2 to 3 mL/kg/min. babies (. 3,000 g [6 lb 10 oz]) with stable
c. Turn the stopcock off to the UVC vital signs, the individual exchange amounts
and open to the collection container. may be 10 mL.
d. Push the blood out of the syringe
and into the collection container.
e. Turn the stopcock off to the collec-
tion container and open to the
donor blood.
  f. Withdraw 5 or 10 mL (an amount
equal to the volume just withdrawn
from the baby) from the blood
donor unit.
g. Close the stopcock to the donor unit
and open it to the UVC.
h.  Slowly push the donor blood out of Be sure to hold the syringe upright so that
the syringe and into the UVC, at a any air bubbles in the syringe will not be
rate no faster than 2 to 3 mL/kg/min. pushed unintentionally into the baby.
  i. Leave the stopcock open to the UVC Withdraw and replace the blood in a slow
and slowly withdraw another 5 or and steady fashion. Rapid shifts in blood
10 mL of blood from the baby. volume can be quite hazardous to a baby.
Continue this pattern of pulling
blood from the baby, discarding it,
and pushing donor blood into the
baby until 180 mL/kg of baby’s
weight of donor blood has been
exchanged.
  j. It should take approximately 1 to There is no advantage to rushing through an
2 hours (depending on the amount exchange transfusion because the rate of the
of blood to be exchanged) to com- exchange has little effect on the amount of
plete a pull-push exchange. bilirubin removed and, as noted earlier, rapid
shifts in fluid volume can be harmful.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

13B. Continuous Method
Infusion steps and removal steps should
be done simultaneously.
Infusion Steps Removal Steps
a. Turn the stopcock so that the 50- to a. Turn stopcocks 1 and 2 so the 50- to
60-mL syringe is open to the donor 60-mL syringe is open to the PAC, UAC,
blood. or UVC being used to withdraw the
b. Fill the syringe with 50 mL of donor baby’s blood.
blood. b. Withdraw the baby’s blood at a rate of
c. Turn the stopcock off to the donor 2 to 3 mL/kg/min.
blood and open it to the UVC or PIV c. When 50 mL has been withdrawn, turn
line being used for infusion. stopcock 1 off to the catheter and open to
d. Begin to infuse the donor blood the collection bag.
at 2 to 3 mL/kg/min. d. Quickly eject the blood into the collection
e. Repeat steps a through d above until bag.
the desired volume (usually 180 mL/ e. Turn stopcock 1 off to the collection bag
kg) of donor blood has been infused. and open to the catheter.
It is important that the rate of infusion f. Repeat steps a through e above. Perform
and withdrawal of blood remain equal steps g through j after every 150 mL of
and constant, so that shifts in the baby’s blood has been withdrawn.
baby’s blood volume do not occur. g. Turn stopcock 1 off to the catheter and
replace the 50- or 60-mL syringe with a
new one.
h. Open stopcock 2 between the heparinized
saline (5 U of heparin per 1 mL of saline)
syringe and the catheter.
i. Open stopcock 1 to the catheter.
j. Gently flush the catheter with 1 to 2 mL
of heparinized saline. Periodically
changing the 50- or 60-mL syringe and
flushing the catheter will help prevent clot
formation.
k. Repeat steps a through j above until the
desired volume (usually 180 mL/kg) of
blood has been withdrawn.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

14. With either method, blood levels should
be checked prior to initiating, including
• Bilirubin
• Hematocrit
• Electrolytes
• Calcium
• Other (coagulation studies, chromo-
somes, or other tests that may be
indicated for the baby undergoing
the exchange)
15. Record each volume of blood withdrawn Every time one operator withdraws blood
and infused on a tally sheet. Use a form from or gives blood to the baby, that person
similar to the one at the end of this unit. should call out the volume to another person
who records it.
At the end of the exchange, the total The recorder also maintains a “running
amount of blood given should equal the total” of how much blood has been with-
total amount of blood withdrawn. drawn and given.
16. Check and record the baby’s vital signs at
least every 15 minutes during the
exchange.
17. Observe for signs of hypocalcemia, Hypocalcemia is more likely to develop
including when citrate phosphate dextrose adenine–
• Jitteriness preserved blood is used, rather than
• Seizures heparinized blood.
• Apnea
If any of the following signs develop or if
See Book 3: Neonatal Care, Unit 3, Umbili-
hypocalcemia is documented,
cal Catheters, for recommendations about
a. Flush the catheter with heparinized
heparin concentration in heparin flushes.
normal saline.
b. Give 100 to 200 mg calcium gluconate Risks are associated with the administration
per kilogram slowly through the UVC of IV calcium gluconate. Therefore, calcium
or PIV line. Use 5% (50 mg/mL) should probably not be given unless the baby
concentration (dilute 10% calcium has developed signs of hypocalcemia.
gluconate with equal parts sterile
water to make 5%).
c. Stop the calcium infusion immediately Calcium injected rapidly, especially through
if the baby’s heart rate begins to slow. a UVC, can cause cardiac arrest. Be sure the
d. Flush the catheter with heparinized calcium and subsequent flush solution is
normal saline, then continue with the given slowly.
exchange transfusion.

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

ACTIONS REMARKS

Preparing the Baby for an Exchange Transfusion (continued)

18. Mix the donor blood several times This is to prevent settling of the donor
during the exchange. blood, which would result in the baby
receiving mostly plasma at the end of the
exchange.
19. Obtain a blood sample for post- Use the last blood withdrawn from the baby
exchange laboratory studies. for these studies.
• Glucose
• Bilirubin
• Hematocrit
• Platelet count
• Electrolytes
• Calcium
• Coagulation studies
Note: Within 30 minutes after the exchange transfusion has been completed, the bilirubin
level may rebound to a level approximating the pre-exchange level. This is due
to equilibrium being established between extravascular and plasma bilirubin
concentrations.
It is unlikely that the bilirubin level will continue to rise that rapidly; however, it is
important to continue to check the bilirubin every 4 to 6 hours after an exchange
transfusion.
A baby with hyperbilirubinemia severe enough to require one exchange transfusion
may require several exchange transfusions.
20. Remove the catheters unless another Babies with evidence of severe hemolysis (eg,
exchange is anticipated. If a PIV line a baby who requires an exchange transfusion
was used for blood infusion, it may be within the first few hours after birth) will
converted into an IV lock until needed. probably require several exchanges. For these
babies, leave the catheters in place for several
hours until the trend of bilirubin increase can
be determined.
Caring for a Baby After an Exchange Transfusion
21. Continue to check the baby’s vital signs
every 15 to 30 minutes for 3 to 4 hours.
22. Monitor glucose levels hourly for Hypoglycemia is more likely to occur after,
several hours. rather than during, an exchange.
23. Reinstitute phototherapy. Phototherapy should be used after every
exchange transfusion performed for
hyperbilirubinemia.
24. Continue to observe the baby for See section 10 in Exchange Transfusions in
complications. the Management of Hyperbilirubinemia.
25. Consider withholding several feedings Some clinicians believe that the intestines
while maintaining hydration and blood may have experienced a trauma from altera-
glucose intravenously. tions in perfusion.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Date ___________________________________ Laboratory values

Baby’s name ___________________________ Pre-exchange

Exchange transfusion # ___________________ Hematocrit _________ Potassium _________

Birth weight ____________________________ Bilirubin _________ Sodium _________

Birth date ______________________________ Calcium _________ Chloride _________

Time __________________________________ Other __________________________________

Mother’s blood group ____________________ Post-exchange

Baby’s blood group ______________________ Hematocrit _________ Potassium _________

Coombs ________________________________ Bilirubin _________ Sodium _________

Blood used: group _______________________ Calcium _________ Chloride _________

Hematocrit value ________________________ Glucose _________ Other _________

Time exchange started ____________________ Coagulation studies ______________________

Time exchange ended _____________________ Total Volume Withdrawn

From baby _____________________________
Staff conducting the exchange
Total Volume Given
_______________________________________ To baby ________________________________

_______________________________________

_______________________________________

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 UNIT 2: EXCHANGE, REDUCTION, AND DIRECT TRANSFUSIONS

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02_Unit2_BKIV_PCEP_019-056.indd 56 5/29/21 8:12 AM
 Unit 3: C
 ontinuous Positive Airway
Pressure
Objectives.............................................................................................................................. 58
1. What is continuous positive airway pressure?........................................................... 60
2. How does continuous positive airway pressure work?............................................. 60
3. Which conditions benefit from continuous positive airway pressure?.................... 60
4. When should a baby receive continuous positive airway pressure?........................ 61

UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

5. How is continuous positive airway pressure administered?..................................... 61
6. How much pressure is used?........................................................................................ 62
7. How is a baby weaned from continuous positive airway pressure?........................ 62
8. How is continuous positive airway pressure administered via
high-flow nasal cannula?.............................................................................................. 63
Skill Unit: Delivery of Continuous Positive Airway Pressure............................................ 65

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Objectives
In this unit you will learn
A. How continuous positive airway pressure (CPAP) works
B. When CPAP should and should not be used
C. How CPAP is administered
D. When and how a baby is weaned from CPAP

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 UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

Unit 3 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them with the answers at the end of the book.
1. Which of the following is an appropriate way to provide nutrition to babies who need
continuous positive airway pressure (CPAP) for acute respiratory disease who have
achieved cardiovascular stability?
A. Intravenous fluids
B. Tube feedings
C. Nipple feedings with a special nipple
D. None of the above
2. For which of the following babies would CPAP be most appropriate?
A. Post-term baby with choanal atresia
B. Preterm baby who is cyanotic because of congenital heart disease
C. Term baby with a pneumothorax
D. Preterm baby with respiratory distress syndrome
3. True False All babies with respiratory disease should receive CPAP.
4. True False High-flow nasal cannula can be used to deliver a consistent level
of CPAP.
5. Which of the following statements best describes the purpose of CPAP?
A. Control the baby’s respiratory rate.
B. Decrease the baby’s metabolic rate.
C. Increase the baby’s arterial oxygen concentration.
D. Decrease the baby’s chance of developing a pneumothorax.
6. Which of the following indicates the general range of pressure used with nasal
CPAP when used in the treatment of respiratory distress syndrome?
A. 2 to 4 cm H2O pressure
B. 4 to 8 cm H2O pressure
C. 10 to 14 cm H2O pressure
D. 14 to 18 cm H2O pressure
7. A baby with respiratory distress syndrome is receiving nasal CPAP at 8 cm H2O
pressure and an inspired oxygen concentration (Fio2) of 60%. Arterial blood
gas results at these settings reveal that Pao2 5 94, Paco2 5 45 mm Hg, and
pH level 5 7.32. Which of the following next steps is the most appropriate one
to take to adjust the baby’s CPAP and oxygen therapy?
A. Decrease the Fio2 to 40% to 50%, and decrease the nasal CPAP to 6 cm
H2O pressure.
B. Decrease the Fio2 to 50%, and maintain the nasal CPAP at 8 cm H2O pressure.
C. Maintain the Fio2 of 60%, and discontinue the nasal CPAP.
D. Maintain the Fio2 of 60%, and increase the nasal CPAP to 10 cm H2O pressure.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

1. What is continuous positive airway pressure?

When babies breathe normally, they pull air into their lungs by contracting their diaphragms,
then exhale by allowing the air to flow passively out of their lungs against the atmospheric
pressure in room air. Continuous positive airway pressure (CPAP) is a technique that allows
babies to exhale against pressure that is slightly higher than atmospheric pressure.
Delivery of CPAP requires the baby’s airway to be connected to a system that can be pressur-
ized. The most common method of connecting the airway to a CPAP system is through nasal
prongs or a nasal mask.

2. How does continuous positive airway pressure work?

Pulmonary compliance is a measure of the stiffness of the lungs, as measured by how much
pressure is required to deliver a certain amount of volume. In lungs with normal compliance,
alveoli stay open during expiration. In lungs with poor compliance (stiff lungs), alveoli tend to
collapse during expiration. When this happens, the baby must re-expand the collapsed alveoli
during each inspiration, which requires the baby to work harder (eg, tachypnea, retractions,
grunting). Babies with respiratory distress syndrome (RDS) have poor lung compliance and
benefit from CPAP to keep alveoli open at the end of expiration.
CPAP is not a form of mechanical ventilation. Air and oxygen are not forced into the
lungs during inhalation. Because of that, CPAP can only be used in babies who breathe
spontaneously.
The pressure provided with CPAP prevents alveoli from collapsing during expiration. The
grunting heard in babies with RDS who are not receiving CPAP is due to the baby’s own
effort to hold open the alveoli by exhaling against a partially closed glottis (upper airway).
Oxygen diffuses across the thin membranes of the alveoli into surrounding capillaries. The
blood flow carries the oxygen from the lung capillaries to the heart and then to blood vessels
throughout the body.
Oxygen cannot enter collapsed alveoli and, therefore, cannot reach the capillaries surrounding
those alveoli. CPAP improves arterial oxygenation by keeping alveoli open, thus allowing
more places for oxygen to enter the bloodstream.

3. Which conditions benefit from continuous positive airway

pressure?
CPAP is effective in the treatment of lung disease caused by poor lung compliance. It is most
commonly used for babies with RDS.

CPAP is not useful, and may even be harmful, for babies with normal lung
compliance.

In general, CPAP should not be used for babies with respiratory distress caused by factors
such as birth asphyxia, most types of cyanotic congenital heart disease, or pneumothorax.
A few babies with respiratory distress caused by factors other than RDS and some small
preterm babies with apnea may also benefit from CPAP. Management of babies with these
special conditions is not discussed in this unit.

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 UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

4. When should a baby receive continuous positive airway pressure?

CPAP is most useful to treat babies who have mild or moderate RDS that is not severe enough
to require endotracheal intubation and mechanical ventilation. CPAP is also useful for babies
who were intubated for surfactant therapy, then extubated after surfactant was given.
Before CPAP is used, the baby will usually have chest radiographic findings compatible with
RDS (low lung volumes, air bronchograms, and a ground-glass appearance) and grunting
respirations or chest retractions (or both). However, since preterm babies born at less than
approximately 30 weeks’ gestation almost always have poor lung compliance after birth,
initiation of CPAP to prevent alveolar collapse and prevent the need for surfactant therapy
is recommended.

5. How is continuous positive airway pressure administered?

The system for delivering CPAP may be a mechanical ventilator set to CPAP mode or a device
that is made solely for the delivery of CPAP. It can also be delivered for short periods with
a flow-inflating resuscitation bag or T-piece resuscitator. (See Book 1: Maternal and Fetal
Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) Several points
are especially important to remember when setting up and maintaining a CPAP system.
A. Flow rate
There should be a sufficient liter-per-minute air/oxygen flow rate through the tubing to
prevent the baby from re-breathing the baby’s own exhaled air. As a general guideline, a
combined air and oxygen liter-per-minute flow rate of 8 to 12 L/min should be used.
B. Pressure regulation
The CPAP delivered to a baby is measured in centimeters of water (cm H2O). Pressure
adjustment should not be attempted until the nasal prongs or mask is positioned prop-
erly on the baby. (See Skill Unit: Delivery of Continuous Positive Airway Pressure.)
If using a mechanical ventilator, set it on CPAP mode and adjust the pressure by turning
the appropriate dial on the front of the ventilator. The pressure delivered to the baby
then registers on the front of the ventilator.
C. Safety pop-off valve
Mechanical ventilators and stand-alone CPAP devices have safety valves built in to pre-
vent the airway pressure from reaching dangerously high levels. With nasal CPAP, the
baby’s mouth also acts as a natural pop-off valve. The mouth should not be taped shut.
A chin strap is sometimes used to mitigate pressure loss through the mouth.
Because babies generally breathe only through their noses, the pressure applied through
the nasal prongs will usually not escape from an open mouth until a pressure of approx-
imately 10 cm H2O or more is reached. This allows adequate CPAP to be delivered to
the lungs but reduces the chance of the baby inadvertently receiving too much pressure.
Set the high-pressure alarm on the CPAP delivery system approximately 2 cm H2O
above the set CPAP level.
D. Stomach decompression
Insert a 5F, 6.5F, or 8F feeding tube into the baby’s stomach through the mouth, gener-
ally using the largest size possible. Tape the tube in place and leave the end open.
When nasal prongs or a mask is used to deliver CPAP, the air/oxygen mixture is forced
primarily into the lungs, but some of the flow may be diverted down the esophagus and

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

into the stomach. The open feeding tube provides a vent so that the stomach does not
become distended with gas.
E. Oxygen concentration
CPAP is a delivery system for oxygen/air and pressure. The concentration of oxygen
delivered through that system must still be regulated according to oxygen saturation
or arterial blood gas values (or both). In general, a baby should be started on CPAP
with the same inspired oxygen concentration (Fio2) that was previously being delivered
to the baby.
If a baby receiving nasal CPAP is crying vigorously, room air (21% oxygen) may be
inhaled through the mouth. Be sure the baby has been quiet for several minutes before
assessing the response to CPAP. The state of oxygenation is assessed with either pulse
oximetry or arterial blood gas determination (or both). Assessment of ventilation
requires arterial or capillary blood gas analysis. If the baby’s pulse oximeter fluctuates
considerably as a result of crying and breathing through the mouth, an oxygen hood
plus nasal CPAP may be helpful in maintaining constant oxygenation.
F. Feedings
In general, babies receiving CPAP for acute respiratory distress who are not yet stable
should not be fed human (breast) milk or formula, by either tube or nipple. Gastrointes-
tinal motility is decreased in sick babies with respiratory disease. This means that a feed-
ing is likely to stay in the stomach longer. However, many neonates with moderately se-
vere RDS tolerate trophic and low-volume feedings. Prolonged NPO periods (“nil per
os” or “nothing by mouth”) are not recommended.
Because of this, a baby is much more likely to regurgitate some of the milk (or formula)
or gastric juices (or both) and aspirate this fluid. Severe aspiration pneumonia could
result. It is, of course, extremely important to maintain intravenous therapy for any
baby receiving CPAP who is not receiving enteral nutrition.
Tube feedings may be used for babies who have recovered from severe respiratory dis-
tress but still require CPAP at relatively low pressure. Tube feedings may also be consid-
ered in newborns with mild respiratory distress who appear comfortable on CPAP.

6. How much pressure is used?

When nasal CPAP is used for RDS, 4 to 6 cm H2O is generally the appropriate starting
pressure. Lower pressure than this is usually ineffective.
Sometimes, the pressure may need to be increased to as much as 8 cm H2O. Pressure should
never be increased to 8 cm H2O without obtaining a chest radiograph to evaluate lung
expansion. A decrease in the CPAP may be needed if the baby received surfactant. Make
adjustments according to work of breathing, as well as pulse oximetry and arterial blood gas
measurement results. The use of higher pressures than are needed place the infant at risk for
developing a pneumothorax or other air leak syndrome.

7. How is a baby weaned from continuous positive airway pressure?

As the baby’s respiratory disease improves, decrease the Fio2 according to arterial blood gas
and pulse oximetry values. CPAP weaning should occur when the baby has improved work of
breathing and when the supplemental oxygen requirement is 35% or lower.

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 UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

With continued improvement in the baby’s condition, lowering the CPAP can continue slowly,
usually in increments of 1 cm H2O. Oxygenation should be assessed constantly with pulse
oximetry, and ventilation should be assessed intermittently with arterial blood gas measure-
ments. Discontinue CPAP when the baby is comfortable on 4 cm H2O pressure with an
oxygen requirement of 25% to 30% (or less), normal arterial blood gas measurements, and
normal work of breathing.
Continue the baby’s oxygen therapy by using an oxygen hood or a low-flow nasal cannula. Be
prepared to increase the Fio2 slightly for a brief period after CPAP is stopped. Adjust the Fio2
according to oximetry or arterial blood oxygen concentrations (or both).
Preterm babies born at less than 30 weeks’ gestation may benefit from remaining on
4 to 5 cm H2O CPAP, even at low concentrations of oxygen, to prevent atelectasis in the first
few weeks after birth. Maintaining the use of CPAP until the baby is on 21% oxygen with no
distress and weaning directly to room air is another acceptable strategy.

8. How is continuous positive airway pressure administered via

high-flow nasal cannula?
There is evidence that a nasal cannula, delivering more than a 2-L/min flow directly to a
baby’s nares, will result in the baby receiving some amount of positive end expiratory
pressure. However, the exact level of positive pressure being delivered by the high-flow
nasal cannula technique fluctuates widely and is unpredictable. Therefore, achieving CPAP
with this technique is not recommended for babies with acute respiratory disease and is not
covered in this unit.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 3 Posttest
After completion of each unit there is a free online posttest available at www.
cmevillage.com to test your understanding. Navigate to the PCEP pages on
www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf file
and save it to print later or come back to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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 UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

SKILL UNIT

Delivery of Continuous Positive Airway Pressure

This skill unit will teach you how to set up and maintain a system for delivery of continuous
positive airway pressure (CPAP) by using nasal prongs or masks. Not everyone will be
required to learn how to administer CPAP. However, all staff members should read this skill
unit to learn the equipment and sequence of steps so they can assist with this treatment.

SKILL UNIT: DELIVERY OF CONTINUOUS POSITIVE AIRWAY PRESSURE

The staff members who will be asked to master all aspects of this skill will need to demon-
strate each of the following steps correctly:
1. Collect and assemble equipment.
2. Establish desired oxygen concentration, temperature, and flow rate within the CPAP system.
3. Select prong size, and position and secure the nasal prongs.
4. Insert an orogastric tube; tape it in place and leave it open.
5. Regulate CPAP.
6. Set a high-pressure alarm.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

PERINATAL PERFORMANCE GUIDE

Using Continuous Positive Airway Pressure

ACTIONS REMARKS

Preparing the Equipment for Nasal CPAP Delivery

1. Collect the following equipment:
• Nasal prongs or mask The nasal prongs shown in this skill unit are
• Apparatus to secure the nasal prongs available from www.medtronic.com (search
or mask “Argyle CPAP nasal cannula”).
• Oxygen source Some other brands are shown with refer-
ences later in the skill unit. Follow the manu-
• Air source
facturer’s directions for use and method of
• Mechanical ventilator with CPAP mode application to the baby.
or stand-alone CPAP device
• Heater/humidifier
• In-line thermometer (may be incorpo-
rated in the heater/humidifier)
• Frame to support the tubing, if needed
• Orogastric tube
2. Assemble all of the above equipment.
3. Make the following preparations for
providing oxygen and positioning and
securing the prongs: Small size
• Select the appropriate size of nasal (extra small not shown)
prongs or mask. Follow the manufacturer’s
recommendations that accompany the
brand in your hospital.
The following is a general guideline:
– An extra-small size is for babies weigh-
ing less than approximately 1,000 g
(,2 lb 3 oz). Large size
– A small size is for babies weighing
between approximately 1,000 and
1,500 g (2 lb 3 oz and 3 lb 5 oz).
– A large size is for babies weighing more
than approximately 1,500 g (.3 lb 5 oz).
Note: Different brands of prongs and
masks will vary slightly in shape.
• Check the oxygen concentration flowing
through the system.
• Check the temperature registered on the Be sure this is within the baby’s neutral
in-line thermometer. thermal environment temperature range.
• Adjust the CPAP system flow rate. Usually 8- to 12-L/min flow is adequate.

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 UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

ACTIONS REMARKS

Preparing the Equipment for Nasal CPAP Delivery (continued)

• Occlude the tubing that connects to Any pressure in the system will be delivered
the prongs or mask and check to see directly to the baby’s lungs as soon as the
that the pressure reads zero. tubing is connected to the nasal prongs or
mask. If this pressure is too high, it could
cause a pneumothorax.
Preparing the Baby for Nasal CPAP
Use a commercially available surgical mask Be careful to position the mask over the
that has one string on each of the 4 corners. baby’s occiput. It should not go over the
Place this mask over the back of the baby’s back of the baby’s neck, or it will pull the
head. Use the strings to tie the nasal prongs or nasal device in the wrong direction.
mask in place.
When positioned correctly, the upper segment
of the nosepiece should be vertical
and at a right angle to the baby’s face. The
prongs should rest comfortably within
the baby’s nose. The prongs should not rest
directly against the nose. Ensure that an “air
cushion” is present to decrease the risk of na-
sal septum breakdown. If using a nasal mask,
the nasal mask should rest comfortably over
the nose without occluding the nostrils.
Some clinicians have recommended that Surgical mask

a small piece of adhesive skin prep

(eg, Tegaderm) with 2 holes made in it be
placed on the upper lip and nasal columella
(septal skin) to decrease skin irritation.
There are also other commercially available nasal prongs and masks that are packaged with
an apparatus designed to secure them. Some are illustrated on the next page. Follow specific
manufacturer’s directions for use and method of application to the baby.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Preparing the Baby for Nasal CPAP (continued)

Hudson Nasal Prongs CPAP System

https://www.teleflex.com/usa/en/
Medin CPAP System product-areas/anesthesia/
www.medin-medical.com/en (Search “infant nasal CPAP.”)
Reproduced with permission from Medical
Innovations GmbH.

CareFusion Infant Flow LP nCPAP System

https://www.bd.com/en-us/
Courtesy and © Becton, Dickinson and Company. Reproduced with permission.

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 UNIT 3: CONTINUOUS POSITIVE AIRWAY PRESSURE

ACTIONS REMARKS

Preparing the Baby for Nasal CPAP (continued)

4. Position either the prongs in the baby’s Nasal prongs should fit fully inside the
nares or the mask over the baby’s nose. baby’s nostrils but not press on the baby’s
nose or upper lip.
A nasal mask should fit comfortably over the
baby’s nose without occluding the nostrils.
5. Position the tubing. • Align the securing device symmetrically
Place the tubing in a neutral position around the baby’s skull.
so it does not pull or press against the • Be sure that the upper segment of the
baby’s nose. nosepiece is at a right angle with the
baby’s face.
By evenly distributing the pressure of the
device between the nasal bridge and septum,
the risk of skin breakdown is minimized.
6. Insert an orogastric tube. This is a feeding The purpose of the tube is to act as a vent,
tube that is inserted through the baby’s so the baby’s stomach does not become
mouth instead of the baby’s nose. distended from swallowed air.
Check the tube position, tape it in place, Check the position of the tube by listening
and leave it open to the air. over the stomach with a stethoscope and
injecting a small amount of air through the
tube with a syringe.
It is important to leave the tube un-capped
and periodically check for gastric distention.
Adjusting CPAP
7. Regulate the pressure by adjusting the
CPAP or positive end-expiratory pressure Oxygen

knob on the ventilator or delivery device. analyzer

Peak-INSP.
• Generally, pressures of 4 to 6 cm H2O CPAP IMV
10
20

are used initially. 20

18
End-Exp.
Pressure
16 40 50 60
• Lower or raise the pressure in incre- 14
12
30
20
70
80
10 10 90
ments of 1 cm H2O as the baby’s condi- 8
6
Oxygen concentration
Inspiratory
tion indicates (as determined by work of
4
2 time Temperature

breathing, arterial blood gas measure- Flow Expiratory

time

ments, and pulse oximetry).

In the illustration on the right, this knob
is labeled “end-exp” for end-expiratory
pressure.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Adjusting CPAP (continued)

8. Set the high-pressure alarm on the ventila-
tor or CPAP delivery mechanism to signal
if the pressure within the system reaches
2 cm H2O above the set CPAP level.

Maintaining Nasal CPAP

9. Periodically check: For all the items listed in the left column,
check, record, and readjust, if necessary, at
least once every hour.
• In-line temperature Keep this within the baby’s neutral thermal
environment range.
• Oxygen concentration Whenever a baby receives oxygen therapy
with an oxygen hood, nasal CPAP, or endo-
tracheal tube and mechanical ventilator, it is
essential to adjust the inspired oxygen con-
centration according to pulse oximetry
and arterial blood gas results, and carefully
monitor the concentration so that sudden
changes do not occur.
• Continuous positive airway pressure Adjust this when the baby is quiet (not
crying). Frequent readjustments are typically
not necessary.
• Flow rate A flow rate of 8 to 12 L/min is generally
adequate.
• Alignment of nasal prongs or mask Adjust this according to the specific way in
which the prongs or mask you are using are
designed to fit in relation to the baby’s nose.
Frequently inspect the baby’s face and skin Both the securing device and the nasal
around the prongs/mask and device. prongs/mask can cause skin irritation or
Adjust the way the device is secured, to breakdown (or both). The prongs/mask can
adjust the pressure points caused by press on the baby’s nose or around it, and
securing the device to the baby’s face. some of the devices may press/rub against
the baby’s forehead.
Frequent skin checks, removing the headgear
(if possible), and alternating between nasal
prongs and mask will help maintain skin
integrity.
10. Remove the CPAP apparatus and use Preterm babies born at less than 30 weeks’
an oxygen hood to deliver the desired gestation benefit from remaining on
concentration of oxygen once the baby 4 to 5 cm H2O CPAP, even at low concentra-
requires less than approximately 35% tions of oxygen, to prevent atelectasis during
oxygen and 4 cm H2O pressure. the first week after birth.

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 Unit 4: Assisted Ventilation With
Mechanical Ventilators
Objectives.............................................................................................................................. 72
1. What is mechanical ventilation?.................................................................................. 75

UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

2. Which babies need mechanical ventilation?............................................................... 76
3. When do you start mechanical ventilation?............................................................... 76
4. What kind of mechanical ventilator should be used?................................................ 77
5. How do you set up a mechanical ventilator?.............................................................. 78
6. What initial settings are used?..................................................................................... 79
7. How do you adjust the ventilator after the baby has been connected?.................. 81
8. What are suggested ventilator adjustments for various clinical findings?.............. 82
9. What can go wrong?..................................................................................................... 85
10. What else should you do for a baby receiving mechanical ventilation?.................. 85
Tables and Figure
Table 4.1. Relative Ventilator Settings for Various Lung Conditions.............................. 80
Table 4.2. Suggested Initial Settings for Mechanical Ventilation..................................... 81
Table 4.3. Suggested Changes to Ventilator Setting........................................................ 82
Table 4.4. Goal Arterial Blood Gas Parameters.............................................................. 82
Figure 4.1. Tracing of Pressure, Flow, and Volume During a Mechanical Breath............. 75
Skill Unit: Endotracheal Tubes........................................................................................... 89

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Objectives
In this unit you will learn
A. The principles of mechanical ventilation
B. Which babies may require mechanical ventilation
C. What criteria are used for starting mechanical ventilation
D. How to set up a ventilator for babies with various types of respiratory problems
E. How to adjust ventilator settings

This unit is intended to teach only indications for, and initiation of, mechanical
ventilation, such as what might be needed for a sick baby prior to neonatal transport.
It will not address long-term management of ventilated babies or weaning of babies
from ventilators. Babies requiring mechanical ventilation for any length of time
should be treated in intensive care nurseries, where different philosophies about
ventilator management may be practiced.

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

Unit 4 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them with the answers at the end of the book.
1. Which of the following measurements cannot be adjusted independently on most
infant ventilators?
A. Peak airway pressure
B. End-expiratory pressure
C. Inspiratory time
D. Inspired oxygen concentration
E. Expiratory resistance
2. Which of the following measurements is least reliable for determining the need for
mechanical ventilation?
A. Capillary Pco2
B. Capillary Po2
C. Arterial pH level
D. Arterial Pco2
E. Arterial Po2
3. Which of the following statements is correct when determining ventilator settings
for a baby with respiratory distress syndrome when compared to a baby with normal
lung findings?
A. End-expiratory pressure should be higher.
B. Inspiratory time should be shorter.
C. Expiratory time should be longer.
D. Peak inspiratory pressure should be lower.
4. In which of the following cases is mechanical ventilation most indicated?
A. A 3,500-g (7 lb 11 oz) baby with congenital pneumonia who is breathing 50%
oxygen and has a Pao2 of 60, Paco2 of 48, and pH level of 7.28
B. A 1,500-g (3 lb 5 oz) baby with respiratory distress syndrome who is breathing
80% oxygen and has a Pao2 of 45, Paco2 of 65, and pH level of 7.28
C. A 1,000-g (2 lb 3 oz) baby with no lung disease who has an apneic spell that
responds to tactile stimulation
D. A 3,000-g (6 lb 10 oz) baby who had severe perinatal compromise and has
a Pao2 of 70, Paco2 of 25, and pH level of 7.20 while breathing 21% oxygen
5. Which of the following statements is correct when determining ventilator settings
for a term baby with meconium aspiration when compared to a preterm baby with
respiratory distress syndrome?
A. Inspiratory time should be longer.
B. Expiratory time should be shorter.
C. End-expiratory pressure should be higher.
D. Ventilatory rate should be faster.
(continued )

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 4 Pretest (continued )

6. Which of the following measurements is least likely to suggest a blocked endotra-
cheal tube?
A. Poor chest movement
B. High Paco2
C. High pH level
D. Low Pao2

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

1. What is mechanical ventilation?

Mechanical ventilation assists, and sometimes controls, the breathing of babies who cannot
move enough air with spontaneous respiration. An oxygen hood increases the concentration
of oxygen a baby breathes. Continuous positive airway pressure (CPAP) prevents the alveoli
from collapsing during exhalation, but only a mechanical ventilator provides artificial
ventilation. The baby must be intubated with an endotracheal tube (ETT) for treatment
with a mechanical ventilator.
Mechanical ventilators work by forcing a humidified oxygen/air gas mixture into an intubated
baby’s lungs at a preset flow rate, maximum pressure, and time for inspiration. At the end
of the inspiration time, the flow is stopped automatically, and the gas is allowed to escape by
either passive or active exhalation with a preset expiratory time (TE) (Figure 4.1).

Peak pressure
Pressure

Positive end-expiratory pressure

(PEEP)

Peak inspiratory flow

Flow
Volume

Peak expiratory flow

Tidal volume

Inspiratory Expiratory time

time (until next
breath)

Figure 4.1. Tracing of Pressure, Flow, and Volume During a Mechanical Breath

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2. Which babies need mechanical ventilation?

Mechanical ventilation is required for babies who cannot move enough gas in and out of their
lungs to achieve adequate oxygenation of the blood or adequate removal of carbon dioxide
from the blood (or both). Most of these babies will be in respiratory distress. (See Book 3:
Neonatal Care, Unit 2, Respiratory Distress.)
Babies may require mechanical ventilation because of primary lung disease, such as respira-
tory distress syndrome (RDS), or because of respiratory depression from generalized illness, a
congenital malformation, birth injury, or extreme prematurity. Examples include babies with
severe recurrent apnea, diaphragmatic paralysis from birth injury, or hypoventilation from
sepsis, brain hemorrhage, or some other central nervous system insult. Extremely preterm
babies have weak respiratory musculature and may need mechanical ventilation even if they
do not have clinically significant lung disease.

3. When do you start mechanical ventilation?

Mechanical ventilation is most commonly initiated when a baby demonstrates respiratory fail-
ure. Respiratory failure is defined as inadequate spontaneous ventilation, even though the
baby may be making considerable respiratory efforts. Arterial blood gas analyses are the prin-
cipal way to decide when respiratory failure occurs. Any one of the following factors indicates
that mechanical ventilation is needed:
A. Very high or rapidly increasing Pco2 level and low pH level
Babies will normally increase their breathing rate when blood carbon dioxide (Pco2)
levels begin to increase. This increased respiratory rate results in lowering the Pco2 to a
normal level. Therefore, if the Pco2 level is high, the baby is not moving enough air in
and out of functional lung tissue.
As the Pco2 level increases, the pH level decreases. Consider mechanical ventilation
when
• Pco2 is consistently higher than 60 mm Hg.
• Pco2 is consistently higher than 45 mm Hg and pH level is less than 7.25.
B. Low Pao2 level despite appropriate administration of oxygen and CPAP therapy
If lung disease becomes severe enough, the baby’s own respiratory efforts may not be
sufficient to provide adequate oxygenation. Consider mechanical ventilation if the Pao2
level is less than 45 mm Hg or if saturation levels are consistently less than 85%, with
the baby breathing 70% to 80% inspired oxygen.
Some experts believe that a baby with worsening RDS can be treated effectively by being
intubated, given surfactant, and then extubated and started on nasal CPAP.
C. Extremely preterm baby
Although controversial, some experts advise electively intubating and mechanically
ventilating extremely low-birth-weight babies (,1,000 g [,2 lb 3 oz]) or extremely
low-gestational-age babies (,26 weeks’ gestation) at birth, rather than waiting for them
to develop respiratory failure. Early, elective intubation is done to avoid acidosis and
other problems likely to develop with respiratory failure. These tiny babies are also can-
didates for surfactant therapy.

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Other experts believe that mechanical ventilation can be avoided by the early use of
nasal CPAP to establish functional residual capacity (volume of air left in the lungs
at the end of passive exhalation). Several studies have demonstrated that early use of
CPAP does not increase adverse outcomes when compared to elective intubation in the
delivery room.
D. Surfactant therapy
Intubation is typically required for surfactant administration. (See Unit 5, Surfactant
Therapy, in this book.) Many of these babies will require mechanical ventilation for a
time after surfactant is administered.
E. Absence of breathing (apnea)
If a baby has apneic spells that require repeated stimulation or bag-and-mask assistance,
mechanical ventilation may be required.

4. What kind of mechanical ventilator should be used?

Many different brands of mechanical ventilators are available. Some deliver a specific volume
of gas, whereas others deliver a specific gas flow and pressure for a specific time. This unit
will discuss only the more common pressure/flow/time-regulated ventilators. Be sure your
ventilator has the following qualities:
A. Designed for babies
Ventilators designed for adults usually do not have the fine adjustment capabilities
required for babies.
B. Infant tubing circuit
Babies’ lungs require only small volumes of gas. If the tubing that connects the ventilator
to the ETT contains a large volume of gas, this gas will be compressed with each ventila-
tor “breath.” This causes the size of the breath that enters the ETT to be far smaller than
the infant-sized breath initially produced by the ventilator. Therefore, the tubing should
contain a small volume of gas (diameter ,2 cm) and be nondistensible.
C. Heated humidifier with thermostat control in the circuit
Ventilator gas should be heated to between 34.0°C and 36.0°C (93.2°F and 96.8°F)
and humidified to greater than 90%. This prevents lung injury secondary to cold air and
inhibits excessive evaporative losses from the respiratory system due to dry air.
D. Oxygen concentration adjustable from 21% to 100%
Blended oxygen (a concentration of oxygen mixed with air that can be varied between
21% and 100%) is required. Many studies have demonstrated that too much oxygen
(resulting in hyperoxia) has many adverse effects on the newborn. Adjusting the oxygen
concentration to keep oxygen saturation levels between 90% and 95% is suggested.

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Self-test A
Now answer these questions to test yourself on the information in the last section.
A1. Most infant ventilators work by
A. Delivering a preset volume into the lungs
B. Delivering a preset pressure for a preset time
A2. List 3 examples of babies who may require mechanical ventilation because of poor respiratory
muscle function.
________________________________________________________________________________________
________________________________________________________________________________________
A3. Respiratory failure requiring mechanical ventilation is indicated by
High ___________________________________________________________________________________
Low ___________________________________________________________________________________
Low ___________________________________________________________________________________
A4. Infant ventilator tubing circuits should have the following characteristics:
________________________________________________________________________________________
________________________________________________________________________________________
A5. True False Respiratory failure refers only to babies who stop breathing completely.
A6. List 2 indications for mechanical ventilation other than respiratory failure or severe apnea.
________________________________________________________________________________________
________________________________________________________________________________________

Check your answers with the list near the end of this unit. Correct any incorrect answers and review
the appropriate section in the unit.

5. How do you set up a mechanical ventilator?

The objective of mechanical ventilation is simple: to move air and oxygen sufficiently to nor-
malize arterial blood gases. The method of achieving this will depend on the type of disease
being treated. The following ventilator settings will need to be adjusted:
• Peak inspiratory pressure (PIP): This is the maximum pressure that the ventilator reaches to
force gas into the lungs. If the pressure is too low, gas movement will be inadequate; if it is
too high, the lungs can be damaged, and a pneumothorax can result.
• Positive end-expiratory pressure (PEEP): This is the pressure at the end of expiration and is
identical to CPAP. If the expiratory pressure is too low, the alveoli may collapse (in babies
with poor lung compliance); if it is too high, expiration will be restricted, and gas movement
will be inadequate.
• Inspiratory time (TI): This is the time during which the ventilator delivers its inflation pres-
sure. If TI is too short, the PIP will not reach the alveoli, and gas movement and lung infla-
tion will be inadequate; if TI is too long, exhalation will be inadequate. Prolonged TI will
also restrict lung blood flow as a result of compression of lung blood vessels by distended
alveoli.

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• Expiratory time (TE): This is the time during which the baby passively exhales. If TE is too
short, expiration will be insufficient, and gas will be trapped in the lungs, possibly causing
lung damage and a pneumothorax. With most ventilators, TE cannot be set independently
but is determined by TI and the ventilatory rate. Expiratory time is calculated with the
following formula:
TE 5 (60/rate) 2 TI
For example, a ventilator for a baby with RDS is set for a TI of 0.3 seconds and ventilatory
rate of 45.
TE 5 (60/45) 2 0.3
TE 5 11∕3 2 0.3
TE 5 1.0 second
• Ventilatory rate: The ventilatory rate or breaths per minute is determined by the lengths of
TE and TI. Most ventilators have a separate knob that allows adjustment of the ventilatory
rate. This knob works by changing the length of TE. Thus, you set only the TI and ventilatory
rate. If the ventilatory rate is too low or very high, gas movement will be inadequate. If the
ventilatory rate is slightly high, gas movement will be excessive, and Paco2 will be too low.
• Inspired oxygen concentration (Fio2): This should be adjusted from 21% to 100%, as
determined by oxygen saturation or arterial blood gas values (or both), which is outlined
in Book 3: Neonatal Care, Unit 1, Oxygen.
• Flow rate: This is the speed at which the ventilator delivers a breath. If flow rate is too low, it
may not be possible for the ventilator to reach the desired PIP; if too high, the lungs may be
damaged. For most babies, regardless of illness, approximately 8 L/min will be adequate. If
very high PIP or very fast ventilatory rates are required, a higher flow rate may be necessary.
Many of the newer ventilators do not have a separate setting for flow rate, because the flow
rate adjusts electronically depending on the ventilation pattern selected.
• Mean airway pressure (MAP): MAP is the average pressure in the airway throughout the
respiratory cycle. It is a function of PIP, PEEP, TI, ventilatory rate, and flow rate settings. It is
not independently adjustable on most ventilators but will change when any one of the other
settings is increased or decreased. The MAP value is displayed on most infant ventilators.
Along with Fio2, MAP is important in determining a baby’s oxygenation level. In addition to
Fio2, adjustments in MAP may also be used to achieve an acceptable Pao2 level.

6. What initial settings are used?

If you decide mechanical ventilation is indicated, you should first stabilize the baby by assist-
ing ventilation with bag or T-piece resuscitator and ETT breathing. During this time, the ETT
should be secured in place (see the skill unit of this chapter; for ETT placement, see Book 1:
Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the
Newborn) and the ventilator should be set up at the bedside.
Set the PIP, PEEP, TI, ventilatory rate, flow rate, and Fio2 before the baby is connected. Test
these settings by occluding the opening of the connector, which will later be attached to the
baby’s ETT. Finer adjustments will be required after the baby is connected to the ventilator.
If a manometer is included in your bag-breathing system (see Book 1: Maternal and Fetal
Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn, Skill Unit:
Free-Flow Oxygen and Positive-Pressure Ventilation), the ventilator PIP and ventilatory rate

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may be set to match the most effective bag ventilation; therefore, note the maximum pressure
and rate at which you are bag breathing for the baby or match the settings being used with
the T-piece resuscitator.
It is also important that you consider the disease process when deciding on initial settings.
Table 4.1 illustrates the relative settings for various conditions, and suggested initial settings
are shown in Table 4.2.

Table 4.1. Relative Ventilator Settings for Various Lung Conditions

Parameter Relative Ventilator Setting
Normal Lung Findings (eg, Apnea With no Lung Disease)
PIP Low
PEEP Low
TI Short
TE Long
Ventilatory rate Slow
Fio2 Usually 21% (room air)
Airway Disease (eg, Meconium Aspiration)
PIP High
PEEP Low
TI Short
TE Long
Ventilatory rate Relatively fast
Fio2 Equal to Fio2 before mechanical ventilation and
adjust to oxygen saturation as measured with
pulse oximetry
Alveolar Disease (eg, Respiratory Distress Syndrome or Pneumonia)
PIP High
PEEP High
TI Long (but not longer than TE)
TE Short
Ventilatory rate Relatively slow
Fio2 Equal to Fio2 before mechanical ventilation and
adjust to oxygen saturation as measured with
pulse oximetry
Abbreviations: Fio2, inspired oxygen concentration; PEEP, positive end-expiratory pressure; PIP, peak inspiratory pressure;
TE, expiratory time; TI, inspiratory time.

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Table 4.2. Suggested Initial Settings for Mechanical Ventilation

Ventilatory
PIP PEEP Rate Flow Ratea
Lung State (cm H2O) (cm H2O) TI (sec) (breaths/min) Fio2 (%) (L/min)
Alveolar disease 25 4–5 0.4 40 Individualizeb 8–10
(eg, respiratory
distress syndrome,
pneumonia)
Airway disease 18–22 3–4 0.3–0.4 60 Individualizeb 8–10
(eg, aspiration)
Normal lung 12 2 0.3 30 Individualizeb 8–10
findings (eg, apnea)
Abbreviations: Fio2, inspired oxygen concentration; PEEP, positive end-expiratory pressure; PIP, peak inspiratory pressure;
TI, inspiratory time.
a
Determined automatically by most new ventilators.
b
Individualize Fio2 depending on Fio2 before mechanical ventilation and results of pulse oximetry or arterial blood gas determinations
(or both).

Some babies will have a combination of problems and will require settings between 2 catego-
ries. For example, an extremely low-birth-weight baby (,1,000 g [,2 lb 3 oz]) may have only
mild RDS but may require mechanical ventilation because of very weak respiratory muscles.
Although the baby has RDS, much lower peak pressure and PEEP will probably be required
than if the baby were bigger or had more severe lung disease (or both). Many experts are
advising short TI and rapid ventilatory rates while using lower PIP to potentially decrease
barotrauma to the lungs of extremely low-birth-weight babies.

7. How do you adjust the ventilator after the baby has

been connected?
After the ventilator has been connected to the baby, the peak pressure and PEEP may
be slightly lower than you had set them earlier. These lower values often result once the
baby is connected to the ventilatory system because additional volume is being added to the
circuit, which causes the pressures and flow to be distributed over a greater area than when
the ventilator settings were initially chosen with either an artificial lung or a capped circuit.
Before changing any settings, evaluate chest movement, skin color, oximetry, and blood gases
if available.
Table 4.3 suggests several possible actions for various abnormal findings. Which action you
choose will depend on the initial settings of the ventilator, the disease you are treating, and the
severity of disease.

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Table 4.3. Suggested Changes to Ventilator Setting

Pao2 Paco2 PIP PEEP Ventilatory Rate
Low Low ↑
Low High ↑
High Low ↓
High High ↓
Normal High ↑
Normal Low ↓
Abbreviations: PEEP, positive end-expiratory pressure; PIP, peak inspiratory pressure.

Any ventilator change you make to correct one variable (eg, Pao2) is likely to affect another
variable (eg, Paco2). Use continuous pulse oximetry and perform an arterial blood gas analy-
sis approximately 20 to 30 minutes after making any significant change to a ventilator setting
(Table 4.4). It is generally recommended that you make only one ventilator change at a time.
Making more than one change simultaneously is likely to confuse what it was that caused the
response in the baby’s ventilation.

Table 4.4. Goal Arterial Blood Gas Parametersa

Parameter Preterm Baby Term Infant
pH level 7.25–7.35 7.30–7.40
Paco2 (mm Hg) 45–55 40–50
Pao2 (mm Hg) 45–55 50–70
a
In venous and capillary blood gas values, Po2 is not reliable; pH level is typically lower than the arterial value,
and Paco2 is typically higher than the arterial value. However, in babies with poor perfusion to the upper or lower
extremities, neither venous nor capillary blood gas values should be used.

8. What are suggested ventilator adjustments for various

clinical findings?

If the baby’s condition changes, assess the baby and the functioning of
the ventilator.

A. To check the ventilator, consider

• Is the proper Fio2 being delivered?
• Is the tubing loose or disconnected?
• Does the pressure reach the preset PIP with each breath?
• Does the pressure fall to the preset PEEP between each breath?
• Have the TI, TE, or ventilatory rate settings been unintentionally changed?

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B. To check the baby, consider the following:

Chest Movement • Rises and Falls With Each Breath

No change
• Moves Little to Not at All
– Check ETT placement.
– Check for blocked ETT (suction).
– Increase PIP.
– Decrease PEEP.
– Increase TI.
• Moves Too Much
– Decrease PIP.
– Decrease TI.

Skin Color • Pink and Well Perfused

No change
• Blue
– Increase Fio2 (guided by oximetry values).
– Check ETT placement.
– Check for blocked ETT (suction).
– If sudden cyanosis, check for pneumothorax.
– Increase MAP.
• Pale and Mottled
– Decrease PEEP.
– Increase TE.
– Check for pneumothorax.
– Consider nonrespiratory etiology.
(continued)

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Arterial Blood Gases • Pao2, Paco2, and pH Levels Normal

No change
• Pao2 Low (,40 mm Hg)
– Increase Fio2 (guided by pulse oximetry).
– Check ETT placement.
– Check for blocked ETT (suction).
– Increase MAP. (See note.)
• Pao2 High (.80 mm Hg)
– Decrease Fio2.
– Decrease MAP. (See note.)
• Paco2 High (.50 mm Hg) or pH Level Low
(,7.25) (or Both)
– Check ETT placement.
– Check for blocked ETT (suction).
– If sudden change, check for pneumothorax
– Increase PIP.
– Decrease PEEP.
– Increase rate.
– Decrease TI.
• Paco2 Low (,35 mm Hg) or pH Level High
(.7.45) (or Both)
– Decrease PIP.
– Decrease ventilatory rate.

Note: If a ventilator adjustment is being made in response to an unacceptable Paco2 level, but
the baby has a normal Pao2 level, keep the MAP constant by adjusting one of the other
settings that also affects MAP. (See section 5.) If the Pao2 level is too low or too high,
adjust the Fio2 first and then consider adjusting the MAP, usually by adjusting the PEEP
or PIP.

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9. What can go wrong?

If it is anticipated that mechanical ventilation will be required for longer than a few hours, the
baby should be transferred to an intensive care nursery.

Mechanical ventilation of babies is an invasive, potentially dangerous therapy that

requires constant attendance by an experienced team.

Possible complications
• Air leaks: If the baby’s condition suddenly deteriorates, pneumothorax should be suspected
immediately. A thoracentesis or the insertion of a chest tube may be lifesaving. Air leaks into
the lung tissue, pericardium, or mediastinum can also occur and are detectable on a chest
radiograph. Refer to Book 3: Neonatal Care, Unit 2, Respiratory Distress, for the procedure
of needle thoracentesis and/or placing a chest tube.
• Blocked or displaced endotracheal tube: If the ETT becomes dislodged from the trachea
or blocked with mucus, the ventilator will continue to cycle, but the baby’s vital signs will
deteriorate. Suction the ETT and attempt to ventilate the baby with a resuscitation bag
connected to the ETT. Check breath sounds and chest movements. Check the return of CO2
with a colorimetric CO2 detector. Check the depth of insertion of the ETT by using the
numerical markings on the side of the tube (see Book 1: Maternal and Fetal Evaluation and
Immediate Newborn Care, Unit 5, Resuscitating the Newborn, for ETT placement). It may
have inadvertently moved out of appropriate position. If there is no improvement in the
baby’s condition, remove the ETT and assist the baby’s ventilation with bag and mask or
T-piece resuscitator until a new ETT can be inserted.
• Endotracheal tube slips in too far: If the tube slips in too far, it may enter the airway of one
lung and block air entry to the other lung. In this case, breath sounds will be unequal when
you listen with a stethoscope over the right and left lateral chest. In addition, one side of the
chest may rise more than the other. Check the depth of insertion of the ETT. If the tube is in
too deep, pull the tube back slightly as you use a stethoscope to listen for improved breath
sounds.
• Disconnected or malfunctioning ventilator: Most ventilators are equipped with alarms that
will sound if the tubing becomes disconnected. Even without an alarm, a tubing or power
disconnection can be detected because the airway pressure gauge will not rise normally with
each breath.

If a ventilator malfunctions, don’t panic! Simply connect a resuscitation bag or

T-piece resuscitator to the endotracheal tube and assist the baby’s ventilation until
the problem can be identified and corrected.

10. W
 hat else should you do for a baby receiving mechanical
ventilation?
All babies receiving mechanical ventilation should have continuous electronic cardiac and
pulse oximetry monitoring and experienced staff in constant attendance. Complete resuscita-
tion equipment should be kept at the bedside.
Remember that continued monitoring for other risk factors (eg, hypoglycemia, hypothermia)
is essential to the baby’s total care. These more routine activities should not get lost because a
baby is receiving sophisticated respiratory support.

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Self-test B
Now answer these questions to test yourself on the information in the last section.
B1. List 5 controls that require adjustment on most infant ventilators.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
B2. Circle the appropriate ventilator setting for each of the 3 lung conditions.
Alveolar Disease Airway Disease Normal Lung
Findings
Peak inspiratory pressure High/Low High/Low High/Low
Positive end-expiratory pressure High/Low High/Low High/Low
Inspiratory time Long/Short Long/Short Long/Short
Expiratory time Long/Short Long/Short Long/Short
Ventilatory rate Slow/Fast Slow/Fast Slow/Fast
B3. List 3 observations or findings to consider before adjusting a ventilator.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
B4. List 4 common complications of mechanical ventilation.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Check your answers with the list on the next page. Correct any incorrect answers and review the
appropriate section in the unit.

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Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.

Self-test A
A1. B. Delivering a preset pressure for a preset time
A2. Any 3 of the following examples:
• Severe generalized illness
• Birth injury causing diaphragmatic paralysis
• Hypoventilation from sepsis, brain hemorrhage, or some other central nervous
system insult
• Extreme prematurity
A3. Paco2
Pao2
pH level
A4. Contain a small volume of gas (tubing diameter #2 cm).
Be nondistensible.
A5. False.  Reason: Babies who have inadequate ventilation despite spontaneous respirations
are also in respiratory failure.
A6. Extreme prematurity (birth weight less than approximately 1,000 g [2 lb 3 oz])
Surfactant therapy
Self-test B
B1. Peak inspiratory pressure (PIP)
Positive end-expiratory pressure (PEEP)
Inspiratory time (TI)
Ventilatory rate
Oxygen concentration
B2. Alveolar Disease Airway Disease Normal Lung Findings
Peak inspiratory pressure High High Low
Positive end-expiratory pressure High Low Low
Inspiratory time Long Short Short
Expiratory time Short Long Long
Ventilatory rate Slow Fast Slow
B3. Any 3 of the following observations:
• Chest movement
• Skin color
• Breath sounds that are equal or unequal
• Arterial blood gases
• Percentage of oxygen saturation
B4. Air leaks, such as a pneumothorax
Blocked or displaced endotracheal tube
Endotracheal tube that slips in too far
Disconnected or malfunctioning ventilator

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Unit 4 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf file
and save it to print later or come back to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

SKILL UNIT

Endotracheal Tubes
This skill unit will teach you how to secure an endotracheal tube and how to suction it. Both
of the skills described in this unit are to be performed by teams of 2 people.
Not everyone will be required to learn and practice these skills; however, all staff members
should read this unit and attend a skill session to learn the equipment and sequence of steps
so they can assist with these skills. A video of endotracheal tube insertion may be viewed at
https://www.youtube.com/watch?v=lGTaA_UdIXw.
The staff members who will be asked to master all aspects of this skill will need to demon-
strate correctly each of the following steps:
Securing an Endotracheal Tube
Tape Method (used for relatively short duration intubations)

SKILL UNIT: ENDOTRACHEAL TUBES

1. Cut and split 2 strips of adhesive tape.
2. Hold the endotracheal tube at the proper level.
3. Place one strip of tape on the baby’s (mannequin’s) upper lip and wrap the loose end around
the tube.
4. Tape the other strip in the reverse direction and wrap it around the tube.
5. Listen to the baby (mannequin) to recheck correct tube placement.

Commercial Stabilizer Method (for intubations of longer duration) (Use the brand stocked in
your hospital.)
1. Select the appropriately sized stabilizer for the tube.
2. Hold the endotracheal tube at the proper level.
3. Secure the stabilizer to the baby’s (mannequin’s) face.
4. Properly secure the tube into the stabilizer and lock it in place.
5. Listen to the baby (mannequin) to recheck correct tube placement.

Suctioning an Endotracheal Tube

1. Collect the appropriate equipment and suction catheters for the tube and baby to be
suctioned.
2. Adjust the suction pressure.
3. Determine the length of suction catheter to be inserted.
4. If not using an in-line device, bag-breathe for the baby by using the appropriate pressure
and respiratory rate, before and after suctioning.
5. Suction the baby’s endotracheal tube.
6. Monitor the baby’s response and oxygen saturation level; adjust the inspired oxygen
concentration as necessary.
7. Suction the baby’s mouth.
8. Readjust the baby’s inspired oxygen concentration, if it had been increased.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

PERINATAL PERFORMANCE GUIDE

Managing Endotracheal Tubes

In Book 1: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating
the Newborn, you learned how to insert and check for proper placement of an endotracheal
tube. You also learned how to secure the tube in place with adhesive tape. If you anticipate
that the endotracheal tube will be required for longer than several hours (ie, for a baby that
requires mechanical ventilation), the tube should be fixed in place more securely than with
tape alone. Be sure the baby is being adequately ventilated and that an assistant is holding the
tube in place while it is being secured.

Securing and suctioning an endotracheal tube are 2-person procedures.

Two different methods for long-term stabilization of an endotracheal tube are described. The
first method uses materials generally available in most hospitals. The second method requires
the purchase of a commercial stabilizer.

ACTIONS REMARKS

Securing an Endotracheal Tube Without a Commercial Stabilizer

1. After inserting the endotracheal tube (ETT) Continue to ventilate the baby while
(see Book 1: Maternal and Fetal Evalua- someone else secures the tube in place. Hold
tion and Immediate Newborn Care, Unit 5, the tube firmly against the palate with your
Resuscitating the Newborn), confirm cor- index finger until it is secure.
rect placement by attaching a CO2 detec-
tor, and look for a detector color change
with each exhalation. Also, listen over the
chest for equal breath sounds on each side,
and listen over the baby’s stomach for
absence of breath sounds.
CO2 detector

Reproduced with permission from American Academy of Pediatrics, American

Heart Association. Weiner GM, ed. Textbook of Neonatal Resuscitation. 7th ed.
American Academy of Pediatrics; 2016.

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

ACTIONS REMARKS

Securing an Endotracheal Tube Without a Commercial Stabilizer (continued)

2. Thoroughly dry the skin around the
baby’s mouth.
3. Secure the tube in place with tape. Some hospitals prefer to use a commercially
available ETT stabilizer (see next section).
• Place a strip of clear adhesive dressing
between the baby’s nose and upper lip.
• Cut 2 pieces of 1/2-inch (1-cm) adhesive
tape 4 in (10 cm) long.
• Split each piece for half its length.
• Stick the unsplit section of the tape
and one tab across the baby’s upper lip
(on top of the clear adhesive dressing).
• Wrap the other tab in a spiral around
the ETT.
• Place the second piece of tape in reverse
direction.

• Listen with a stethoscope for breath

sounds over both sides of the chest, and
over the stomach. You should hear dis-
tinct breath sounds over both lungs and
no, or soft, distant sounds over the stom-
ach. Listen again after taping to be sure
the tube has not been displaced.

Reproduced with permission from American Academy of Pediatrics, American

Heart Association. Weiner GM, ed. Textbook of Neonatal Resuscitation. 8th ed.
American Academy of Pediatrics; 2021.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Securing an Endotracheal Tube With a Commercial Stabilizer

1. Be sure the stabilizer fits the brand of ETT This skill describes 2 brands of stabilizers.
being used. Others are available. Follow the directions
supplied by the manufacturer of the brand
used in your hospital.
NEO-fit Neonatal Endotracheal Grip

From https://www.coopersurgical.com/medical-devices/detail/neo-fit-neonatal-endotracheal-tube-grip

2. Collect the necessary equipment and Holders are manufactured to fit tubes of
supplies. various sizes but are not made for use with
• Plastic tube grip with adjustable hook 2.0-mm or smaller ETTs.
and loop strap
• Foam foot pads
• Foam “lollipop” securing tapes
3. If the tube was previously taped, remove Note the markings on the tube at the level of
the tape and ask an assistant to hold the the baby’s lip. Be sure the tube is held at this
tube in place. position.
4. Trial-fit the NEO-fit on the patient The ETT should be located near the center
prior to removing the adhesive liner. of the baby’s mouth.
Pectin-based skin prep may minimize
skin damage.
5. Remove the adhesive liners from the
bottom of the adhesive pads.
6. Affix the adhesive pads to the patient
adjacent to the ETT above the upper lip.

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

ACTIONS REMARKS

Securing an Endotracheal Tube With a Commercial Stabilizer (continued)

7. Wrap the tube holder strap snugly around Do not wrap too tightly, as this could
the ETT by pulling from the end of the obstruct the ETT and prevent appropriate
strap. suctioning.
8. Secure the strap by using the hook-and- Note the ETT marking just above the
loop material of the strap. If needed, stabilizer for easier identification, if
secure by using lollipop foam adhesive adjustments are needed.
tape or other tape as needed.
NeoBar Endotracheal Tube Stabilizer

From https://www.neotechproducts.com/product/neobar/.

1. Collect the necessary equipment and The following instructions are a summary of
supplies. the instructions supplied by the manufacturer.
• ETT holder of the correct size to match Be sure to read the manufacturer’s full
the ETT being used instructions before use.
• Measuring tape that comes with the
NeoBar
2. Use the NeoBar tape to measure from the • Use the measuring tape that comes with
midline at the nasal septum to the opening the NeoBar to determine which size bar
of the ear canal. to use.
• The corresponding color on the tape that
falls over the opening of the ear canal cor-
responds to the NeoBar size for the baby. If
the size borders 2 colors, use the larger size.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Securing an Endotracheal Tube With a Commercial Stabilizer (continued)

3. Prepare the hydrocolloid tabs by warming
them. Hold the tabs in your hands for
60 seconds or under radiant heat.
4. Pull off the covering on the tabs and secure
the tabs onto the bony prominence in front
of both ears (the far side of the cheek).
5. Position the NeoBar across the center of
the mouth between the upper and lower
lip, without touching the lips.
6. Tape the ETT to the NeoBar. Begin by
wrapping 1/2-in (1-cm) cloth tape around
the arch of the NeoBar and then bring the Change the NeoBar every 5 to 7 days, or
ETT to the platform (center arch) and when clinically indicated. Slowly peel back
wrap the tape around both. the tabs as you saturate them with water or
saline. For emergency removal, carefully cut
the thin portion of the NeoBar with blunt
scissors, at the junction of the bar and tab.

Checking/Changing the Endotracheal Tube Position

1. Obtain a portable chest radiograph to The tube tip should be visible on a radio-
check for tube placement. graph, just below the level of the clavicles
and 1 to 2 cm (0.4–0.8 in) above the carina
(the point where the mainstem bronchi
branch from the trachea).
2. Adjust the tube position (farther out or in), • NEO-fit: The tube may be adjusted by
if necessary. simply unwrapping it, sliding the tube the
• Tape method: Remove the adhesive tape. desired distance, and then rewrapping the
Hold the tube in place as it is strap. If the ETT needs to be re-placed,
being re-taped in the new position. you will usually need to remove and
re-place the stabilizer too.
• Commercial device: Follow the instruc-
tions appropriate for each device. • NeoBar: Untape the tube, adjust, and
re-tape.
3. Check to be sure the tube has not slipped
since the radiograph was obtained.
• Watch to see if the baby’s chest is
moving symmetrically.
• Listen to both sides of the chest for equal
breath sounds and over the stomach to be
sure the tube is not in the esophagus.
• If in doubt, insert a CO2 detector or
check the position with a laryngoscope
and obtain another chest radiograph.

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

ACTIONS REMARKS

Suctioning an Endotracheal Tube

1. Collect the necessary equipment and
supplies.
• Appropriately sized suction catheter Suction catheter sizes for various sizes of
• Sterile gloves ETTs:
• 1/2 mL sterile saline Endotracheal Tube Suction
Inner Diameter Catheter Size
• Suction source and tubing
2.5 mm 5F or 6F
• Resuscitation bag with pressure
manometer 3.0 mm 5F or 6F
3.5 mm 6F or 8F
4.0 mm 6F, 8F, or 10F
If secretions are thin, select a small catheter
to decrease the chances of collapsing the lung
during suctioning. If secretions are thick,
select the largest possible catheter.
2. The ETT may need to be suctioned An ETT bypasses the baby’s normal mecha-
periodically to be sure it is clear for nism to clear the lungs of mucus and debris.
maximum airflow.
ETT suctioning should not be done Listen to the baby’s chest with a stethoscope.
routinely, but only as needed to clear If coarse rhonchi are heard instead of clear
secretions. breath sounds or if the baby has increased
distress or an increasing oxygen requirement,
the baby’s ETT may need suctioning.
3. Monitor the baby’s oximetry and adjust Suctioning is stressful for a baby and can
the inspired oxygen concentration as cause the blood oxygen concentration to fall
necessary. temporarily. It is important for you to mini-
mize the degree and duration of that drop.
4. Completely occlude the suction source.
Adjust the vacuum to approximately
60 to 80 mm Hg.
5. Connect the hub of an appropriately sized Leave the rest of the catheter within the
catheter to the tubing from the suction sterile package.
source.
6. Put on a pair of sterile gloves and remove Suctioning should be performed as a sterile
the suction catheter from its package. procedure.
7. Estimate the length of the ETT and hold Except in unusual circumstances, the purpose
the suction catheter that distance from the of the suction catheter is only to clear the
tip of the catheter. ETT itself of mucus. If the catheter is repeat-
edly permitted to extend significantly beyond
the tip of the ETT, the tracheal mucosa can
be damaged.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

ACTIONS REMARKS

Suctioning an Endotracheal Tube (continued)

Some catheters are made with centimeter
marks printed on the catheter. If the ETT
also has centimeter marks, the depth of
suctioning can be judged by matching the
catheter and ETT markings.
8. Have an assistant disconnect the ETT from Suctioning is a 2-person procedure.
the bag or ventilator.

9. Quickly insert the suction catheter only to Stimulation from the catheter tip will proba-
the measured distance. Begin suctioning by bly cause the baby to cough. Avoid excessive
occluding the thumbhole on the catheter stimulation.
and continue suctioning as the catheter is If the baby’s heart rate falls significantly, the
withdrawn. baby turns blue, or the oxygenation level
drops dramatically, stop the procedure
and assist the baby’s ventilation with a
resuscitation bag and appropriate oxygen.
10. Do not insert the catheter too far. The trachea can be damaged or even perfo-
rated by suctioning that is too vigorous.
11. The assistant should connect the resusci- Suctioning may cause some collapse of lung
tation bag and deliver several breaths at segments, which need to be reinflated after
slightly higher pressures than the baby the procedure.
was receiving prior to suctioning.
12. If significant amounts of material If the suctioned material is thick, consider
(eg, mucus, meconium) are retrieved by instilling 1/2 mL of sterile physiological
suctioning, repeat steps 8 through 11 (normal) saline down the ETT.
once the baby’s oxygenation level
is stable again.
13. Gently suction the baby’s mouth to clear To avoid contamination of the baby’s airway,
it of any saliva or mucus. always suction the mouth after the trachea
has been suctioned.

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 UNIT 4: ASSISTED VENTILATION WITH MECHANICAL VENTILATORS

ACTIONS REMARKS

Suctioning an Endotracheal Tube (continued)

14. Return the baby’s inflation pressure and
inspired oxygen concentration to the
pre-suctioning levels.
15. Reconnect the baby to the ventilator or
continue bag breathing for the baby.
In-line Suction
• In-line suction (eg, the Ballard Suction device) is a suction system that remains attached to
the ETT at all times. Follow the manufacturer’s instructions for use.
• This allows for repeated sterile suction without preparing a sterile field or the use of sterile
gloves.
• It also reduces the risk of exposure of the caregiver to respiratory secretions.
• Post a sign at the bedside of the baby, giving the safe depth of catheter insertion.
• Replace the in-line suction when it becomes visibly soiled or the number markings have
worn off.

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 Unit 5: Surfactant Therapy
Objectives.............................................................................................................................100
1. What is surfactant?......................................................................................................102
2. When is surfactant made during fetal development?...............................................102
3. What is surfactant deficiency?....................................................................................103
4. How can surfactant deficiency be treated?................................................................104
5. Does maternal steroid administration affect neonatal respiratory
distress syndrome and the need for surfactant therapy?.........................................104
6. Are all surfactant preparations the same?.................................................................104
7. How is surfactant administered?................................................................................106

UNIT 5: SURFACTANT THERAPY

8. Which babies should be treated and when?..............................................................107
9. How often should you administer surfactant?..........................................................108
10. What are the recognized complications of surfactant therapy?..............................108
11. Should surfactant always be administered in an intensive care facility?...............109
Figures
Figure 5.1. Normal and Collapsed Alveoli.................................................................... 102
Figure 5.2. Fetal Lung Development.............................................................................. 103
Skill Unit: Surfactant Administration...............................................................................113

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Objectives
In this unit you will learn
A. The nature of surfactant deficiency
B. How surfactant deficiency is treated
C. Which babies are likely to benefit from surfactant therapy
D. The recognized complications of administering surfactant
E. The general considerations for administration of commercial preparations of surfactant

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 UNIT 5: SURFACTANT THERAPY

Unit 5 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them with the answers at the end of the book.
1. Which of the following statements about natural surfactant is accurate?
A. Contains phospholipids and proteins
B. Raises surface tension in the alveoli
C. Prevents alveolar collapse during inspiration
D. Is manufactured in the liver
2. Which of the following statements best describes the action of natural surfactant
when it is injected through an endotracheal tube?
A. Spreads very slowly to the lower airways
B. Is mostly absorbed into the pulmonary circulation and degraded by the liver
C. Will have a direct effect on alveolar stability
D. Is most commonly administered as a powder
3. Which of the following statements about surfactant deficiency is accurate?
A. It is the cause of respiratory distress syndrome.
B. Incidence increases with increasing gestational age.
C. It can be treated with intravenous surfactant.
D. It is only seen in preterm babies.
4. Which of the following babies is at lowest risk for developing respiratory distress
syndrome?
A. Baby was born at 29 weeks’ gestation.
B. Mother has diabetes mellitus.
C. Baby is infected with group B b-hemolytic streptococcus.
D. Mother is infected with HIV.
5. Preterm babies who have been stressed in utero have a__________ incidence of
respiratory distress syndrome.
A. Higher
B. Lower
6. Which of the following methods of surfactant administration is appropriate?
A. Bolus instillation into the trachea
B. Intravenous drip
C. Intratracheal drip
D. All of the above
7. True False All commercial surfactants contain the same components.
8. True False Betamethasone or dexamethasone administered to a pregnant
woman, plus surfactant administered to the preterm baby, is more
beneficial than surfactant administered alone.
9. True False By 32 weeks’ gestation, approximately 60% of fetuses are producing
adequate surfactant to prevent respiratory distress syndrome.
10. True False All surfactant components are produced by the lung at the same time
during gestation.
11. True False Studies have shown that the earlier surfactant is used, the more
effective it is.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

1. What is surfactant?
Surfactant is a complex of substances (phospholipids and proteins) that are essential to normal
lung function. The substances are produced by special cells in the lining of the alveoli and
are then secreted onto the surface of the alveoli. The surfactant components work together to
alter the surface tension at the air-liquid interface, so that the alveoli will remain open and not
collapse completely during exhalation (Figure 5.1).

Normal Collapsed
alveoli alveoli

Figure 5.1. Normal and Collapsed Alveoli

2. When is surfactant made during fetal development?

The various components of the surfactant complex are produced at different stages of fetal
development (Figure 5.2). All components are necessary for normal physiological function of
the complex, but all are not produced and secreted until midway through the third trimester.
By 32 weeks’ gestation, approximately 60% of fetuses will have adequate surfactant for
normal extrauterine respiration.
The surfactant that is secreted into alveoli also appears in the amniotic fluid because of fetal
respiration and a net efflux of lung fluid. The presence of surfactant or, more specifically,
its components (eg, lamellar body count, lecithin, phosphatidylglycerol) as a sign of fetal
lung maturity can be measured from an amniotic fluid sample obtained via amniocentesis.
(See Book 1: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 2, Fetal Age,
Growth, and Maturity.) The lamellar body count is the test generally used for assessing fetal
lung maturity in the United States. Lamellar body counts are a direct measurement of
surfactant production by type II pneumocytes.

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 UNIT 5: SURFACTANT THERAPY

Embryonic period Fetal period

Alveolar

Saccular

Canalicular

Birth
Pseudoglandular

Embryonic Surfactant

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Weeks

Gener- 0 2 4 6 8 10 12 14 16 17 18 19 20 21 22 23
ations
Bronchi Bronchioles Terminal Respiratory Alveolar ducts Alveolar
bronchioles bronchioles sac

Conducting zone Transitional and respiratory zones

Figure 5.2. Fetal Lung Development

Based on University of Fribourg, University of Lausanne, University of Bern. Respiration tract. Phases of lung development. In: Human Embryology: Organogenesis.
http://www.embryology.ch/anglais/rrespiratory/phasen01.html. Accessed April 24, 2020.

3. What is surfactant deficiency?

Without adequate surfactant, alveoli will collapse during exhalation, causing the development
of respiratory distress syndrome (RDS) in the baby. (See Book 3: Neonatal Care, Unit 2, Respi-
ratory Distress.) Factors that increase the risk of surfactant deficiency include
A. Preterm birth: All surfactant components have not yet been produced by the lung. The
more preterm a baby is, the greater the risk of RDS.
B. Maternal diabetes mellitus: Excess insulin produced by the fetus in response to high
maternal blood glucose inhibits surfactant production. (See Book 1: Maternal and Fetal
Evaluation and Immediate Newborn Care, Unit 2, Fetal Age, Growth, and Maturity.)
C. Pneumonia: Inflammation of the lung causes leakage of serum proteins into the alveoli;
these proteins inhibit surfactant function.
D. Aspiration syndrome: Foreign substances such as meconium, blood, or amniotic fluid
aspirated into the alveoli may inactivate surfactant.
Conversely, preterm babies who have had a moderate amount of stress in utero (eg, fetal
growth restriction due to placental insufficiency) may have a decreased incidence of RDS
because the stress may stimulate natural surfactant production.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

4. How can surfactant deficiency be treated?

Surfactant deficiency in newborns can be treated by the administration of surfactant to the
airways of the lung; several liquid surfactant preparations are available commercially. Because
of its tendency to spread rapidly, surfactant placed in the trachea will move quickly through-
out the airways of the lungs to have a direct effect on maintaining alveolar stability. In addi-
tion, the administered surfactant will eventually be absorbed by the lungs and re-secreted as
natural surfactant.

5. Does maternal steroid administration affect neonatal respiratory

distress syndrome and the need for surfactant therapy?
Administration of steroids (betamethasone or dexamethasone) to the pregnant woman prior
to delivery will stimulate fetal surfactant production and secretion, thus decreasing the chance
of a preterm baby developing RDS. If RDS is present, however, surfactant therapy acts addi-
tively with antenatal corticosteroids to reduce the severity of RDS. See Book 1: Maternal and
Fetal Evaluation and Immediate Newborn Care, Unit 2, Fetal Age, Growth, and Maturity, and
Book 2: Maternal and Fetal Care, Unit 9, Preterm Labor, for more information and recom-
mendations about the antenatal administration of steroids.

6. Are all surfactant preparations the same?

No. The surfactant preparations that are available commercially are not the same compounds.
They can be divided into 2 groups.
A. Natural surfactants
Beractant (Survanta), calfactant (Infasurf), and poractant (Curosurf) are surfactant prep-
arations that have been extracted from animal lung, although by different methods.
These preparations contain all the surfactant phospholipids and 2 of the 3 proteins, but
in different proportions. Beractant and calfactant are bovine (cow)-derived surfactants,
while poractant is a porcine (pig)-derived surfactant.
B. Synthetic surfactants
Synthetic surfactant preparations have been manufactured from phospholipids and
spreading agents or protein analogues designed to replace the surfactant-specific proteins
present in natural surfactants. Lucinactant (Surfaxin) is a synthetic surfactant that con-
tains the peptide sinapultide (KL4 acetate), 1,2-dipalmitoyl-sn-glycero-3-phosphocholine,
1-palmitoyl-2-oleoyl-sn-glycero-3-phosphoglycerol (as the sodium salt), and palmitic
acid. It was approved for use in the United States by the US Food and Drug Administra-
tion in 2012.
Each of the commercial preparations has been studied extensively. All have been shown to be
effective in treating RDS. While the natural surfactants have relatively minor differences, as a
group they seem to have a more rapid onset of action and a more striking effect on oxygen-
ation and lung compliance than the synthetic surfactants that have been developed. No studies
have been large enough to demonstrate a clear difference in mortality or chronic lung disease
for any of the preparations.

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 UNIT 5: SURFACTANT THERAPY

Self-test A
Now answer these questions to test yourself on the information in the last section.
A1. The naturally occurring surfactant complex is composed of 2 groups of substances:
________________ and ________________.
A2. Surfactant works by __________________ surface tension in the alveoli and preventing alveoli from
collapsing during __________________.
A3. True False All components of the surfactant complex appear for the first time at
32 weeks’ gestation.
A4. True False A preterm fetus that has been subjected to chronic stress will have a greater
chance of developing respiratory distress syndrome.
A5. List 4 factors known to increase the likelihood of a baby developing respiratory problems from
surfactant deficiency.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A6. True False When commercially available surfactant is given through an endotracheal
tube, it will eventually be absorbed by the lungs and re-secreted as natural
surfactant.
A7. True False Preterm babies born to women who received betamethasone or dexametha-
sone are more likely to require surfactant therapy than preterm babies born to
women who did not receive steroids.
A8. True False All commercially available surfactants contain the main components of
naturally occurring surfactant, but in different proportions.
Check your answers with the list near the end of the unit. Correct any incorrect answers and review
the appropriate section in the unit.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

7. How is surfactant administered?

All the surfactant preparations are administered directly into a baby’s trachea through an
endotracheal tube, although each manufacturer recommends a different administration tech-
nique. It is recommended that Survanta, Infasurf, and Curosurf be administered through a
catheter inserted into the endotracheal tube.
Recommendations about the need to divide the dose and tilt the baby into various positions
also differ considerably. No studies have clearly demonstrated that any one technique is supe-
rior to another. Bolus administration, however, has been shown to be preferable to aerosol or
slow-drip administration, although new techniques for aerosol delivery are being evaluated.

Correct endotracheal tube position is very important to ensure that the surfactant
is administered into the trachea, not into one mainstem bronchus and thus into
only one lung.

There is increasing evidence to support the use of “less invasive surfactant administration” tech-
niques in neonates with RDS. After surfactant administration, the compliance (stiffness) of the
lung is likely to change rapidly. As compliance improves (the lungs become less stiff), you should
make corresponding changes in ventilator or bag-and-mask ventilation pressures. Usually, a rapid
decrease in peak inspiratory pressure is needed first, but other changes may also be needed.
Monitor oxygen saturation continuously, check arterial blood gases frequently, and adjust the
baby’s inspired oxygen concentration and inspiratory pressure according to oxygen saturation
and Pao2 results. Low Paco2 is also an important indication to decrease peak inspiratory
pressure and rate.

To minimize the chance of developing a pneumothorax, anticipate likely changes

in the baby’s lung compliance after surfactant administration. Make appropriate
reductions in ventilation pressures promptly in response to oxygen saturation and
blood gas results.

After surfactant administration, some clinicians recommend assisting ventilation with an

anesthesia bag and in-line manometer for a brief period, rather than immediately reconnecting
the baby to a ventilator. A T-piece resuscitator can also be used to ventilate the baby during
surfactant administration. Inspiratory pressure should be monitored continuously and
adjusted immediately, according to apparent changes in lung compliance and oxygen
saturation readings. Once the oxygen saturation level seems to have stabilized, reconnect the
baby to the ventilator with settings that reproduce those used to bag breathe for the baby.
Alternatively, the ventilator may remain in use during surfactant administration if an in-line
catheter is used. In this scenario, an experienced clinician should be available at the bedside
during surfactant administration to adjust the ventilator settings accordingly, as the compli-
ance of the baby’s lungs changes.
Several studies have demonstrated that many babies with mild to moderate RDS can be extu-
bated immediately after the surfactant administration and maintained with nasal continuous
positive airway pressure (CPAP) alone.

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8. Which babies should be treated and when?

If a baby has moderate to severe RDS, has already undergone endotracheal intubation for
treatment of RDS, and requires more than 30% to 40% oxygen to maintain satisfactory
oxygen saturation as measured with pulse oximetry, most experts agree that the baby should
receive surfactant therapy. However, there is not uniform agreement as to when a baby should
be primarily intubated for surfactant administration. Both animal and human studies have
shown that the earlier surfactant is administered, the more effective it will be. However, since
endotracheal intubation is required for the administration, the timing of administration can
be influenced by many factors. The following 3 scenarios have been advocated:
A. Administer surfactant prophylaxis solely on the basis of gestational age.
On the basis of early surfactant clinical trials, some clinicians continue to advocate for
intubating all babies born before a certain gestational age. Of note, that gestational age
has continued to decrease as more neonatal units are implementing immediate noninva-
sive ventilation for spontaneously breathing babies in the delivery room. Recommenda-
tions were originally to intubate babies less than 30 weeks’ gestation but are now aimed
toward intubation of babies less than 26 weeks’ gestation within 5 to 10 minutes after
birth, administering surfactant, and then weaning mechanical ventilation as oximetry
and arterial blood gases indicate. However, this strategy will result in unnecessarily intu-
bating and treating some babies who would not have required either intubation or
surfactant. Therefore, most experts recommend the prompt initiation of noninvasive re-
spiratory support—generally nasal CPAP—in spontaneously breathing neonates born at
gestational ages of more than 24 to 25 weeks. In this situation, the decision to adminis-
ter surfactant is based on oxygen requirement, work of breathing, and chest radiography
results.
B. Administer surfactant prophylaxis solely on the basis of gestational age, but immediately
follow it with extubation to nasal CPAP.
Randomized controlled trials have shown no difference in outcomes when compared
to patients treated by using scenario A, although one study showed that once babies
are intubated, a large proportion tend to remain intubated (ie, once a patient has been
intubated, clinicians are hesitant to extubate).
C. Initiate nasal CPAP at birth and maintain nasal CPAP for all babies born less than a
certain gestational age (eg, 32 weeks) until they require intubation for respiratory failure.
Then intubate and administer surfactant.
This strategy is recommended by most experts and has been shown to result in a small
decrease in the incidence of bronchopulmonary dysplasia—for every 35 patients treated
with surfactant, there is 1 fewer case of bronchopulmonary dysplasia. Of note, while one
study showed an increased incidence of pneumothorax in patients maintained initially
on CPAP alone by using 8 cm H2O pressure, meta-analyses did not show an increased
risk of pneumothorax or other adverse events.
If surfactant is to be given prophylactically in the delivery room, the baby should receive
any necessary resuscitation measures prior to surfactant administration. In addition, pro-
viders should ensure that the baby’s vital signs have stabilized and that the endotracheal
tube is in the correct position prior to surfactant administration. Usually, these resuscita-
tive or stabilization measures (or both) can be accomplished quickly, allowing surfactant
to be given within 5 to 10 minutes after birth.

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The administration of surfactant after respiratory disease has developed is termed “res-
cue therapy.” Many clinicians elect to administer surfactant prophylactically to babies
born extremely preterm and to use a rescue approach for more mature babies who
develop respiratory distress after birth. Some experts advise a modified approach in
which surfactant is not given prophylactically but rather is given if a preterm baby
develops the slightest signs of RDS. These modifications have not been rigorously tested,
and their use must be guided by clinician preference. The presence and timing of mater-
nal antenatal steroid administration may also influence the decision.
Several reports have demonstrated that babies—including term babies with meconium
aspiration syndrome, pneumonia, and perhaps acute RDS—also benefit from surfactant
rescue therapy. There is currently insufficient information to recommend specific criteria
for treating such babies. However, some studies have shown that administration of
surfactant to patients with respiratory failure due to meconium aspiration syndrome
may reduce the need for extracorporeal membrane oxygenation in this population.
(See Cochrane Database Syst Rev. 2014;14[12]:CD002054.)

9. How often should you administer surfactant?

Depending on the surfactant preparation used, if a baby was treated prophylactically or
received the first dose soon after birth, a single dose will often suffice. However, because
surfactant may be absorbed, metabolized, or inactivated after administration (or any combina-
tion of those), repeat doses are sometimes administered.
Recommendations about repeat doses vary, depending on which type of surfactant is being
used. If a baby continues to require endotracheal intubation or positive-pressure ventilation
and has an inspired oxygen concentration of 30% to 40% or higher, many clinicians
will administer a repeat dose every 6 to 12 hours, until a maximum of 4 doses has
been achieved.

10. What are the recognized complications of surfactant therapy?

A. Administration to only one lung
If surfactant is administered into one lung (because the endotracheal tube was
placed too low), the baby may develop a marked compliance difference between the
2 lungs. This can result in major problems with ventilation; the treated lung can
become overinflated, while the other lung cannot be inflated as well at the same
pressure. Therefore, it is important to have a clinician who is experienced in endotra-
cheal intubation of neonates present to evaluate endotracheal tube placement prior
to the administration of surfactant. Before administering surfactant, confirm correct
endotracheal tube position by
• Visualizing the vocal cord stripe on the endotracheal tube before removing the
laryngoscope
• Listening with a stethoscope laterally over both sides of the chest for equal breath
sounds
• Obtaining a chest radiograph to confirm tube placement (usually not done when
surfactant is administered in the delivery room)

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B. Development of air leaks

If bagging or ventilator pressures are not decreased as the baby’s lung compliance
changes, the baby may develop a pneumothorax or pulmonary interstitial emphysema
(bubbles of air within the lung tissue).
C. Endotracheal tube that becomes slippery
The phospholipids in surfactant make it extremely slippery. After surfactant administra-
tion, the endotracheal tube, the tube connector, and the baby’s airway may also be slip-
pery, perhaps making tube adjustment, tube security, or reintubation difficult. Be certain
that all connections are tight and that all adjustments have been made before administer-
ing surfactant.
D. Endotracheal tube that becomes blocked with the surfactant solution
Sometimes, during surfactant administration, the surfactant solution will back up into
the endotracheal tube and prevent gas movement. If liquid is seen to be blocking the
tube, use slightly higher pressure and a longer inflation time for several breaths, until the
tube clears. If the baby’s condition deteriorates despite these measures, the surfactant can
be suctioned from the tube, or the tube can be replaced.
E. Severe oxygen desaturation that occurs during administration
Babies with severe RDS may not tolerate the introduction of liquid into their endotra-
cheal tubes. Most manufacturers recommend that the dose be divided into 2 or 4
aliquots. After each partial dose, the baby should be ventilated for a brief period of
time, until the oxygen saturation is greater than 90%, before the next partial dose is
administered.

11. Should surfactant always be administered in an intensive

care facility?
Surfactant administration requires considerable expertise with endotracheal intubation and
mechanical ventilation. Babies who require surfactant usually also require intensive care for
the management of other immature organ systems, in addition to the lungs. It is recommended
that surfactant therapy be administered only in hospitals that are appropriately equipped and
staffed for, and experienced in, the management of low-birth-weight and preterm babies,
including the use of mechanical ventilators. (See American Academy of Pediatrics, The
American College of Obstetricians and Gynecologists. Neonatal complications. In: Guidelines
for Perinatal Care. 7th ed. American Academy of Pediatrics; 2012:347.)
An appropriate exception may be administering surfactant in a non–intensive care setting to a
baby with severe RDS for whom there may be a significant delay in transport to an intensive
care nursery. If surfactant is to be administered under these conditions, it should be adminis-
tered by individuals who are skilled in endotracheal intubation and who have reviewed in
detail the specific recommended techniques for administering the commercial surfactant being
used. In addition, familiarity and skill with rapid lowering of inspiratory pressures with either
bag breathing or ventilator adjustment after surfactant administration is important. In some
settings, the neonatal transport team will provide this service.

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Self-test B
Now answer these questions to test yourself on the information in the last section.
B1. Which of the following techniques have been shown to be important for administering all
commercially available surfactant products?
Yes No
____ ____ Administration through a special endotracheal tube connector, which has a
side port
____ ____ Careful positioning of the endotracheal tube tip in the mid-trachea
____ ____ Turning the baby 360°
____ ____ Monitoring oxygen saturation during administration
____ ____ Anticipating changes in lung compliance and adjusting ventilation pressures
accordingly
B2. True False Studies have shown that surfactant administered immediately after birth is more
effective than waiting until a baby develops clinically significant respiratory disease.
B3. Many clinicians recommend that a baby who continues to have clinically significant respiratory
distress after initial surfactant administration be re-treated in ______ to ______ hours.
B4. List 4 possible complications of surfactant therapy.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Check your answers with the list near the end of the unit. Correct any incorrect answers and review
the appropriate section in the unit.

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Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.

Self-test A
A1. The naturally occurring surfactant complex is composed of 2 groups of substances:
phospholipids and proteins.
A2. Surfactant works by altering surface tension in the alveoli and preventing alveoli from
collapsing during exhalation.
A3. False. Reason: The various components of surfactant are first produced at different times
during gestation. By 32 weeks of gestation, 60% of fetuses have adequate surfactant
for normal extrauterine respiration.
A4. False. Reason: Fetuses subjected to chronic stress are less likely to develop respiratory
distress syndrome.
A5. Preterm birth
Maternal diabetes mellitus
Pneumonia
Aspiration syndrome
A6. True
A7. False. Reason: Antenatal steroids and neonatal surfactant have an additive effect on
preventing respiratory distress syndrome.
A8. True. Beractant (Survanta), calfactant (Infasurf), and poractant (Curosurf) contain all the
natural phospholipids, but only 2 of the 3 proteins; synthetic surfactants contain
synthetic phospholipids, and no surfactant-specific protein, and currently none are
available commercially.
Self-test B
B1. Yes No
____   X   Administration through a special endotracheal tube connector, which has
a side port
  X   ____ Careful positioning of the endotracheal tube tip in the mid-trachea
____   X   Turning the baby 360°
  X   ____ Monitoring oxygen saturation during administration
  X   ____ Anticipating changes in lung compliance and adjusting ventilation pressures
accordingly
B2. True
B3. Many clinicians recommend that a baby who continues to have clinically significant
respiratory distress after initial surfactant administration be re-treated in 6 to 8 hours.
B4. Any 4 of the following complications:
• Administration to one lung
• Development of air leaks (eg, pneumothorax)
• Endotracheal tube that becomes slippery
• Endotracheal tube that becomes blocked with surfactant
• Severe oxygen desaturation that occurs during surfactant administration

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 5 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf file
and save it to print later or come back to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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SKILL UNIT

Surfactant Administration
There are several different commercial surfactant preparations. Each has been shown to be effec-
tive in preventing and treating neonatal respiratory distress syndrome, although the techniques for
administration vary slightly among the different preparations. Each manufacturer has prepared
detailed instructions about the recommended method for administering that company’s particular
product. These instructions are available in written and video formats. A sample surfactant
administration video may be viewed at https://www.youtube.com/embed/1tic3rMVBMs. You
may be asked to participate in a skill session to practice surfactant administration according to
the methods recommended for the surfactant chosen for use in your hospital.
Because administration techniques vary for the different products, it is recommended that
your hospital use only one brand of surfactant and that all staff become skilled in using that

SKILL UNIT: SURFACTANT ADMINISTRATION

particular product. Switching between brands makes it more difficult to become skilled in the
use of each product and increases the risk of errors in administration.

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 Unit 6: Therapeutic
  Hypothermia for

UNIT 6: THERAPEUTIC HYPOTHERMIA FOR NEONATAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Neonatal Hypoxic-Ischemic
Encephalopathy
Objectives ............................................................................................................................116
1. What is hypoxic-ischemic encephalopathy?..............................................................119
2. What causes hypoxic-ischemic encephalopathy?.....................................................119
3. How do newborns with hypoxic-ischemic encephalopathy present?.................... 121
4. How do you determine if a newborn is eligible for therapeutic hypothermia?..... 123
5. How should early management of neonates with hypoxic-ischemic
encephalopathy be approached?............................................................................... 126
Tables, Figure, and Boxes
Table 6.1. Terms and Definitions Surrounding Hypoxic-Ischemic Encephalopathy...... 119
Table 6.2. Causes of Hypoxic-Ischemic Encephalopathy.............................................. 120
Table 6.3. Hypoxic-Ischemic Encephalopathy Severity Classification........................... 121
Table 6.4. Patterns of Brain Injury That Occur After Hypoxic-Ischemic
Encephalopathy and Clinical Correlates...................................................... 122
Table 6.5. Criteria for Defining Moderate to Severe Encephalopathy........................... 125
Table 6.6. Pre-transport Therapeutic Hypothermia Goals and Instructions.................. 127
Figure 6.1. Decision Criteria to Initiate Therapeutic Hypothermia for the
Neonate With Hypoxic-Ischemic Encephalopathy....................................... 126
Box 6.1. Risk Factors for Hypoxic-Ischemic Encephalopathy.................................... 120
Box 6.2. Is Therapeutic Hypothermia Indicated? A 3-Step Approach........................ 123
Recommended Routines ................................................................................................. 130
Skill Unit: Passive Cooling............................................................................................... 133

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Objectives
In this unit you will learn to
A. Identify hypoxic-ischemic encephalopathy
B. Understand how hypoxic-ischemic encephalopathy occurs
C. Recognize how newborns with hypoxic-ischemic encephalopathy present
D. Determine if a newborn is eligible for therapeutic hypothermia
E. Approach early management of neonates with hypoxic-ischemic encephalopathy

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 UNIT 6: THERAPEUTIC HYPOTHERMIA FOR NEONATAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Unit 6 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them against the answers at the end of the book.
1. Hypoxic-ischemic encephalopathy (HIE) is a term used to describe neonates with
encephalopathy at birth that is caused by hypoxia-ischemia around the time of
delivery. Which one of the following findings is supportive of a hypoxic-ischemic
event as the cause of the encephalopathy?
A. A cord blood gas analysis with a base deficit of 8 or base excess of 28.
B. A cord blood gas analysis with a base deficit of 16 or base excess of 216.
C. An arterial blood gas analysis at 2 hours after birth with a pH level of 7.1.
D. An Apgar score of #5 at 5 minutes after birth.
E. A history of forceps-assisted delivery.
2. HIE can be classified as mild, moderate, or severe on the basis of the degree of
encephalopathy. Which of the following findings would be seen in a newborn with
moderate encephalopathy?
A. Coma
B. Jitteriness
C. Dilated pupils
D. Hypotonia
E. Apnea
3. Therapeutic hypothermia is the only neuroprotective treatment currently available
to neonates with HIE. How soon should therapeutic hypothermia be initiated for
optimal brain protection?
A. Before 1 hour of age
B. Before 3 hours of age
C. Before 6 hours of age
D. Before 12 hours of age
E. Before 24 hours of age
4. A baby is born after emergent cesarean delivery for placental abruption. Therapeutic
hypothermia would not be indicated in which one of the following clinical scenarios?
A. A baby born at 38 weeks’ gestation with mild encephalopathy and seizures
B. A baby born at 33 weeks’ gestation with severe encephalopathy
C. A baby born at 39 weeks’ gestation with moderate encephalopathy
D. A baby born at 37 weeks’ gestation who required intubation for apnea and is
noted to be hypotonic at neurological examination
E. A baby born at 36 weeks’ gestation with Apgar scores of 1, 4, and 5 at
1 minute, 5 minutes, and 10 minutes, respectively

(continued )

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 6 Pretest (continued )

5. A newborn with HIE has been found to be eligible for therapeutic hypothermia.
You are arranging for transfer to your referral cooling center. Which of the following
statements regarding the supportive management of newborns with HIE is correct?
A. Avoid hyperthermia.
B. Maintain oxygen saturation levels of 98% to 100% to increase oxygen delivery to
the baby’s brain.
C. Start intravenous fluids at 120 mL/kg/day to ensure adequate organ perfusion.
D. Administer sodium bicarbonate to correct the baby’s acidosis.
6. You are considering initiating passive cooling for a newborn with severe HIE. Which
one of the following statements regarding passive cooling is correct?
A. The patient’s rectal temperature should be monitored every 30 minutes to avoid
overcooling.
B. A cool gel pack (or ice pack) should be placed on the baby’s head, while another
should be placed on the baby’s chest.
C. The temperature goals for pre-transport cooling are 33°C to 34°C (91.4°F–93.2°F).
D. Bradycardia should not occur with passive cooling.
E. Active cooling, not passive cooling, should be initiated in neonates with
severe HIE.

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 UNIT 6: THERAPEUTIC HYPOTHERMIA FOR NEONATAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY

1. What is hypoxic-ischemic encephalopathy?

Neonatal encephalopathy occurs when there are acute disturbances of neurological function
at birth, characterized by an abnormal level of consciousness, abnormal muscle tone, and
depressed reflexes. Newborns with neonatal encephalopathy can also present with seizures.
The diagnosis does not presume the cause of the encephalopathy, however.
In fact, the term neonatal encephalopathy should preferentially be used when the cause of the
encephalopathy is not clear. While hypoxia-ischemia is the most common cause of encepha-
lopathy in the newborn, other causes—including metabolic and genetic disorders, stroke,
and infections—lead to encephalopathy in 40% to 56% of cases (Curr Opin Neurol.
2002;15[2]:151–157).
Hypoxic-ischemic encephalopathy (HIE) presents at birth and is caused by a newborn
experiencing a hypoxic and/or ischemic event around the time of delivery. The term
perinatal asphyxia is also sometimes used. See Table 6.1 for additional terms and definitions
surrounding HIE.

Table 6.1. Terms and Definitions Surrounding Hypoxic-Ischemic Encephalopathy

Term Definition
Hypoxemia Decrease in blood oxygen content.
Hypoxia Decreased oxygen supply at the tissue level (brain).
Anoxia Complete lack of oxygen delivery to the tissues (brain).
Ischemia Inadequate blood flow to an organ (brain). Ischemia can be global or focal (stroke).
Asphyxia Impairment of gas exchange with presence of hypercapnia, acidosis, and
hypoxemia.

Use the diagnosis “neonatal encephalopathy” if you are unsure of the

underlying cause.

While the incidence of HIE has decreased over the past several decades, it remains a major
global problem. HIE is the third leading cause of neonatal mortality worldwide and the fifth
leading cause of neonatal mortality in the United States, with an incidence of 1.5 to 2.0 per
1,000 live births (Early Human Dev. 2010;86[6]:329–338).
Importantly, neonates with HIE are at high risk for long-term neurodevelopmental impair-
ment, including cerebral palsy, seizures, and neurocognitive deficits.

2. What causes hypoxic-ischemic encephalopathy?

HIE is often the result of one or more factors that lead to hypoxia and/or ischemia within
the central nervous system before or during labor or at delivery. The origins of HIE can be
maternal, uteroplacental, and/or fetal (Table 6.2).
Of note, readily identifiable sentinel events, which are most commonly thought of as the cause
of HIE, are identified in only 30% to 40% of cases (Am J Perinatol. 2019;36[1]:27–33;
BMJ. 1998;317[7172]:1554–1558). Preconception, antenatal, and intrapartum risk
factors can be identified in most cases of HIE, in addition to sentinel events (Box 6.1).

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The absence of a sentinel event does not rule out HIE in a newborn with
encephalopathy.

Table 6.2. Causes of Hypoxic-Ischemic Encephalopathy

Origin Factor
Maternal Cardiac arrest
Shock
Eclampsia, status epilepticus
Respiratory failure
Carbon monoxide poisoning
Severe anaphylaxis
Uteroplacental Uterine rupture
Placental abruption
Cord prolapse
Hypertonic uterine dysfunction
Fetal Acute fetal blood loss:
• Severe fetomaternal hemorrhage
• Twin-to-twin transfusion syndrome
• Vasa praevia
Arrhythmia
Severe anemia
Thrombosis

Box 6.1. Risk Factors for Hypoxic-Ischemic Encephalopathy

Pre-conception Antepartum Intrapartum

Maternal age ($ 35 years) Gestational age . 41 weeks Prolonged second stage of

Maternal hypertension History of urinary tract infec- labor

Infertility treatment tion during pregnancy Prolonged rupture of

Preeclampsia membrane
Lower socioeconomic
status Fetal growth restriction Failed instrumental delivery

Abnormal placenta Abnormal fetal heart tracing

Tight nuchal cord
Shoulder dystocia
Meconium-stained amniotic
fluid
Clinical chorioamnionitis
Sentinel event

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 UNIT 6: THERAPEUTIC HYPOTHERMIA FOR NEONATAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY

3. How do newborns with hypoxic-ischemic encephalopathy present?

The diagnosis of encephalopathy in a newborn is challenging and requires a careful standard-
ized neurological examination to recognize. The diagnosis of HIE requires not only the
presence of neonatal encephalopathy on examination, but also evidence of perinatal onset
(see Box 6.2). The goal of the neurological examination is 2-fold:
• To recognize encephalopathy in neonates with a sentinel event, a low Apgar score, or an
unexpected need for resuscitation.
• To classify HIE as mild, moderate, or severe, depending on the clinical findings. This is an
important distinction because only neonates with moderate or severe HIE have been shown
to benefit from therapeutic hypothermia.
The standardized neurological examination for HIE was first described by Sarnat and Sarnat
and is often referred to as the Sarnat score. Of note, it is common for neonates with HIE to
have a mixture of mild, moderate, or severe findings. Elements of the neurological examination
findings are listed in Table 6.3.

Table 6.3. Hypoxic-Ischemic Encephalopathy Severity Classification

Examination Element Mild HIE Moderate HIE Severe HIE
Level of consciousness Alternating: hyperalertness, Lethargy Coma
irritableness, lethargy
Muscle tone Normal or increased Decreased (hypotonia) Flaccid
(hypertonia) Increased (hypertonia)a
Spontaneous movements Normal or increased Decreased Absent
Jitteriness
Posture Normal Strong distal flexion Intermittent decere-
Complete extension brate posturing (arms
Frog leg position and legs extended,
wrist flexed, hand
fisted)
Deep tendon reflexes Normal or increased Increased Depressed or absent
Myoclonus (> 4–5 beats) Present Present Absent
Primitive reflexes
Suck Active Weak Absent
Moro Normal or exaggerated Incomplete Absent
Grasp Normal or exaggerated Exaggerated Absent
Dolls eye Normal Overactive Decreased or absent
Seizures None Frequent Frequent, delayed
Autonomic system
Pupils Normal or dilated Constricted (myosis), Variable, unequal,
(mydriasis), reactive reactive poor light reflex, fixed
Heart rate Normal or tachycardia Bradycardia Bradycardia
Respiration Regular Periodic Apnea, need for
intubation
Abbreviation: HIE, hypoxic-ischemic encephalopathy.
a
Can be seen in infants with cerebral cortical and deep gray nuclei injury. These infants may be noted to be hypertonic, particularly
with stimulation and manipulations.
Derived from Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress: a clinical and electroencephalographic study.
Arch Neurol. 1976;33(10):696–705.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Because sentinel events are not always identified in newborns with HIE, a high index of suspi-
cion should be applied for infants with neonatal encephalopathy at birth. Conversely, the
presence of a sentinel event, low Apgar scores, and/or an unexpected need for resuscitation at
birth should prompt a careful neurological assessment of the newborn to rule out the presence
of encephalopathy. The early recognition and accurate classification of HIE is critically impor-
tant to be able to implement therapeutic hypothermia without delay (see Section 4). Providing
therapeutic hypothermia for eligible newborns as soon as possible after birth has been shown
to improve long-term outcomes.

Maintain a high index of suspicion. Moderate encephalopathy in newborns can

easily be missed at birth.

The type of brain injury that occurs after HIE depends on the duration and severity of the
hypoxic-ischemic insult. Understanding the type of injury that occurred is helpful in under-
standing its potential long-term neurodevelopmental effects. There are 2 major types of injury
that occur after HIE in near-term and term infants (Table 6.4).

Table 6.4. Patterns of Brain Injury That Occur After Hypoxic-Ischemic

Encephalopathy and Clinical Correlates
Injury Pattern Description
Selective cortical necrosis Affects the most metabolically active areas of the brain. Injury will vary,
(basal ganglia/thalamus depending on the severity and duration of the hypoxic-ischemic insult:
predominant pattern) • Moderate to severe, prolonged ➝ Injury to the central gray nuclei
(basal ganglia, thalamus) and perirolandic cortex
• Abrupt and severe ➝ Injury to the central gray nuclei and brainstem
• If too severe and/or too prolonged ➝ Global brain injury will occur
Initial clinical correlates
Hypotonia, seizures, lethargy, or coma. In addition, if brainstem
injury is present, ptosis, oculomotor disturbances, respiratory issues,
and impaired suck-and-swallow reflex may also occur.
Long-term clinical correlates
Cognitive deficit, spastic quadriparesis, epilepsy. If brainstem injury:
choreoathetosis, ataxia, bulbar and pseudobulbar palsy.
Parasagittal cerebral injury Chronic partial hypoxic-ischemic insult
(watershed pattern) Affects arterial watershed brain regions (white matter injury)
Initial clinical correlates
Weakness of proximal limbs, with upper extremities affected more often
than lower extremities.
Long-term clinical correlates
Less severe. Motor deficits are less common but children can have
spastic quadriparesis. Children should be monitored for cognitive
deficits, specifically language or visual-spatial deficits.
Derived from Volpe JJ, Inder TE, Darras BT, et al, eds. Volpe’s Neurology of the Newborn. 6th ed. Elsevier; 2017.

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4. How do you determine if a newborn is eligible for

therapeutic hypothermia?
Therapeutic hypothermia is indicated for neonates who have moderate to severe HIE and has
been demonstrated to be effective in improving the outcomes of these infants born after 35
weeks’ gestation (Cochrane Database Syst Rev. 2013;2013[1]:CD003311). The neuroprotec-
tive effects of therapeutic hypothermia are due to its effect on multiple cellular and metabolic
pathways involved in the pathogenesis of hypoxic-ischemic brain injury (Semin Fetal Neonatal
Med. 2010;15[5]:287–292). For optimal benefits, therapeutic hypothermia should be initi-
ated within 6 hours of age, although the earlier cooling is started after birth, the better the
outcomes.
Therapeutic hypothermia can be achieved via either whole-body cooling or selective head
cooling with mild systemic cooling. The goals of treatment are to maintain the neonate’s core
body temperature between 33°C and 34°C (91.4°F and 93.2°F) for a duration of 72 hours.
Infants are subsequently slowly rewarmed, typically over a period of 12 hours, to avoid
complications such as electrolyte imbalance, as well as rebound hyperthermia or seizures
(Clin Perinatol. 2018;45[2]:241–255).
While criteria vary slightly between trials (Early Hum Dev. 2010;86[6]:329–338), the deter-
mination of moderate to severe HIE and therefore indications for therapeutic hypothermia is
a 3-step process (Box 6.2) (Pediatrics. 2014;133[6]:1146–1150). Providers are encouraged to
familiarize themselves with the specific protocols used at their referral center.

Box 6.2. Is Therapeutic Hypothermia Indicated? A 3-Step Approach

The following 3 steps should be followed when deciding whether or not therapeutic
hypothermia is indicated for hypoxic-ischemic encephalopathy (HIE) in a specific neonate
(see also Figure 6.1):
STEP 1: GENERAL CRITERIA
The newborn must meet all of the following criteria:
• Gestational age $ 35 weeks (variability is noted from center to center and ranges
from $ 34 weeks’ to $ 36 weeks’ gestation).
• Birth weight $ 2,000 g ($ 4 lb 6 oz) (some centers will cool babies weighing $ 1,800 g
[$ 4 lb]).
• Younger than 6 hours of age. (A trial suggested that therapeutic hypothermia initiated
between 6 and 24 hours after birth may result in neuroprotection [JAMA. 2017;318(16):
1550–1560]. Providers are encouraged to contact their referral center to discuss such cases
further.)
• No suspected lethal congenital anomaly.

(continued )

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Box 6.2. Is Therapeutic Hypothermia Indicated? A 3-Step Approach (continued )

• Relative exclusion criteria to consider and discuss with the referral center:
—Severe congenital anomalies, genetic syndromes, metabolic disorders
—Severe intracranial hemorrhage
—Septic shock
—Uncorrectable, clinically relevant coagulopathy

Contact your referral center about infants who are slightly outside these
criteria to discuss potential eligibility for therapeutic hypothermia.

STEP 2: DOCUMENTATION OF A HYPOXIC-ISCHEMIC EVENT AROUND THE TIME

OF DELIVERY
This step ensures that the cause of the encephalopathy is likely hypoxia-ischemia. Further, it
also documents that the hypoxic-ischemic insult occurred recently, which is a critical require-
ment for therapeutic hypothermia—mediated neuroprotection. Hypoxic-ischemic insults that
occur remote from birth may cause encephalopathy but are not amenable to therapeutic
hypothermia.
While criteria vary slightly between trials, the determination that a hypoxic-ischemic insult
occurred around the time of delivery can be ascertained if any one of the following is present
in a blood gas sample obtained from the umbilical artery or vein at birth or from the baby
within 1 hour of birth:
• Presence of severe metabolic acidosis at birth (pH level # 7.00, but some centers use a
pH level # 7.10)
—Base deficit $ 16 (some centers use base deficit $ 10 to 12)
• Low Apgar score (score # 5) at 10 minutes after birth
• Need for prolonged resuscitation, with the newborn requiring chest compressions and/or
ventilation support at 10 minutes after birth
• Acute perinatal event:
—Late or variable decelerations
—Prolonged sustained fetal bradycardia (heart rate , 80 beats/min) for .15 minutes
—Sentinel event: cord prolapse, cord rupture, uterine rupture, maternal trauma, hemorrhage,
or cardiorespiratory arrest
STEP 3: PRESENCE OF MODERATE TO SEVERE ENCEPHALOPATHY AT NEUROLOGICAL
EXAMINATION OR SEIZURES
This step ensures that the hypoxic-ischemic event was prolonged enough to cause significant
brain injury that may benefit from therapeutic hypothermia.
As discussed previously, the determination of the presence or absence of encephalopathy is
based on standardized neurological assessments that support the presence of moderate to
severe HIE, as shown in Table 6.3. For the purpose of determining eligibility for therapeutic
hypothermia, the following requirement should be met:
• Presence of seizures (clinical or confirmed with amplitude-integrated electroencephalography
[EEG] or conventional EEG).
• Evidence of moderate to severe encephalopathy as delineated in Table 6.5.

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Table 6.5. Criteria for Defining Moderate to Severe Encephalopathy

Category Moderate Severe
At least 1 item from at least 3 of the following 6 categories:
Level of consciousness Lethargy Coma
Delayed but complete response Unresponsive or delayed and incom-
to external stimuli plete response to external stimuli
Spontaneous activity Decreased Absent
This criterion is not reliable in This criterion is not reliable in sedated
sedated neonates. neonates.
Posture Strong distal flexion Arms and legs extended
Complete extension Wrist flexed
Frog leg position Hand fisted
Any abnormal posture
Muscle tone Hypotonia (focal or general) Flaccid or rigid
Hypertonia
Normal
Primitive reflexes
Suck Weak or has bite Absent
Moroa Incomplete Absent
Autonomic nervous system
Pupils Constricted Dilated, nonreactive, asymmetric
Heart rate Bradycardia b
Variable
Heart rate , 100 beats/min, Heart rate varies widely (between
occasionally .120 beats/min ,100 and .120 beats/min)
Respiration Periodic breathing Apnea, requiring mechanical
With or without desaturations ventilation
and/or need for oxygen
Providers should familiarize themselves with the specific protocols used at their referral center, as local protocols may vary.
a
Gently raise and lower the head to check the Moro reflex in intubated patients.
b
Do not assess if the infant is cooled and bradycardia is expected under these circumstances.
Adapted from Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic
encephalopathy. N Engl J Med. 2005;353(15):1574–1584; and Natarajan G, Laptook A, Shankaran S. Therapeutic hypothermia:
how can we optimize this therapy to further improve outcomes? Clin Perinatol. 2018;45(2):241–255.

The neurological examination of neonates suspected of having HIE is challenging because

neurological signs may evolve and/or fluctuate after birth. In addition, the delivery process
and/or maternal sedation or anesthesia may also affect the behavior of the infant. To decrease
variability, experts recommend examining the newborn in a 2-step process:
1. Observation to assess spontaneous activity, posture, muscle tone in the resting state, heart
rate, and respiration
2. Examination to assess level of consciousness, tone, primitive reflexes, and pupils.
Serial neurological examinations are recommended for neonates who have a history of a senti-
nel event and/or biochemical evidence of hypoxia-ischemia but who do not meet the criteria
for therapeutic hypothermia on initial examination. Of note, ongoing trials are investigating
the benefits of therapeutic hypothermia for neonates with mild HIE.

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TIME IS BRAIN. Contact your referral center as soon as any stage of HIE is
suspected in a neonate, to discuss the eligibility for therapeutic hypothermia,
as well as the initiation of passive or active cooling and transfer of the neonate,
if applicable.

GA ≥ 35 weeksa No
Step 1 Birth weight ≥ 1,800 to 2,000 g Not eligiblec
< 6 hours after birthb

Yes

Documentation of a HYPOXIC-ISCHEMIC EVENT

around the time of birth
Any ONE of the following:
• pH ≤ 7.00 or base deficit ≥ 16d No
Step 2 Not eligiblec
• Apgar score ≤ 5 at 10 minutes
• Assisted ventilation initiated at birth
and continued for at least 10 minutes
• Acute perinatal evente
Yes

MODERATE-TO-SEVERE ENCEPHALOPATHY
Using a standardized neurological examinationf No
Step 3 Not eligiblec
OR
SEIZURES
Yes

Goal INITIATE THERAPEUTIC HYPOTHERMIA

Therapeutic hypothermia as soon as possible
< 6 HOURS after birth OR
Sooner is better TRANSFER to a cooling center as soon as possible
Discuss pre-transport cooling with your referring center

Figure 6.1. Decision Criteria to Initiate Therapeutic Hypothermia for the Neonate With Hypoxic-Ischemic Encephalopathy
GA, gestational age. a 5 Neonates $ 34 weeks’ gestation and/or those with unclear gestational age may be eligible and should
be discussed with your referral center. b 5 Neonates 6–24 hours old may be eligible and should be discussed with your referral
center. Infants slightly outside these criteria or of uncertain gestational age should also be discussed with your referral
center. c 5 See Table 6.5. d 5 Blood gas (umbilical, arterial, venous, or capillary sampling) should be obtained within 1 hour
of birth. e 5 Late or variable decelerations, prolonged sustained fetal bradycardia (heart rate < 80 beats/min) for more than
15 minutes, cord prolapse, cord rupture, uterine rupture, maternal trauma, hemorrhage, or cardiorespiratory arrest.
f
5 Discussion of borderline cases is recommended, particularly regarding the severity of encephalopathy determination.

5. H
 ow should early management of neonates with hypoxic-ischemic
encephalopathy be approached?
The goals of treatment for neonates with HIE are to prevent conditions that may aggravate
brain injury and provide timely evidence-based therapeutic hypothermia for neuroprotection.
In addition to supportive management and therapeutic hypothermia, evaluation for sepsis is
recommended in these patients.

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Supportive Treatment
When providing supportive treatment, close monitoring is required to prevent further brain
injury and includes the following:
A. Close monitoring of the neonate’s temperature, even if passive or active cooling is not
initiated (see Table 6.6)
• Ideally, the neonate’s temperature should be monitored continuously using a rectal
temperature probe. If that is not possible, monitoring of core temperature every
15 minutes is recommended, because neonates with severe HIE can develop marked
hypothermia even if cooling is not initiated.
• In addition, preventing hyperthermia is important in these patients. Studies indicate
that increased temperatures in neonates with HIE lead to increased risk of death or
disability.
B. Close monitoring of vital signs
• Heart rate
• Oxygen saturation
• Blood pressure
• Blood gases in intubated patients
See Table 6.6 for vital signs goals and instructions.

Table 6.6. Pre-transport Therapeutic Hypothermia Goals and Instructions

Parameter Instructions
Method Passive cooling: Turn off radiant warmer.
Active cooling:
• Turn off radiant warmer.
• Apply single cool gel pack (preferred) or ice pack to the neonate’s head
or trunk. Additional cooling packs may be required if the baby’s tem-
perature remains above 35°C (95°F) after 1 hour of active cooling.
• Change the position of the cooling pack every 15 minutes to prevent
possible thermal injury.
• Remove the cool pack when the neonate’s temperature comes down to
34°C (93.2°F).
Do not initiate active cooling unless the neonate’s temperature remains
above 35°C (95°F) after 1 hour of passive cooling.
Temperature goals 33°C–34°C (91.4°F–93.2°F)
If the neonate’s temperature is below 33.5°C (92.3°F), place a receiving
blanket over the baby.
If the neonate’s temperature continues to decrease, restart the use of an
external heat source.
If the neonate’s temperature is below 31°C (87.8°F), apply a warming
pack until the temperature increases above 33°C (91.4°F).
Temperature monitoring Continuous rectal temperature (insertion to 5 cm [2 in] is preferred).
Rectal temperature should be checked every 15 minutes.

(continued )

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Table 6.6. Pre-transport Therapeutic Hypothermia Goals and Instructions (continued )

Parameter Instructions
Heart rate goals . 80 beats/min
Lower heart rates are expected in cooled neonates.
Do not initiate cooling in hemodynamically unstable neonates unless you
are practicing in a unit that is able to initiate volume resuscitation and/or
blood pressure support.
Oxygen saturation goals 92%–98%
Hyperoxemia has been shown to negatively affect outcomes.
Blood pressure goals Mean arterial blood pressure $ 35 mm Hg
If hypotension is present, administer 10 mL/kg of normal saline.
Dopamine may be required in some infants.
Blood gases goals Maintain Pco2 within normal range.
In cases of severe acidosis (base excess of at least 212), consider adminis-
tering normal saline (10 mL/kg).
The use of sodium bicarbonate is not recommended.
Blood glucose goals 50–150 mg/dL
Administer a 2 mL/kg bolus of dextrose 10% if the neonate’s glucose
level is ,50 mg/dL.

C. Avoidance of hypoglycemia or hyperglycemia

• Neonates with moderate to severe HIE should be given nothing by mouth and should
receive intravenous fluids of dextrose 10% initiated as soon as possible to prevent
hypoglycemia.
• Total fluid goals should be maintained between 60 and 80 mL/kg/day, with a minimal
glucose infusion rate of 4 mg/kg/min.
D. Close monitoring for seizures
• Seizures in neonates may be difficult to recognize, and providers should maintain a
high level of suspicion. In the neonate, seizures may manifest as rhythmic tonic or
clonic movements or may be more subtle and include eye deviation, lip smacking, and
swimming or bicycling movements.
• If seizures are suspected, a phenobarbital dose of 20 mg/kg can be given as first-line
therapy, if available.

Neuroprotective Interventions
Currently, the only neuroprotective strategy shown to improve the outcomes of neonates with
HIE is therapeutic hypothermia. Other neuroprotective approaches under investigation include
the use of erythropoietin, melatonin, topiramate, magnesium sulfate, xenon, and stem cell therapy.
Although delayed therapeutic hypothermia started between 6 and 24 hours after birth may be
neuroprotective, current data indicate that the initiation of therapeutic hypothermia as soon
as possible and prior to 6 hours after birth is important to be able to optimize long-term out-
comes. For neonatal units that do not provide therapeutic hypothermia, early identification of
eligible infants is therefore critical. Once identified, transfer of the neonate to a referral center
that is able to provide therapeutic hypothermia should occur without delay.

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Providers in centers that do not provide therapeutic hypothermia may consider the initiation
of passive or active cooling, particularly if transfer of the neonate to the referral center would
result in the initiation of cooling beyond 6 hours after birth. Passive or active cooling should
be considered only if the following conditions are met:
• Ability to closely monitor the neonate, including
— Continuous temperature monitoring (preferred) or monitoring of rectal temperature
every 15 minutes
— Continuous heart rate and oxygen saturation monitoring
— Close blood pressure monitoring
— Monitoring of serum blood glucose level
• Stable intravenous access
• A guideline in place that highlights the monitoring parameters and interventions for out-of-
range values (Table 6.6).
Of note, active cooling is not recommended in level 1 or 2 nurseries. Additional details on
passive and active cooling are provided in Table 6.6.

Self-test
Now answer these questions to test yourself on the information in the last section. Use the chart to
find the answers to the questions.
A1. For which of the following cases is the baby eligible for therapeutic hypothermia?
Yes No
____ ____  3-hour-old, 39 weeks’ gestation baby with seizures and a cord pH level
A
of 6.9
____ ____ A 5-hour-old, 40 weeks’ gestation baby with a 10-minute Apgar score of 5 and physical
examination findings of hypotonia, lethargy, and abnormal Moro reflex
____ ____ A 1-hour-old, 36 weeks’ gestation baby with a base excess of 210 and irritability and
tachypnea at examination
A2. List 3 findings in a neurological examination that are consistent with a diagnosis of severe
encephalopathy.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A3. What is the goal core temperature for neonates who are undergoing therapeutic hypothermia for
moderate to severe hypoxic-ischemic encephalopathy?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A4. List 3 recommended supportive care measures when caring for neonates with hypoxic-ischemic
encephalopathy.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

THERAPEUTIC HYPOTHERMIA FOR NEONATAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Recommended Routines
All the routines listed here are based on principles of perinatal care presented in the unit you
have just finished. They are recommended as part of routine perinatal care.
Read each routine carefully and decide whether it is standard operating procedure in your
hospital. Check the appropriate blank next to each routine.

Procedure Standard Needs Discussion Recommended Routine

in My Hospital by Our Staff
______________ ______________ 1. Establish a mechanism to recognize neonates at risk
for hypoxic-ischemic encephalopathy (HIE) who
may benefit from therapeutic hypothermia. This in-
cludes performing a cord blood gas analysis or
early baby blood gas analysis in all neonates with:
a. A history of a sentinel event (eg, abruption,
cord prolapse, uterine rupture)
b. A low Apgar score at 10 minutes
c. An unexpected need for resuscitation at birth
d. Abnormal examination findings consistent
with encephalopathy
______________ ______________ 2. Develop a procedure to educate providers on
how to:
a. Recognize encephalopathy in a baby.
b. Determine whether or not the baby meets
criteria for therapeutic hypothermia. This
includes discussion of borderline cases with
your referral center and may include serial
neurological examinations.
______________ ______________ 3. Establish a policy on how to provide safe passive
cooling for babies who meet the criteria for
therapeutic hypothermia:
a. Turn off the radiant warmer.
b. Initiate a procedure for continuous (preferable)
or close core temperature monitoring.
c. Adhere to the guideline for the management
of temperature below 33.5°C (92.3°F).
______________ ______________ 4. Establish a written guideline for the supportive
care of neonates with moderate to severe HIE
that includes recommendations for:
a. Maintenance of adequate oxygen saturation levels.
b. Avoidance of hypo- or hyperglycemia.
c. Maintenance of mean arterial blood pressure
$ 35 mm Hg.
d. Monitoring for the development of seizures.
______________ ______________ 5. Establish a standard work procedure to refer
eligible infants to your referral center to avoid
unnecessary delays.
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Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.
A1. Yes No
  X   ____ A 3-hour-old, 39 weeks’ gestation baby with seizures and a cord pH level
of 6.9
  X   ____ A 5-hour-old, 40 weeks’ gestation baby with a 10-minute Apgar score of 5
and physical examination findings of hypotonia, lethargy, and abnormal
Moro reflex
____   X   A 1-hour-old, 36 weeks’ gestation baby with a base excess of 210 and irri-
tability and tachypnea at examination
A2. Absent spontaneous movement
Flaccidity
Coma
A3. 33°C to 34°C (91.4°F–93.2°F)
A4. Maintain adequate oxygen saturation
Avoid hypo- and hyperglycemia
Monitor closely for seizures

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 6 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf
file and save it to print later or return to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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 UNIT 6: THERAPEUTIC HYPOTHERMIA FOR NEONATAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY

SKILL UNIT

Passive Cooling
This skill unit will teach you how to initiate passive cooling for neonates with moderate to
severe encephalopathy, by following these basic steps:
1. Collect and prepare equipment.
2. Establish a plan for temperature monitoring.
3. Know the steps to correct temperatures below the goal temperature.

First, you must decide if the baby meets the cooling criteria. Does the baby meet any of these
criteria?
• Gestational age # 35 weeks
• Birth weight , 1,800 g (, 4 lb)
• Age more than 6 hours after birth
• Known lethal congenital anomaly

SKILL UNIT: PASSIVE COOLING

If yes: Therapeutic hypothermia is not indicated in most cases. Please discuss with your
referral center questionable or borderline cases and babies 6 to 24 hours old who present
with concerning neurological signs or symptoms.
If no: therapeutic hypothermia may be considered if the baby meets the following criteria:
1. Documentation of a hypoxic-ischemic event
2. Presence of moderate to severe encephalopathy

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PERINATAL PERFORMANCE GUIDE

Initiating Passive Cooling

ACTIONS REMARKS

Preparing the Baby for Passive Cooling

1. Collect the following items:
• Temperature probe (preferred) or For continuous temperature monitoring
• Thermometer
• Permanent marker or tape To mark the length to be inserted
• Tape To secure the temperature probe
• Lubricant To insert the temperature probe
• Supplies necessary for placement of
peripheral intravenous (PIV) line
• Gloves

Insert a PIV Line

2. Insert a 22- or 24-gauge PIV line by To initiate intravenous (IV) hydration (dextrose
following standard procedures. 10%), since the baby will receive nothing by
mouth for the duration of
cooling.

Continuous Temperature Monitoring

3. Insert the rectal temperature probe
• Mark 5 cm (2 in) from the tip of the
temperature probe.
• Lubricate the probe.
• Insert the probe rectally about 5 cm
(2 in).
• Secure the probe in place with tape.
• Connect the probe to the monitor.

Intermittent Temperature Monitoring

4. Measure rectal temperature every
15 min.

Initiate Passive Cooling

5. Place the baby supine.
6. Turn off the radiant warmer.
7. Document the temperature every 15 min.

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ACTIONS REMARKS

What Can Go Wrong?

• The core temperature may fall below the A neonate with severe encephalopathy
goal of 33°C (91.4°F). may become severely hypothermic rapidly,
emphasizing the need for close temperature
monitoring during passive cooling.
• If the neonate’s temperature is below 33.5°C
(92.3°F), place a receiving blanket over the
baby.
• If the neonate’s temperature continues to
decrease, restart the use of an external heat
source.
• If the neonate’s temperature is below 31°C
(87.8°F), apply a warming pack until the
temperature increases above 33°C (91.4°F).
• The core temperature may not decrease. If the baby’s temperature does not fall below
34°C (93.2°F) after 1 hour of passive cooling,
discuss the next step with your referral center.
The use of one cooling pack to the head or trunk
may be indicated, particularly if the transport
team is not expected to arrive right away.
• The rectal temperature probe may This may result in inaccurate readings. Check
become coated with meconium. and clean the probe after the production of
meconium stool.
• The baby may become bradycardic. A slower heart rate, typically above 80 beats/min,
is expected to occur in babies that are cooled.
If the heart rate falls below 80 beats/min and the
baby becomes hemodynamically unstable, pro-
ceed with rewarming to 34°C (93.2°F) and
consult your referral center.
• The baby may develop arrhythmia. This is uncommon at the temperature used for
therapeutic hypothermia.
If an arrhythmia occurs, proceed with
rewarming the baby to 34°C (93.2°F) and
consult your referral center.
• The baby may become hypotensive. If the baby develops hypotension, administer a
10- to 20-mL/kg normal saline bolus.
Discuss next steps with your referral center. This
may include rewarming to 34°C (93.2°F) or ini-
tiation of vasopressors, depending on the local
setup.

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 Unit 7: Continuing Care for At-Risk Babies
Objectives............................................................................................................................ 138
1. What is continuing care?............................................................................................ 141
2. Which babies require continuing care?..................................................................... 141
3. What specific issues are involved in continuing care?............................................. 141
4. What is involved in the discharge of a baby from the hospital?............................. 158
Subsection: Babies With Special Problems

UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

1. What special problems may be encountered in babies who
require continuing care?............................................................................................. 161
2. How do you care for babies with these special problems?..................................... 164
Tables and Figure
Table 7.1. Timing of the First Eye Examination Based on Gestational
Age at Birth................................................................................................. 153
Table 7.2. Monitoring and Treatment Guidelines for Babies With
Special Problems......................................................................................... 165
Figure 7.1. Fenton Preterm Growth Chart—Girls......................................................... 145
Recommended Routines.................................................................................................. 175

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Objectives
In this unit you will learn to
A. Provide long-term care for an at-risk baby who remains in your hospital for longer than
several days.
B. Provide continuity of care for an at-risk baby who returns from an intensive care nursery
to your hospital.
C. Recognize the special problems some sick or preterm babies may develop, and the
monitoring and treatment guidelines for those problems.
D. Plan for the discharge of an at-risk baby from the hospital.

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 UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

Unit 7 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them with the answers at the end of the book.
1. A term baby with short bowel syndrome recently returned to your nursery from a
regional perinatal center. Which of the following measurements is least important for
you to monitor in this baby?
A. Urine pH level
B. Weight gain
C. Frequency of stool production
D. Blood electrolytes
2. Two weeks ago, a 1,500-g (3 lb 5 oz), preterm baby returned to your hospital after
3 weeks in a regional perinatal center. The parents live in your town and have visited
the baby once in the past 2 weeks. What would you do?
Yes No
_____ _____ Request consultation from social service department staff.
_____ _____ Call the parents and chat with them about their baby.
_____ _____ Begin making plans for the baby to be sent to a foster home.
3. Which of the following babies is at highest risk for developing hydrocephalus?
A. A term baby treated for hypoglycemia
B. A 1,000-g (2 lb 3 oz), preterm baby requiring assisted ventilation
C. A baby at 36 weeks’ postmenstrual age who received an exchange transfusion
D. 1,800-g (3 lb 151/2 oz) baby born at 40 weeks’ gestation
4. All of the following statements about retinopathy of prematurity are correct except
A. Laser photocoagulation may be helpful in reducing poor visual outcome from
retinopathy of prematurity.
B. Retinopathy of prematurity is unlikely to develop in babies born at term.
C. Mild to moderate retinopathy of prematurity may resolve completely.
D. All preterm babies with a Pao2 greater than 100 mm Hg will develop retinopathy
of prematurity.
5. A preterm baby requires assisted ventilation and several weeks of intensive care at a
regional perinatal center. Now the baby is stable, weighs 1,500 g (3 lb 5 oz), has no
respiratory distress, and is returning to your nursery for further weight gain. Which
of the following things should be done for this baby?
Yes No
_____ _____ Measure the baby’s head circumference once a week.
_____ _____ Start the baby on phenobarbital.
_____ _____ Weigh the baby daily.
_____ _____ Administer iron dextran intramuscularly.
_____ _____ Check the baby’s hematocrit value at least once a week.
_____ _____ Attach the baby to a cardiac or respiratory monitor.

(continued )

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Unit 7 Pretest (continued )

6. True False A 4,540-g (10 lb) baby has seizures that are controlled with a
certain drug dose. By the time the baby reaches 9,070 g (20 lb),
he should be receiving twice as much medication.
7. True False When a preterm baby reaches 1,500 g (3 lb 5 oz) and her respiratory
disease has resolved, it is safe to assume the baby will not have an
apneic spell.
8. True False Nipple feedings should be used for any baby who has a gag reflex
and can suck on a nipple.
9. True False Babies with chronic lung disease can grow completely new,
healthy lung tissue.
10. True False After a baby with hydrocephalus has a shunt placed, it is no longer
necessary to measure the baby’s head circumference.
11. True False It is a good sign if a baby with congenital heart disease gains 60 g
(2 oz) or more per day for several days in a row.
12. True False Babies who require caffeine to control apneic spells may have the
drug stopped and be sent home the next day, as long as they have
reached a weight of 1,800 g (3 lb 151/2 oz).
13. True False Any baby with short bowel syndrome will need an ostomy
(colostomy or ileostomy) for the rest of their life.
14. All of the following findings are common causes of anemia in preterm babies except
A. Blood taken from the baby for laboratory tests
B. Drop in hemoglobin level or hematocrit value after birth
C. Bronchopulmonary dysplasia
15. Which of the following things should you do when supplementing a baby’s nipple
feedings with tube feedings given through a nasogastric or an orogastric tube?
A. Feed the baby as much as he or she will take by nipple, and then insert a feeding
tube and give the remainder of the feeding through the tube.
B. Feed the baby as much as he or she will take by nipple while a feeding tube is in
place, and then give the remainder of the feeding through the tube.
16. All of the following steps are important in weaning a baby from an incubator except
A. Putting a stocking cap on the baby’s head
B. Wrapping the baby in blankets
C. Recording the baby’s daily weight during the weaning period
D. Adjusting the room temperature to a neutral thermal environment during the
weaning period
17. Indicate which of the following things should be routinely checked for a hospitalized
baby with congenital heart disease and congestive heart failure:
Yes No
_____ _____ Blood electrolytes
_____ _____ Volume of urine output
_____ _____ Stool pH level
_____ _____ Hematocrit value
_____ _____ Weight gain
_____ _____ Blood calcium level

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 UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

1. What is continuing care?

At-risk babies, even though they are not sick, require certain daily caretaking activities and
types of monitoring.
These babies may have been born in your hospital and have recovered from their initial acute
newborn problems, or they may have been transferred to your hospital from another insti-
tution. If they have been transferred for continuing care, it is important that there has been
complete and effective communication between the referring and receiving hospitals about the
baby’s history, ongoing problems, and need for special assessment and follow-up.

2. Which babies require continuing care?

A. Babies who need additional weight gain
Preterm babies who have recovered from their initial illness are now at risk, but stable,
and need continued hospitalization until they gain adequate weight to be discharged.
B. Babies who need to continue to mature
Preterm babies often need to continue to mature physiologically. Physiological matura-
tion involves a variety of functions, including feeding skills, temperature control, and
establishing regular respirations.
C. Babies who need special monitoring and/or intervention
Any baby who has recovered from an initial illness but has a special medical problem
that requires continued hospitalization for special monitoring or intervention.
D. Babies who have positive newborn screening (NBS) findings
NBS is a public health program of screening in babies shortly after birth for conditions
that are treatable but are not necessarily clinically evident in the newborn period. The
goal is to identify babies at risk for these conditions early enough to confirm the diag-
nosis and provide intervention that will alter the clinical course of the disease and pre-
vent or ameliorate the clinical manifestations. All babies in the United States receive
NBS. Each state decides which tests are required, and recommendations can vary
greatly. Most NBS tests are conducted by measuring metabolite levels or enzyme activ-
ity in whole blood samples collected on filter paper. Bedside tests for hearing loss by
using automated auditory brain stem response, and tests for congenital heart defects by
using pulse oximetry are included in some NBS programs. Babies who have positive
screening results undergo further testing to determine if they are truly affected with a
disease or if the test result was false-positive. Follow-up testing is typically coordinated
between geneticists and the baby’s pediatrician or primary care physician.

3. What specific issues are involved in continuing care?

The following list provides routine care practices needed for babies who require continuing care:
A. Temperature control
Babies weighing less than 1,500 to 1,600 g (,3 lb 5 oz to 3 lb 8 oz) should be kept in
an incubator in the appropriate neutral thermal environment. (See Book 1: Maternal
and Fetal Evaluation and Immediate Newborn Care, Unit 7, Thermal Environment.)
When they reach a weight of approximately 1,500 to 1,600 g, you may begin to wean
them from the incubator to a crib.
• How do you wean a baby from an incubator to a crib?
Step 1. Dress the baby in a single-layer shirt or sleeper, wrap the baby with one
blanket, and place a stocking cap on the baby’s head. Reduce the heat in the

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incubator by 0.2°C (0.36°F) to 0.5°C (0.9°F). Monitor the baby’s tempera-

ture, maintaining an axillary temperature higher than 36.4°C (97.6°F).
Step 2. If the baby’s temperature is stable after 3 to 6 hours, continue to decrease the
incubator temperature slowly, as indicated above, until an incubator tempera-
ture of 27.0°C to 28.0°C (80.6°F–82.4°F) is achieved. Continue to monitor the
baby’s temperature during this process, maintaining an axillary temperature
higher than 36.4°C (97.6°F). Do not decrease the temperature by more than
2.0°C (3.6°F) in the first 24 hours, and no more than 1.0°C (1.8°F) in subse-
quent 24-hour periods. It is appropriate to add one additional blanket to cover
the baby. It is not appropriate to leave the port holes of the incubator open.
Step 3. Once the baby’s temperature is stable and the incubator has been weaned
down to 26.0°C to 27.0°C (78.8°F–80.6°F), place the baby in an open crib.
This process could take several days to achieve. Continue to monitor the
baby’s temperature while in the open crib.
Note: If the baby becomes cold (temperature , 36.5°C or , 97.7°F) at any time,
add an additional blanket and check for abnormal routes of heat loss. Do
not use more than 2 blankets at any given time. If the baby continues to be
cold and all other routes of heat loss have been checked, place the baby back
in the incubator at the appropriate neutral thermal environment and wait at
least 24 hours to begin the weaning process again.
• What is “kangaroo care”?
Kangaroo care means skin-to-skin contact between a baby’s body and the parent’s
chest. This usually provides sufficient thermal support for a baby to be able to
maintain a normal body temperature while outside an incubator. The baby should
be naked, except for a diaper, and in direct contact with the bare skin of the parent’s
chest. The baby should wear a cap and be covered with a blanket that is placed over
both the baby and the parent’s chest.
Note: Any benefits of kangaroo care have been shown to diminish dramatically if the
baby is on the parent’s chest for only a few minutes. If a parent has only a
short time to spend with the baby at a particular visit, moving the baby for
this brief period is not recommended, especially if the baby is small and
attached to a number of monitors, intravenous lines, and other equipment.
If a breastfeeding mother does not wish to provide kangaroo care, put a cap on the
baby and wrap the baby in extra blankets. It may also be possible to use a radiant
warmer positioned over the baby and mother.
In all situations when a baby is outside an incubator, the baby’s temperature should
be monitored frequently.
• What can go wrong?
The baby may have a normal temperature but may be using a significant number of
calories to keep warm. This may cause the baby to lose weight or fail to gain weight.
Any baby who has just been weaned to a crib and loses weight for 2 to 3 days in a
row should be placed back in an incubator for at least 24 hours before undergoing
the weaning process again.
Caution: Weight loss may occur for other reasons, too. You should consider
• Checking for infection
• Assessing feeding patterns and caloric intake

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B. Feeding
• Postmenstrual age is calculated as the baby’s gestational age at birth plus the postna-
tal age or corrected age, which is calculated by subtracting the number of weeks born
before 40 weeks of gestation from the chronological age.
To determine a baby’s current postmenstrual age, use the gestational age at birth and
add the number of weeks that have passed since birth. Babies less than approximately
32 weeks’ postmenstrual age should be fed with tube feedings. It is unusual for
a baby to have sufficiently achieved neurological maturity to coordinate sucking,
swallowing, and breathing before 32 weeks’ postmenstrual age.
Begin to feed the baby by nipple when he or she meets all of the following criteria:
• Reaches a postmenstrual age of 32 weeks
• Shows signs of readiness for oral feedings (sucks on a pacifier for 3 minutes with a
normal suck-burst-rest pattern, transitions to an alert state, and tolerates holding)
• Has a gag reflex
• Has a normal respiratory rate (,70 breaths/min)
• Is not critically sick (eg, stable respiratory status, not receiving vasopressors)
• Can demonstrate sucking proficiency at the breast or from a nipple on a bottle
Feeding may be from a bottle or by breast if the mother desires to breastfeed. Babies
who will be breastfeeding should be encouraged to explore the breast during kangaroo
care, even if they are less than 32 weeks’ postmenstrual age. They will generally not
latch onto the breast and, even if they aspirate a small amount of breast milk, it will
generally not injure their lungs.
The baby should be offered a pacifier to suck on during tube feedings. This has been
shown to aid in gastric motility and progression in oral feeding skills.
• Temperature control
Some babies may be ready to feed by mouth before they are able to control their tem-
peratures outside an incubator. If a baby weighs less than 1,500 g (,3 lb 5 oz) but oth-
erwise meets the criteria for oral feedings, the feedings may be given in the incubator.
• Fatigue
Frequently, babies tire when they first start to feed by nipple. For this reason, it is
recommended that you begin with oral nipple feeding, based on the baby’s cues, once
or twice per day. Then, you can work up to alternating feedings by mouth with tube
feedings and supplementing oral feedings with tube feedings.
Note: You may leave the feeding tube in place during a nipple feeding, but never
insert it immediately after a feeding. This may cause the baby to vomit and
aspirate milk into their lungs.

Wait at least 1 hour after an oral feeding before inserting a feeding tube.

• How do you transition from tube to oral feedings?

To alternate feedings by mouth with tube feedings, consider following these steps:
Step 1. Give the baby the full feeding by tube (nasogastric or orogastric tube).
Step 2. At the time of the next feeding (2–3 hours later), give the baby the feeding by
nipple (breast or bottle).
Step 3. Give the next feeding by feeding tube.

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Step 4. Repeat the previous cycles for 24 hours. If the baby is managing feedings well by
mouth, increase the number of nipple feedings and decrease an equal number of
tube feedings until the baby is managing all feedings by mouth. Always follow
the baby’s cues.
Some babies will be unable to ingest the entire amount of a feeding by mouth and will
require supplemental feedings. To supplement partial oral feedings with tube feedings,
follow these steps.
Step 1. Give the baby the full feeding by tube. Leave the tube in place.
Step 2. At the time of the next feeding (2–3 hours later), give the baby as much of the
scheduled feeding by mouth as the baby will tolerate.
Step 3. S ubtract the amount the baby ingested by mouth from the total amount of
the planned feeding. The remaining amount should now be given through the
feeding tube.
Example
• The planned feeding is 45 mL (1.5 oz) every 3 hours.
• The baby ingests 30 mL (1 oz) by mouth.
• 45 mL (1.5 oz) – 30 mL (1 oz) 5 15 mL (0.5 oz) of the feeding that has not been
ingested.
• Give the remaining 15 mL (0.5 oz) to the baby through the feeding tube.
As a baby becomes less tired during feedings, the amount ingested by nipple will
increase. Do not force a baby to ingest more by mouth than the baby is capable of eat-
ing easily. This just tires the baby and makes it less likely that the next feeding by nipple
will go well. Some experts recommend not supplementing with tube feedings if the baby
ingests greater than 75% of the baby’s planned feeding by mouth.
Note: O
 ther feeding methods, such as cup feeding and finger feeding, have been used.
The value and safety of these techniques for preterm babies are undergoing
evaluation and therefore are not discussed here.
See Book 3: Neonatal Care, Unit 6, Feeding, for additional information about feeding
preterm babies, as well as their vitamin and iron requirements.
C. Assessment of growth
The growth chart (Figure 7.1) can be used to plot the growth of a female baby born
preterm, while that baby remains hospitalized. There are separate growth charts for
boys and girls. The x-axis is postmenstrual age, or “corrected” age. Once the baby has
regained their birth weight (see Book 3: Neonatal Care, Unit 6, Feeding), this chart can
be used to plot the baby’s incremental weight, length, and head circumference.
• Weight
It is important for a baby to have consistent weight gain before being discharged
from the hospital. Daily weights should be obtained and recorded on a growth chart
that shows the normal weight gain for preterm babies. (See Book 3: Neonatal Care,
Unit 6, Feeding.)
Most preterm babies will be ready for discharge from the hospital when their weight
has reached 1,800 to 2,000 g (3 lb 151/2 oz–4 lb 61/2 oz), as long as they have met all
other discharge criteria. Stable preterm babies should demonstrate steady weight gain
of approximately 20 to 30 g (7⁄10 oz–1 oz) every day.
Many preterm babies are initially fed a 24-kcal/oz formula. They are usually changed
to a 22-kcal/oz formula when they reach approximately 1,800 g (3 lb 151/2 oz). Babies
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Postmenstrual age (weeks)

Figure 7.1. Fenton Preterm Growth Chart—Girls

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

receiving breast milk may also have supplements added to it to increase the caloric density
and vitamin content. See Book 3: Neonatal Care, Unit 6, Feeding, for additional infor-
mation about feeding preterm babies, as well as their vitamin and iron requirements.
If the baby loses weight or does not gain weight appropriately for several days in a
row, you should ask:
– Is the baby getting adequate calories?
– Is the baby cold?
– Is the baby infected?
Example
Baby Crosby is a preterm baby who was transferred back to your hospital when he
was 14 days of age. His growth chart was sent with him.
Several days after arrival at your hospital, daily weights show Baby Crosby to be
gaining less than 20 to 30 g/d (,7⁄10 oz–1 oz/d). His growth is no longer following
the curve on the chart.
You examine the baby and find that his vital signs, color, activity, and feeding pattern are
all normal. You check the amount of calories he is receiving and find that it is adequate.
Baby Crosby is being weaned from his incubator. You note that for the past several
shifts he has been slightly cold, with an axillary temperature of 36.4°C (97.6°F).
You place Baby Crosby back in the incubator for several days. His weight gain gradually
returns to normal and again follows the line that other babies of his birth weight follow.
Prolonged, unrecognized cold stress may divert calories to produce heat, impairing
growth. Despite some unique compensatory mechanisms (eg, chemical [non-shivering]
thermogenesis), neonates—particularly low-birth-weight infants—have limited capac-
ity to thermoregulate and are prone to having a decreased core temperature. By
maintaining the baby in a thermoneutral environment, calorie consumption can be
used for appropriate weight gain and not be diverted for temperature control.
• Head circumference
It is important to measure the baby’s head circumference and record it on the middle
curves of the growth chart. Head size for some babies will increase more rapidly than
normal, while for other babies, head growth will be less than normal. Because the
normal increase in head size is only a very small amount each day, head circumference
is usually measured on a weekly (not daily) basis. Normally, a preterm baby’s head
circumference will increase between 0.5 and 1.0 cm (0.2 in and 0.4 in) each week.
Increased Head Growth/Hydrocephalus
Babies with very low birth weight or those who were critically ill who sustained an
intraventricular hemorrhage are at highest risk for developing hydrocephalus. Babies
with hydrocephalus may have
– Rapidly increasing head circumference (.1.25 cm/wk [.0.5 in/wk])
– Bulging fontanels
– Split sutures
– Eyes that look downward (“sunsetting eyes”)
– Prominent veins over the scalp
– Increased irritability
– Persistent vomiting
– Apnea

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If you note any of these signs, the baby should be observed very carefully
and evaluated with ultrasonography for possible hydrocephalus.

Babies with severe fetal growth restriction may have a bulging fontanelle and split
sutures as their nutrition and subsequent brain growth improves. Cranial
ultrasonography (US) in these babies would show normal ventricular size.
Decreased Head Growth
Head size for some babies will not increase as expected. These babies may have had
severe perinatal compromise or a congenital infection. Rarely, they may have prema-
ture closure of the cranial sutures and fusion of the cranial bones. They should be
evaluated with US. A magnetic resonance (MR) imaging study of the brain may be
indicated. Consult your regional perinatal center.
Head size for some babies will not increase as expected. These babies may have had
severe perinatal compromise or a congenital infection. Rarely, they may have prema-
ture closure of the cranial sutures and fusion of the cranial bones. Imaging studies,
such as head ultrasonography, computed tomography (CT), and MR imaging, may be
indicated. Consult your regional perinatal center for the best imaging technique to
consider for each specific case, as CT entails a significant amount of radiation expo-
sure. If head growth is very poor, the family should be counseled about the possibility
of developmental compromise, and the baby’s developmental progress should be
followed with regular, detailed evaluations.
• Length
A baby’s length should be measured and recorded every week. The most accurate
measurement requires that 2 individuals assist in measuring a baby by using a length
board. Normally, a baby’s length will increase approximately 0.5 cm/wk (0.2 in/wk).
If a baby’s length is not increasing, the baby likely has inadequate caloric intake. Less
common causes for poor increase in length include malabsorption of nutrients and rickets.
D. Monitoring for apnea
1. Which babies should be monitored for apnea?
Preterm babies and sick babies of any postmenstrual age may have apneic spells.
(See Book 3: Neonatal Care, Unit 2, Respiratory Distress.) For this reason, they re-
quire electronic monitoring of heart and respiratory rates. Babies in the following
groups should be monitored:
• All preterm babies weighing less than 1,800 g (,3 lb 151/2 oz)
• All babies less than 35 weeks’ postmenstrual age
• Any baby who has had an apneic spell
• All sick babies
2. How long should these babies be monitored?
Preterm babies should be electronically monitored until they are apnea free and have
reached a
• Weight of 1,800 g (3 lb 151/2 oz)
and
• Postmenstrual age of 35 weeks or more
Babies who have had an apneic spell, regardless of their weight or
postmenstrual age, should be electronically monitored until they are
apnea free.
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The specific duration of monitoring is controversial. Most experts agree that moni-
toring until a baby is apnea free for 5 to 8 consecutive days is adequate. Some ex-
perts recommend that babies born at younger gestational ages may need a longer
period of monitoring (7–8 days), while babies born at older gestational ages could be
safely monitored for a shorter duration (5–6 days). (See the following information if
medication is required to treat frequent apnea episodes.)
3. How do you monitor a baby who is receiving medications to prevent apnea?
Some babies have such frequent episodes of apnea that medications (most commonly
caffeine) are used to decrease the number of apneic spells by stimulating their central
nervous system.
If a baby referred to you is receiving a methylxanthine (caffeine), you should
• Provide continuous electronic cardiorespiratory monitoring. (See Book 1: Maternal
and Fetal Evaluation and Immediate Newborn Care, Unit 4, Is the Baby Sick?
Recognizing and Preventing Problems in the Newborn, Skill Unit: Electronic
Cardiorespiratory Monitoring.)
• Consider obtaining a methylxanthine level if the baby continues to have apnea or
if apnea recurs to determine if a higher dose of medication is warranted. If the
baby has tachycardia or vomiting, which are signs of toxicity, the medication
should be discontinued if the level is too high.
4. How long does a baby require medication to treat apnea?
Most preterm babies stop having frequent apneic spells when they reach a weight of
approximately 1,800 g (3 lb 151/2 oz) or a postmenstrual age of 32 weeks. Regardless
of a baby’s weight, the medication should be stopped when the apneic spells have
decreased to only 1 to 2 mild spells per day. This will allow time for the drug to be
metabolized and removed from the baby’s body to determine if the baby will have
apneic spells when the drug is no longer present in the blood. The amount of time
required for caffeine to be removed from the body varies, depending on the baby,
but generally takes 5 to 8 days.
Some centers obtain a blood level of caffeine to ensure that only minimal traces
of the drug (,5 mg/L) (ie, subtherapeutic levels) are present after discontinuing its
administration, followed by 5 to 8 consecutive days without an apneic spell.
Most experts are reluctant to discharge babies who are receiving a methylxanthine
except in rare, special cases, with very careful follow-up arrangements made between
you as the provider, the family, and the regional perinatal center. Babies who are dis-
charged on caffeine and not followed up carefully may eventually outgrow their orig-
inal drug dose, resulting in a low blood level of the medication. They may then have
a serious apneic spell at home. Babies who are sent home with medication for apnea
should also be discharged with an apnea monitor, and arrangements should be made
for adequate follow-up.
5. When can a baby who has had apnea go home?
• Predischarge preparation
Apnea may lead to hypoxia and bradycardia. If a spell is severe and goes undetected,
some babies will die.
In general, however, if a baby is not taking a medication for stimulation of the
respiratory center and has been apnea free for 5 to 8 consecutive days, it is
unlikely there will be a severe apneic spell at home.

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Therefore, babies who have had apnea may be discharged home when the baby
– Has had no apneic attacks for 5 to 8 consecutive days. (If a medication was used
to treat apnea, the “apnea countdown” should not commence until at least a suf-
ficient amount of time has been allowed for the medication to have reached a
subtherapeutic level, usually 5 days since the last dose administration. Most neo-
natal units have discontinued obtaining a xanthine drug level to confirm that it is
subtherapeutic.
– Maintains their body temperature in a bassinet or open crib
and
– No longer has any other problems
Or
• Home apnea monitoring
Occasionally, some babies are sent home with apnea monitors. These may include
– Babies who have demonstrated apnea despite weighing more than 1,800 g (.3 lb
151/2 oz) and reaching a postmenstrual age of 35 weeks or more
or
– Technology-dependent babies who have abnormal regulation of breathing or
symptomatic chronic lung disease (CLD) or airway abnormalities
– Babies who are discharged with methylxanthine for apnea
Discharging a baby with home apnea monitoring requires careful coordination
among the family, the regional perinatal center staff, and you as the provider. The
family must have received good instruction in use of the monitor and good train-
ing in cardiopulmonary resuscitation. The monitor company must be available to
assist the family and care for the monitor.

Discharge of a baby with home monitoring requires extremely careful

follow-up. Consult your regional perinatal center staff about these special
situations.

E. Monitoring for anemia

Almost all preterm babies will develop anemia at some time prior to discharge from the
hospital.
1. Why does a baby develop anemia?
Preterm and sick babies are at risk for developing anemia because of
• Lower hematocrit values at birth in preterm babies
• Blood taken from the baby for various laboratory tests
• Normal decreases in hemoglobin levels or hematocrit values that occur in all babies
during the first several weeks after birth
• Iron deficiency
• A combination of these factors
2. How do you monitor a baby’s anemia?
The baby’s hematocrit or hemoglobin level should be checked every 2 to 3 weeks
while receiving intensive care. If the hematocrit value is less than 25%, it should be
checked every 3 to 4 days. Once the baby is “feeding and growing,” checking the he-
matocrit or hemoglobin level can be done less frequently, unless the baby is showing
symptoms of anemia.

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3. What degree of anemia is dangerous?

Most babies do not have problems until the hematocrit value is less than 25%. If the
hematocrit value is less than 25%, you should look for the following signs:
• Sustained increase in heart rate (.160 beats/min)
• Sustained increase in respiratory rate (.60 breaths/min)
• Onset of apneic spells or an increase in the number or severity of apneic spells
• Failure to feed well and gain weight
4. What do you do if a baby who is anemic develops signs of anemia?
The baby may need a blood transfusion, or an addition or change in medication for
apnea, or an increase in caloric intake for poor weight gain. Discuss the best treat-
ment for each specific baby with your regional perinatal center staff.
Because of concern for transmission of infections (HIV, cytomegalovirus, hepatitis)
through blood transfusions, many experts recommend transfusions in anemic babies
only if they are clearly symptomatic from anemia. Before giving a transfusion, you
should inform the baby’s parents, discuss the risks and benefits of transfusion with
them, and obtain a signed informed consent from them.
Note: S ome regional perinatal centers administer erythropoietin to the baby to stimu-
late red blood cell production in the bone marrow to prevent the need for
transfusion. (If the decision is made to conduct a transfusion, the erythropoietin
would be stopped.) If you receive a baby who is being given this medication,
consult with the regional perinatal center staff about the dosage, the duration
of therapy, monitoring, and iron supplementation.
5. Why does a baby require iron?
Preterm babies are born with insufficient iron stores for their subsequent growth.
At 4 to 6 weeks of age, when the infant’s bone marrow begins producing red blood
cells, an external source of iron is needed to keep up with that production. Otherwise,
anemia will persist or worsen.
A baby transferred back to your hospital may have some degree of anemia and will
likely be receiving supplemental iron.
6. How is supplemental iron provided?
Additional iron may be provided through the use of commercially available, iron-
fortified formulas for formula-fed babies or iron supplements for breastfed babies.
A normal dosage is 2 mg/kg of elemental iron per day. This amount is provided
in iron-fortified formulas when a formula-fed baby is managing full feedings. If a
baby is iron deficient, receiving breast milk, or had a birth weight of less than 2,000 g
(,4 lb 61/2 oz), 5 to 6 mg/kg of elemental iron per day should be considered.
If supplements are used, whether they are for breastfed babies or a baby with severe iron
deficiency, liquid ferrous sulfate administered daily is started around 2 to 4 weeks of age,
when the baby is tolerating feedings. (See Book 3: Neonatal Care, Unit 6, Feeding.) If a
baby has received a blood transfusion, iron supplementation should be withheld for 2
weeks after the transfusion, since a significant iron load is contained in the transfused blood.

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F. Administering immunizations
Preterm or chronically ill babies who require prolonged hospitalization should be
immunized. Most babies, including preterm babies, who are 8 weeks’ postnatal age
respond appropriately to immunizations.
• Administration of the following vaccines should be considered for all babies at
8 weeks’ postnatal age, regardless of their degree of prematurity:
– Diphtheria, tetanus, acellular pertussis vaccine
– Haemophilus influenzae type b conjugate vaccine
– Enhanced inactivated poliovirus vaccine
– Pneumococcal conjugate vaccine
• Vaccines should be administered in full doses.
• Combination vaccines (the typical combinations used for any other infant) are available.
• Administering a rotavirus vaccine to the hospitalized baby is controversial. Please
consult local infectious disease experts and your regional perinatal team.
• Administration of hepatitis B vaccine should follow the schedule outlined in Book 3:
Neonatal Care, Unit 8, Infections.
• For babies who are returning to your hospital after a period of intensive care, you will
need to determine which vaccines have already been administered and when the next
doses are due according to the standard schedule.
• In general, vaccine-related adverse effects are no more common in preterm babies
than in term babies, although there are some reports of more apneic or bradycardic
spells in preterm babies, as well as an increased transient need for oxygen (typically
24–48 hours), especially in babies who were recently weaned off of oxygen therapy.
• Inactivated influenza vaccine should be administered to infants who are 6 months of
age or older.
Palivizumab (respiratory syncytial virus [RSV] prophylaxis): The American Academy
of Pediatrics recommends that palivizumab (a monoclonal antibody against RSV) be
administered before discharge and then monthly during RSV season to babies in the
groups listed below. RSV season usually runs from October through April, but it may
start earlier or end later in certain areas.
Eligibility Criteria for Palivizumab Administration
• Preterm babies born at less than 29 weeks’ gestation.
• Preterm babies with CLD who are younger than 12 months at the start of RSV season.
CLD is defined as occurring in a baby born at less than 32 weeks’ gestation who
requires greater than 21% supplemental oxygen or positive pressure ventilation for
at least the first 28 days after birth.
• Preterm children with CLD who are between 12 months and 2 years of age at the
start of RSV season and continue to require medical therapy. Medical therapy is
defined as necessitating corticosteroid therapy, diuretics, or supplemental oxygen
during the 6-month period prior to RSV season.
• Babies with hemodynamically significant congenital heart disease who are younger
than 12 months at the start of RSV season. These include babies who
– Require medication to control congestive heart failure
– Have moderate to severe pulmonary hypertension
– Have cyanotic heart disease (preoperative or postoperative)

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Other babies who qualify for palivizumab administration include babies with cystic
fibrosis, anatomical pulmonary abnormalities, or neuromuscular disorders, as well
as babies who have undergone a cardiac transplantation or are severely
immunocompromised during RSV season.
G. Screening for hearing deficits
Preterm and sick babies are at risk for hearing deficits. These babies should receive a
hearing screening before discharge.
Universal screening of all neonates, whether they are sick, at risk, or well, is recommended
and is mandated in most states.
The following factors place babies at risk for hearing loss:
• Birth weight less than 1,500 g (,3 lb 5 oz)
• Any of the congenital TORCH infections (toxoplasmosis, rubella cytomegalovirus,
herpes simplex, and HIV). (See Book 3: Neonatal Care, Unit 8, Infections.)
• Severe perinatal compromise
• Exposure to ototoxic medications
• Bacterial meningitis
• Severe hyperbilirubinemia
• Family history of childhood hearing impairment
• Malformations that involve the head or neck
• Stigmata or other findings associated with a syndrome known to include hearing impairment
When and how should hearing screening be conducted?
Hearing should be evaluated for all babies prior to discharge from the hospital or
by 3 months of age.
Initial screening involves electrophysiological response to sound, by using instruments
designed for newborns. However, it is recommended that babies who required more than
5 days of neonatal intensive care unit care be tested by using brainstem auditory evoked
response technology, because of their increased risk of nerve injury. If results of the initial
screening are equivocal, the baby should be referred for formal diagnostic testing. All
babies should continue to receive routine hearing tests at health supervision examinations.
Some babies are at increased risk of progressive hearing loss in early childhood and will
require rescreening after discharge, even if they have passed the initial NBS. Some states
mandate screening for congenital cytomegalovirus and, if results are positive, antiviral
therapy may be ordered. Serial screening for sensorineural hearing loss is recommended.
H. Screening for retinopathy of prematurity
Retinopathy of prematurity (ROP) is an eye disease of preterm babies that may result
from many different factors, including receiving oxygen therapy. The degree of visual
impairment may range from slight impairment to total blindness. The likelihood and
severity increases with the degree of prematurity. Once ROP has developed, it must be
closely followed with repeated examinations. The ocular damage may progress to cause
retinal detachment if it is not treated promptly, or it may completely resolve.
At-risk, preterm babies need to be examined at recommended time points to be able to
detect the changes of ROP and provide treatment before permanent vision loss occurs.
1. Which babies need examinations for ROP?
In general, the following babies should receive a dilated funduscopic examination by
an ophthalmologist who has experience in ROP:
• Any baby born at less than 30 weeks’ gestation or who had a birth weight of
1,500 g (3 lb 5 oz) or less

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• Any baby with a birth weight between 1,500 and 2,000 g (3 lb 5 oz and 4 lb
61/2 oz) but an unstable clinical course, who is believed to be at high risk for ROP
2. When and how should ROP screening be conducted?
The timing of the first eye examination depends on the baby’s gestational age at
birth (Table 7.1). The initial examination may have been conducted at the regional
perinatal center before the baby was discharged. First examinations should be
performed according to babies’ initial gestational age and corrected age.
The timing of follow-up examinations is dictated by the findings of the first examina-
tion. If both retinas are fully vascularized at the time of the first examination,
additional examinations may not be needed. If the retinas are not fully vascularized,
repeat examinations are indicated, even if there is no initial evidence of ROP.
The ophthalmologist will recommend follow-up examinations based on the initial
retinal findings. If the retina is not fully vascularized, follow-up examinations will be
recommended at intervals ranging from less than 1 week to as long as 3 weeks. The
ophthalmologist will also recommend when treatment is indicated.

To minimize the risk of retinal detachment, treatment should generally be

performed within 72 hours of treatable disease being identified.

Clear communication among clinicians and with parents must stress that follow-up is
essential for successful therapy and that there is a critical period during which treatment,
if needed, can be administered to prevent severe vision loss or blindness.
Even if laser or intravitreal medical therapy is not indicated, it is important for an oph-
thalmologist to follow up with the baby so the parent or parents will know what to ex-
pect for and from their baby. In addition, babies who have had ROP, whether or not
treatment was required, are at increased risk for other vision disorders, including strabis-
mus, amblyopia, and cataracts. Eyeglasses may be indicated in some cases and are most
beneficial when fitted at an early age.

Table 7.1. Timing of the First Eye Examination Based on Gestational Age at Birth
Age (weeks) at Initial Examination
Gestational Age (weeks) at Birth
Postmenstrual Age Chronological Age
22 31 9
23 31 8
24 31 7
25 31 6
26 31 5
27 31 4
28 32 4
29 33 4
30 34 4
Older gestational age, high-risk factors associ- Consider timing based on severity of comorbidities.
ated with the development of retinopathy of
prematurity (eg, anemia, poor weight gain, early
gestational age, low birth weight, lower Apgar
score, prolonged oxygen therapy)

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I. Predischarge cranial US
Most preterm babies born at less than 30 weeks’ gestation will have undergone cranial
US during their acute illness. Current recommendations include repeat cranial
US examination at 36 to 40 weeks’ postmenstrual age to be able to detect the late
development of unsuspected intraventricular hemorrhage, any increase in the size
of the ventricles, and/or periventricular leukomalacia (a risk factor for cerebral palsy).
Although controversial, it is generally not recommended for babies to undergo MR
imaging prior to discharge from the hospital, unless clinically indicated (eg, babies
with a concerning cranial US finding or neurological examination finding).
J. Sleep positioning and sleep environment
There is strong evidence that prone sleeping (on the stomach) increases the risk of
sudden unexpected infant death (SUID). While there are often good reasons for prone
positioning during acute care in the hospital, babies who are receiving continuing care
should be placed on their backs for sleep, and this should be communicated clearly to
the baby’s parent or parents. The American Academy of Pediatrics recommends a safe
sleep environment to reduce the risk of all sleep-related infant deaths. Recommendations
include supine positioning, the use of a firm sleep surface, room-sharing without bed-
sharing, and the avoidance of soft bedding and overheating. Additional recommenda-
tions for SUID reduction include breastfeeding; routine immunizations; the use of a paci-
fier; and the avoidance of exposure to smoke, alcohol, and illicit drugs.
As a further precaution against an apparent life-threatening event or a brief resolved
unexplained event (BRUE), soft objects, such as pillows and stuffed or plush toys, should
not be placed in a baby’s sleeping area. Teach parents that loose or excessively soft bed-
ding should also be avoided, and the baby’s clothing should be close fitting. A one-piece
sleeper with no blanket or quilt may suffice.
K. Car seat testing
It is recommended that all infants born preterm (,37 weeks of gestation), those with a
birth weight of less than 2,500 g (,5 lb 8 oz), those with a cyanotic heart lesion or who
have undergone cardiac surgery, those who are hypotonic, and those who have micro-
gnathia undergo car seat testing prior to discharge home. These infants are at high risk
for desaturation and bradycardia while they are restrained in car seats.
Infants should be appropriately fitted and restrained in the car seat the parent or parents
will be using and should be monitored for 90 to 120 minutes or for the duration of
travel, whichever is longer. The infant’s heart rate, oxygen saturation level, and respira-
tory rate should be monitored. Failure of the car seat evaluation results would be
considered if there is
• Apnea for 20 seconds or longer
• Bradycardia with heart rate less than 80 beats/min
• Oxygen desaturation below 90% for more than 10 seconds
If an infant fails the car seat evaluation, reasons for the failure should be investigated
prior to discharge home. Use of a car bed may also be considered.
L. Assessment of the baby’s family
The birth of an at-risk or sick baby may create enormous emotional and financial
stresses for a family or single parent.
Feelings of anxiety, guilt, inadequacy, and anger are common. Additionally, geographic
distance often separates parents from their baby, which makes visiting difficult.

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The family—particularly the mother—may experience a sense of isolation. Young or

inexperienced parents may be overwhelmed by their new responsibilities.
All these factors influence the normal process of parent-baby bonding and subsequent
interactions of the baby and the baby’s family. Because of the increased stresses created
by the birth of an at-risk or sick baby, these babies are at risk for poor growth and
neglect. Close, frequent contact between the parent or parents and their baby is impor-
tant for the development of a healthy relationship.
Personnel who are caring for these babies must be aware of this high-risk situation. It is
important to promote parent-baby attachment and teach parenting skills (eg, feeding
and bathing their baby), as well as observe family interactions.
1. How can you assess parent-baby interaction?
• Keep a record of telephone calls made by the parent or parents.
• Keep a record of visits.
• Keep a record of caregiving activities taught to the parent or parents and per-
formed successfully by them (eg, feeding, giving the baby vitamins, bathing).
• Assign one nurse to be primarily responsible for communicating with the family.
• Have daily or weekly discussions, starting from the date of admission, among the
nurses, physicians, and social workers, concerning the progress of parent-baby
attachment and family interactions. Promptly address any identified problems.
• Start the assessment of parent-baby interactions immediately and modify the assess-
ment as necessary, as the baby’s hospital course progresses. This may include re-
questing that parents spend additional time at the bedside or room-in with their
baby overnight, if feasible, to allow for more instruction and observation time. Do
not wait until the baby is ready for discharge to assess family interactions, teaching
that has been done and is needed, and the parent’s or parents’ ability to care for
their baby.
2. What can you do to promote parent-baby attachment and positive family
interactions?
• Maintain liberal or unlimited visiting hours.
• Make time available to instruct the mother or the parents in the routine care of
the baby.
• Allow and encourage the parent or parents to stay for long periods and care for the
baby as much as possible while the baby is in the hospital (change diapers; bathe,
hold, and rock the baby; provide frequent and extended kangaroo care [if parents
wish to do so]; feed the baby; and learn to perform any special procedures the baby
will need after discharge).
• Make time to answer questions.
• Praise the parent or parents for well-performed tasks.
• Be patient with timid and inexperienced parents.
• Involve social service personnel and request increased assistance for families with
marked social, transportation, or economic problems.
• Consider involving public health agencies to aid in the assessment of the home
environment.
• Arrange for the mother or parents to “room in” with the baby and provide all daily
care prior to discharge.

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• Request psychiatric assistance for parents who have marked emotional problems.
Providers are encouraged to work closely with their social workers to facilitate
these referrals and ensure that a safe discharge plan is in place.
M. What is developmental care?
Much interest has centered on modifying the nursery environment to reduce light, noise,
handling, and interrupted sleep when providing care to sick and at-risk babies. These
measures have come to be lumped under the term developmental care and have been
used for acutely ill babies and babies who need continuing care.
Many developmental care measures make intuitive sense, and some are particularly
welcomed by parents. Although data are accumulating that suggest individualized care
and family involvement can preserve the child’s development and outcome, large, well-
designed studies are needed to identify what actually makes a difference in childhood
outcomes before specific recommendations can be made about these care measures.
The staff in some neonatal intensive care units believe in caring for babies in a relatively
constant low-light environment while they are extremely immature and critically ill. As
these babies approach term and are getting ready for discharge, they should be exposed
to the day-night light variation they will encounter at home.

Self-test A
Now answer these questions to test yourself on the information in the last section.
A1. Provide 2 reasons why a baby may need continuing care.
________________________________________________________________________________________
________________________________________________________________________________________
A2. List at least 7 basic components of continuing care for preterm babies.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A3. What are 3 important ways to assess the growth of babies who require continuing care?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A4. Preterm babies who need continuing care should be monitored for ____________ until they weigh
more than ____________ grams (_____lb _____ounces), have reached a postmenstrual age of
____________ weeks, and have had no apneic spells for ____________ to ____________ consecutive
days.
A5. True False Most babies respond to immunizations when they reach 8 weeks’ postnatal age,
regardless of their gestational age at birth.
A6. True False To give a supplemental feeding, you first feed the baby as much as the baby will eat
orally, then insert a feeding tube and give the remainder of the calculated volume of
feeding through the tube.

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A7. Which of the following actions is important in weaning a baby from an incubator to a crib?
Yes No
_____ _____ Place a stocking cap on the baby’s head.
_____ _____ Begin antibiotics.
_____ _____ Give the baby at least 25% more calories.
_____ _____ Wrap the baby in extra blankets.
A8. If a baby’s head grows more rapidly than normal, the baby may be developing ____________.
A9. After being weaned to a crib, a baby does not gain weight for several days in a row. List 4 possible
reasons for the lack of weight gain.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A10. Babies who require medications to treat apnea need 2 types of monitoring.
________________________________________________________________________________________
________________________________________________________________________________________
A11. True False Babies may not have a gag reflex, even though they are at 32 to 34 weeks’ esti-
mated postmenstrual age.
A12. True False A 2,100-g (4 lb 10 oz) baby who requires caffeine for management of apneic spells
has had no apnea for 5 to 8 consecutive days. The baby may be safely discharged
home, with no additional monitoring needed.
A13. A baby should be evaluated for possible hydrocephalus if the head circumference grows more than
_______________________________ cm/wk (_________________in/wk).
A14. A normal weight gain is ______________________________ to ______________________________ g/d
(___________________________to _______________________________ oz/d).
A15. Name a drug that may be used for certain babies to decrease the number of apneic spells.
________________________________________________________________________________________
________________________________________________________________________________________
A16. A 1,900-g (4 lb 3 oz) baby has an apneic spell. The baby should be monitored until no apnea has
occurred for _______________________________ to _______________________________ consecutive
days.
A17. Name at least 3 signs that indicate when a low hematocrit value may be dangerous.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A18. Name at least 3 ways to assess parent-baby bonding.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A19. It is recommended that a baby’s
• Weight be determined every _______________________________
• Head circumference be determined every _______________________________
• Length be determined every _______________________________
A20. Name 3 reasons why a baby who requires continuing care may become anemic.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

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A21. Which of the following encourage parent-baby attachment?

Yes No
_____ _____ Unlimited visiting hours
_____ _____ Adapting care routines for parents who wish to provide “kangaroo care”
_____ _____ Many nurses caring for the baby and talking with the family
_____ _____ Involvement of social service in special cases
_____ _____ Teaching parents how to bathe and feed their baby
A22. List 2 groups of babies who should receive an eye examination.
________________________________________________________________________________________
________________________________________________________________________________________
A23. True False During respiratory syncytial virus season, babies in certain groups should receive
palivizumab prior to discharge from the hospital.
A24. True False Routine immunizations with diphtheria, tetanus, acellular pertussis; enhanced
inactivated poliovirus; and pneumococcal conjugate can be given at 8 weeks of age
for most preterm babies, but the dose of each vaccine should be reduced from that
given to healthy, term babies.
A25. True False Treatment for retinopathy of prematurity should be administered within 72 hours of
a treatable condition being identified.
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

4. What is involved in the discharge of a baby from the hospital?

Preparation for discharge is an important task. Although most babies will have few, if any,
major problems at the time of discharge, care must be taken to ensure that both baby and
family are ready for home care to begin.
A. What are the criteria for discharge?
• The baby’s weight is approximately 1,800 to 2,000 g (3 lb 151/2 oz–4 lb 61/2 oz).
Note: Some mature but growth-restricted babies (eg, small for gestational age) may
be discharged at a lower weight, if they are gaining weight appropriately.
• The baby is gaining weight.
• The baby can maintain normal body temperature in a crib.
• The baby is eating well via nipple or breastfeeding well every 3 to 4 hours.
• The baby has been
– Apnea free 5 to 8 consecutive days, never requiring caffeine
or
– Apnea free 5 to 8 consecutive days and off caffeine with a subtherapeutic drug level
(,5 mg/L) prior to the start of the apnea countdown
or
– Apnea free with caffeine and you have detailed plans for careful follow-up of drug
levels
or
– Discharged with an apnea monitor and you have detailed plans for careful
follow-up
Note: Some centers use slightly different discharge criteria for babies with apnea.
• The baby’s medical condition is stable. For example, if the baby has congestive heart
failure, it is well controlled with medications.

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• The baby is stable when breathing room air or receiving low-flow oxygen therapy.
If the baby will be discharged with home oxygen therapy, then oxygen equipment, a
home cardiorespiratory monitor, and an oximeter should be arranged through a home
medical equipment agency. The parent or parents need to be trained in oxygen and
monitor use. The primary care physician should be informed about the baby’s special
medical needs. Usually, the regional perinatal center will also continue to be involved
in the baby’s care.
• The baby’s hematocrit value is stable or not rapidly decreasing. No baby who has
anemia symptoms should be discharged. A baby may be discharged if the hematocrit
value is as low as 22%, as long as the baby is otherwise doing well. Close follow-up
by the baby’s primary care physician will be important.
• Appropriate neonatal screening tests have been conducted (metabolic screening stud-
ies, eye examinations, hearing screening congenital heart disease screening).
– Many babies do not pass their initial hearing screening. Most will pass with repeat
testing; therefore, it is reasonable to repeat the screening prior to discharge.
– Many preterm babies have abnormal results from their newborn metabolic screen-
ings, especially screenings for congenital adrenal hyperplasia and hypothyroidism.
In addition, babies whose blood has been transfused prior to screening do not have
a valid hemoglobinopathy screening result, and this screening will need to be re-
peated in several weeks. It is important that newborn metabolic screening issues
have been resolved prior to discharge or clearly identified for follow-up.
• Immunizations have been administered according to the baby’s age and history.
or
Arrangements have been made for the baby’s primary care physician to see the baby
soon after discharge and to administer the immunizations.
– Palivizumab has been administered, as appropriate, according to the baby’s age, his-
tory, and risk factors, and according to the season of the year.
– Encourage parents to receive an influenza vaccine prior to or during the flu season.
Likewise, siblings and other caregivers should receive an influenza vaccine.
• The baby’s parent or parents have demonstrated the ability to care for their baby, and
the home situation is considered acceptable.
• The baby can tolerate being in a car seat and has passed a car seat test.
B. How do you plan for discharge?
• Anticipate the discharge a minimum of 2 weeks before the baby goes home.
• Notify the parent or parents of the possible discharge date. Solicit and answer their
questions and concerns.
• Notify any special individuals or groups involved in the care of the child (consultants,
public health department, social services).
• Check the parental visiting record and inquire about the home environment. If the
home situation seems unacceptable or unstable, request evaluation by a public health
nurse or social service representative (or both).
• If the baby requires special medications or treatments, make certain the parent or
parents understand the baby’s medical condition, are able to administer the medicines
appropriately, and can perform any necessary treatments. It is also recommended that
parents bring in discharge prescriptions to ensure that the medication formulations,
concentrations, and directions are the same as prescribed.

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• Inform the parent or parents of expectations for the baby’s feedings—anticipated

volumes, frequency of feeds, types of formula needed, and feeding preparations if the
baby will be bottle fed. If the baby is being discharged with a higher caloric formula,
instruct the parent or parents in its preparation. Breastfed babies will usually be dis-
charged with a vitamin D supplement (usually a multivitamin) and iron. If the baby
is eligible for the Special Supplemental Nutrition Program for Women, Infants, and
Children, complete the program prescription. Additionally, providing instructions for
the primary care physician about when to change the baby’s caloric density is helpful.
• Perform a detailed, thorough physical examination of the baby.
• Document the baby’s weight, length, and head circumference measurements. These
will be important for outpatient follow-up care.
• Provide car seat instruction and testing, by using the same car seat the parent or
parents will use for the baby.
• Talk with the parent or parents frequently, and speak with them on the day of dis-
charge. Answer questions, explain the hospital course, and help the parent or parents
anticipate the course the baby will follow for the next several weeks or months.
• Review the immunization schedule.
• Make appointments for well-baby care.
• Arrange for a home visiting nurse or other community-based home visiting program
to assess the baby and the home situation if the baby has significant medical problems
or if the social situation seems unstable.
• Make appointments, as necessary, for follow-up hearing tests or eye examinations (or
both). Ensure clear communication with the parent or parents and other care provid-
ers regarding follow-up eye examinations and the critical need to keep appointments
according to the schedule recommended by the examining ophthalmologist.
• If babies are at high risk for neurodevelopmental delay, refer them to local early inter-
vention programs. Eligibility requirements vary by region.
• Prepare information to send to the baby’s follow-up physicians and/or primary care
physician. Include the baby’s history and current status of problems, growth measure-
ments at the time of discharge, any medications with details about measuring serum
levels, explanations about the need to adjust medication doses as the baby gains
weight, and a list of follow-up appointments.
• In addition to sending written information home with the baby, for babies who have
complex medical problems or discharge needs, consider contacting the baby’s primary
care physician directly.
• Reinforce the need for the at-risk baby to be seen for serial developmental evaluations.
Many regional perinatal centers have follow-up clinics. Babies for whom serial devel-
opmental follow-up is appropriate include very low-birth-weight babies (birth weight
,1,500 g [,3 lb 5 oz]) and extremely low-birth-weight babies (birth weight ,1,000 g
[,2 lb 3 oz]), as well as babies with a history of intraventricular hemorrhage, seizures,
hydrocephalus, hypoxic-ischemic encephalopathy, CLD, or other chronic medical
conditions.

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 UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

Self-test B
Now answer these questions to test yourself on the information in the last section.
B1. True False A baby who has started receiving a new drug to treat an unstable medical condition
can be discharged the same day.
B2. True False An asymptomatic baby with a stable hematocrit value of 22% to 24% can be dis-
charged from the hospital.
B3. A baby is medically ready for hospital discharge. However, despite repeated attempts to contact the
parents, you have been unable to reach them for 2 weeks. One day, they appear unexpectedly at the
hospital and want to take their baby home. What would you do?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
B4. List at least 5 activities that are important when planning for discharge.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
B5. True False An appropriate-size-for-gestational-age baby weighs 1,400 g (3 lb 1 oz), has never
had an apneic spell, and is gaining weight steadily. This baby can safely be dis-
charged home at this time.
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

Subsection: Babies With Special Problems

1. What special problems may be encountered in babies who require

continuing care?
Most babies referred to you will be stable preterm babies. However, some babies who recover
from an initial severe illness will develop special problems that require frequent, but not con-
stant, attention.
For example, some babies who were born extremely preterm or who required assisted ventila-
tion for treatment of severe respiratory distress syndrome may develop lung damage. These
babies can eventually recover but may require supplemental oxygen for long periods. They
may have needed numerous blood gas determinations during the acute phase of the disease. At
this stage of the illness, they need blood gas analyses much less often, especially if continuous
pulse oximetry is used. Sudden changes are not expected, yet the babies must be monitored
for this special problem, as well as receive the routine care described earlier in this unit.
The following list is problems sometimes seen in babies who are recovering from acute
neonatal illnesses. If you are caring for a baby who has one of these problems, your regional
perinatal center can give you more specific information about the cause, treatment, and
prognosis of the particular problem in that particular baby.
A. Chronic lung disease of prematurity
Postneonatal CLD (also known as bronchopulmonary dysplasia) is a form of lung dis-
ease thought to result from the combined effects of high concentrations of oxygen and

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

trauma to the lungs from ventilator therapy. It is generally defined as requiring supple-
mental oxygen at 36 weeks’ postmenstrual age. Some extremely preterm babies will
develop CLD, even if they did not need therapy with a ventilator or a high oxygen con-
centration. Babies with CLD may require supplemental oxygen via nasal cannula for
weeks or even months.
In general, these babies exhibit steady improvement and progressively require less
oxygen to maintain a good blood oxygen concentration. It is important to remember,
however, not to decrease supplemental oxygen too quickly, because chronic low blood
oxygen levels may cause serious, permanent damage to a baby’s heart and lung blood
vessels.
Unlike adults with CLD, these babies form new, healthy lung tissue as they grow;
therefore, they may eventually recover completely. If they become ill, it is usually related
to the onset of pneumonia or fluid retention.
Occasionally, some babies will require supplemental oxygen for such long periods that
you, the regional perinatal center, and the family may decide it is most reasonable for
the baby be cared for at home. These are very special cases, with the baby receiving
supplemental oxygen and other medications at home, and will be managed by you and
the regional perinatal center together.
B. Gastroesophageal reflux
Gastroesophageal reflux occurs when the stomach contents reflux into the esophagus.
This disorder, which is apparently more common in preterm babies than term babies,
is being diagnosed with increasing frequency in sick and at-risk babies. It typically
manifests with frequent spitting or vomiting after feedings or continual regurgitation,
and it may be associated with apnea and bradycardia.
Treatment regimens may include thickening feedings and positioning the baby. There is
no evidence that the use of acid inhibitors (H2-receptor antagonists or proton pump
inhibitors) decreases reflux, and there is increasing evidence that acid inhibition can
increase a baby’s risk for sepsis and necrotizing enterocolitis.
Consult with your regional perinatal center staff to establish a treatment plan specific to
each particular baby.
C. Short bowel syndrome
Sometimes babies are born with less than the normal length of intestines. Other babies
have variable lengths of intestine removed during surgery for certain types of bowel
disease, such as necrotizing enterocolitis.
Sometimes these babies have ostomies. If an ostomy is present, it will require special
care, and parents should receive detailed instructions. Ostomies may be permanent, or
the bowel may be reconnected at a later date.
Babies with a decreased amount of intestine for any reason may have trouble absorbing
milk or formula. They may have problems with weight gain, blood electrolyte imbal-
ance, or dehydration (or any combination of those). Breast milk remains the preferred
source of nutrition, because of growth hormones and digestibility. If breast milk is not
available, infant formulas with partially hydrolyzed protein or amino acid–based formu-
las are often needed. These babies will also require frequent weight checks and occa-
sional checks of blood electrolyte levels. Blood electrolyte samples are needed more
often if the volume of ostomy output or the number of stools increases.

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 UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

D. Cholestatic jaundice
Babies who have required long periods of parenteral nutrition therapy may develop
increases in their direct (conjugated) bilirubin level. This may be associated with increases
in their liver enzyme levels. In most cases, this condition will resolve over time, with no
long-term complications. Abdominal US may be performed to rule out other causes. Many
babies benefit from the drug ursodiol, which stimulates bile solubility and flow. Monitoring
usually includes serial measurements of total and direct bilirubin and liver enzyme levels. If
the conjugated bilirubin level is highly increased and the baby’s stool is lacking pigment,
provide a water-soluble (liquid) form of fat-soluble vitamins (vitamins A, D, E, and K, or
“ADEK”) until the cholestasis resolves, and consider consulting a gastroenterological expert.
E. Seizures
There are many causes of seizures in the newborn period. Babies may be receiving anti-
convulsants, such as phenobarbital, when they are sent home from nurseries. These
babies must be monitored for the recurrence of seizures and have their anticonvulsant
drug dose adjusted as they grow. Some will require determination of blood levels of their
anticonvulsant medication.
They must also be observed carefully for signs of developmental delay.
F. Hydrocephalus
Babies who were ill at birth will occasionally develop hydrocephalus, particularly if
they were born extremely preterm and developed an intraventricular hemorrhage. These
babies may require the insertion of a shunt to prevent the accumulation of excess cere-
brospinal fluid in the brain. The shunt may malfunction, and fluid pressure may build
up. These babies may also get shunt infections. Babies with shunts must be monitored
for change in activity level (eg, increased lethargy) or increase in head size (or both),
which would suggest a shunt malfunction or infection.
Babies with mild hydrocephalus but without shunts should have head circumferences
and tenseness of their fontanels checked frequently. Coordinate with the regional
perinatal center to schedule follow-up cranial US examinations.
G. Congenital heart disease and patent ductus arteriosus
Babies with congenital heart disease may be cyanotic (blue) or acyanotic (pink), depend-
ing on the type of abnormalities in the formation of their hearts.
Cyanotic babies frequently require surgery early in life. They require monitoring for the
level of blood oxygen, medication levels, and development of acidosis, and for “blue
spells.”
Babies with acyanotic heart disease are frequently receiving medications for congestive
heart failure. They require monitoring for signs of congestive heart failure and may need
adjustment of their medications.
Many preterm babies have a patent ductus arteriosus (PDA) during their acute illness.
Medications (indomethacin, ibuprofen, or acetaminophen) may have been used to close
the PDA, or surgical ligation may have been required. Some babies may continue to have
a small PDA that is causing no or minimal symptoms. A systolic murmur may be heard.
The usual course for these PDAs is to eventually close on their own. However, follow-up
with a pediatric cardiologist should be arranged.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Soft, systolic murmurs are often heard in the growing preterm baby. These “physiologi-
cal,” “innocent,” or “flow” murmurs are not associated with other symptoms. They are
often associated with mild to moderate anemia, which causes rapid blood flow through
the lung.

2. How do you care for babies with these special problems?

Certain monitoring and treatment routines should be performed for these babies. Use the
following guidelines (Table 7.2), but do not hesitate to call the regional perinatal center if you
have questions or if the baby appears to be worsening.
Note that the intervals suggested for monitoring are intended for stable babies. An unstable
baby may need more frequent monitoring.

Knowledge of the best treatment for these conditions changes rapidly.

Frequent communication with your regional perinatal center staff is important if
you are caring for a baby who has a special problem.

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07_Unit7_BKIV_PCEP_137-180.indd 165

Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems
Monitoring Reason for Monitoring Abnormality Action
A. CLD (Also Known as Bronchopulmonary Dysplasia)
Weight (every day) Babies with CLD may retain fluid in their lungs and Rapid increase in weight • Decrease the baby’s fluid intake, perhaps by
may have right-sided heart failure. gain increasing the caloric density of the
feedings.
• Increase the diuretic dose or begin diuret-
ics.
Babies with CLD require more energy to breathe. Lack of weight gain • Review the concentration of calories in for-
Therefore, they may require more than the normal mula or human (breast) milk supplements.
number of calories to breathe and grow. • Check the baby’s blood oxygen concentra-
tion. Babies with chronically low blood ox-
ygen levels will not gain weight well. The
baby’s oxygen saturation levels should be
maintained slightly higher (eg, 92%–96%).
Medications Babies with CLD are frequently receiving several • Worsening arterial Increase the dose appropriately for the baby’s

UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

medications. These medications may require blood gas results weight.
frequent dose adjustment. Some medications are • Increased weight gain
tapered routinely, while others are increased
gradually as the baby grows.
Albuterol Nebulized albuterol is frequently used to decrease • Increased wheezing • Administer the dose immediately; monitor
bronchospasm in babies with CLD. (too little drug) the baby’s heart rate.
Dosage: 0.1–0.5 mg/kg/dose every 4–6 hours • Tachycardia, 180 • May need to withhold the dose and in-
beats/min (too much crease the interval between doses.
drug)
Caffeine citrate Used more often than aminophylline, since the ther- • Restlessness Therapeutic level: 8–20 mcg/mL
apeutic index is greater, although the relative effect • Recurrent vomiting
on bronchospasm is not well defined, and the
availability in outpatient settings is limited.
Loading: 20 mg/kg enterally or intravenously over
30 minutes.
165

Maintenance: 5–10 mg/kg enterally or intravenously

every 24 hours.
(continued )
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PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
A. CLD (Also Known as Bronchopulmonary Dysplasia) (continued)
Spironolactone Dosage: 1–3 mg/kg/dose every 24 hours, given May cause hyperkale- • Monitor serum electrolyte levels.
(Aldactone) orally mia; use with caution • Try to wean the baby off the medication as
in patients receiving the lung disease improves.
supplemental potassium. • Consider adding potassium chloride supple-
Furosemide (Lasix) Dosage: 1–4 mg/kg/day divided into 3–4 doses • Electrolyte abnormali- ments to feedings to correct hypochloremic
ties (hypochloremic alkalosis.
Chlorothiazide Dosage: 10–20 mg/kg/dose every 12–24 hours, given
orally alkalosis from
chloride loss)
• Osteopenia and
kidney stones from
increased calcium
excretion
Hematocrit value Babies with CLD may become worse if they become Hematocrit value , 30% • Look for the cause of anemia.
(bi-weekly) anemic. for babies still requiring • Treat the cause of anemia.
oxygen therapy • Consider transfusion if oxygen requirements
are high and the baby is not improving.
Electrolytes (every Diuretics may cause abnormalities in serum sodium, Decreased levels of • Increase sodium, potassium, and chloride
week) potassium, chloride, or calcium levels (or any com- sodium, potassium, intake in the baby’s diet.
bination of those). Low chloride excretion has been and chloride • A decrease in serum sodium level in the
associated with poor growth and poor outcome. presence of increased body weight may
High calcium excretion has been associated with indicate excess fluid retention, in which
renal calculi. case sodium chloride therapy would be
contraindicated.
• Consider decreasing the dose of furosemide
or adding spironolactone (or both).
CLD may lead to fluid overload, with a dilutional Decreased sodium level Assess the baby for weight gain. Restrict
decrease of serum sodium level. fluids; increase the diuretic dose.
(continued )
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07_Unit7_BKIV_PCEP_137-180.indd 167

Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
A. CLD (Also Known as Bronchopulmonary Dysplasia) (continued)
Chest radiography Babies with CLD frequently develop pneumonia. Pneumonia (always • Consider starting antibiotics.
compare follow-up ra- • Provide chest physical therapy.
diographs with prior
baseline radiographs)
Electrocardiography or CLD may lead to right ventricular hypertrophy. Worsening right • The baby’s oxygen saturation levels
echocardiography ventricular hypertrophy should be maintained slightly higher
(eg, 92%–98%). Make certain the baby’s
Pao2 is $ 60 mm Hg or the oxygen satura-
tion is 92%–98% (or both) during sleep
and all activities.
• Make certain the baby is receiving
adequate doses of diuretics.
• Extended periods of suboptimal oxygen-
ation or deteriorations should be evaluated

UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

with echocardiography or electrocardiogra-
phy. Consider these modalities in babies
,30 weeks’ gestation who still require sup-
plemental oxygen at 36 weeks’ gestation.
• Consult the regional perinatal center if
there is worsening right ventricular hyper-
trophy at electrocardiography or echocar-
diography; the treatment for CLD may be
inadequate.
Heart rate and Continuous electronic heart rate and oximetry mon- Bradycardia • Administer oxygen.
oximetry monitoring itoring is warranted for any hospitalized baby who • Assess the baby for increased secretions
requires supplemental oxygen. Bradycardia may oc- and blocked airway.
cur with desaturations. Oximetry should be used to • Assess the baby for infection.
determine whether supplemental oxygen is needed.
167

(continued )
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PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
A. CLD (Also Known as Bronchopulmonary Dysplasia) (continued)
Physical findings Babies with CLD frequently have reactive airways Increased wheezing • Assess the arterial blood gas and/or
Note: Sustained de- and demonstrate marked bronchospasm (wheezing). oxygen saturation.
crease in respira- Often, these babies require bronchodilators. • Assess the bronchodilator level/dose and
tory rate is a Bronchospasm can also result from chronic hypoxia. the diuretic dose.
good indicator of • Consider administering an immediate dose
improvement. of an inhaled bronchodilator.
• Assess the baby for pneumonia.
Rales may be caused by infection or fluid retention Increased rales and • Assess the arterial blood gas or oxygen sat-
in the lungs. Babies with CLD may also have hepa- increased uration.
tosplenomegaly from right-sided heart failure. hepatosplenomegaly • Assess the diuretic dose.
• Assess the baby for pneumonia.
Babies with CLD may have excess secretions that, if Excess secretions, signs • Increase the frequency of chest physical
not removed, predispose the baby to pneumonia. of pneumonia therapy. Administer the therapy at least
twice a day.
• Assess the baby for pneumonia.
Supplemental Fio2 As the baby improves, you will be able to lower the None Decrease the Fio2 for saturations consistently
Fio2 required to maintain a Pao2 of approximately .94%
60 mm Hg and an oxygen saturation level of
90%–94%.
Any Fio2 greater than that necessary to maintain a Persistently high Fio2 • Monitor the arterial blood gases or oxygen
Pao2 of 60 mm Hg (or oxygen saturation of saturation.
90%–94%) may be unnecessarily damaging to • Decrease the Fio2 for consistent Pao2
the lungs of babies with chronic disease. . 70 mm Hg or oxygen saturation
. 94%.
Too low an Fio2 may cause a low Pao2, increased Cyanosis, increased • Monitor the arterial blood gases or oxygen
bronchospasm, or decreased blood flow to the lungs bronchospasm, saturation.
and may also inhibit the baby’s growth. tachypnea, or wheezing • Increase the Fio2 for consistent Pao2
, 60 mm Hg or oxygen saturation , 90%.
(continued )
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Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
A. CLD (Also Known as Bronchopulmonary Dysplasia) (continued)
Blood gas Initially, blood gases are frequently monitored in None None
sick babies, but monitoring frequency decreases as
the baby grows older and more stable. Generally,
capillary blood gases checked 1–2 times per week in
babies who require positive pressure with continu-
ous pulse oximetry provides adequate monitoring.
Oxygen Pao2 should be kept at approximately 60 mm Hg. Pao2 ,60 mm Hg or • Increase supplemental oxygen.
Oxygen saturation during all activities (feeding, oxygen saturation • Look for the cause of decreased Pao2
sleeping) should be kept slightly higher than that for ,90% (pneumonia, increased secretions, worsen-
respiratory distress syndrome (eg, 90%–94%). ing right-sided heart failure).
• Assess the baby for bronchospasm.
Carbon dioxide The carbon dioxide level is usually increased in CLD. Increased Paco2 over • Assess the baby for pneumonia.
• If the baby’s carbon dioxide level is progressively the baseline value • Obtain a chest radiograph.
increasing, the baby’s condition is worsening. • Suction any secretions.
• If the carbon dioxide level is decreasing, the baby
is improving.

UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

pH level The pH level is usually normal in babies with CLD. Decrease in pH level • Assess the baby for bronchospasm.
If it is increased or decreased, the baby should be • Assess the baby for pneumonia.
evaluated for the presence of an intercurrent illness. • Obtain a chest radiograph.
• Suction any secretions.
B. Retinopathy of Prematurity
Evaluation by an Examine babies born at 30 weeks’ gestation or with Blindness may occur if • Laser coagulation or medical therapy
ophthalmologist a birth weight ,1,500 g (,3 lb 5 oz) and babies the retinopathy is not may be helpful. If needed, it should be
with a birth weight between 1,500 and 2,000 g treated appropriately. performed within 72 hours of a treatable
(3 lb 5 oz and 4 lb 6½ oz) but with an unstable condition being identified.
clinical course and believed to be at high risk for • Contact your regional perinatal center staff
ROP. If the baby’s retinas are not fully vascularized, for information concerning management
repeat examinations are indicated according to and referral.
gestational age and retinal status, even if there was • Intraocular injection of monoclonal antibody
no initial evidence of ROP. Dilated funduscopic (bevacizumab) to vascular endothelial
169

examination should be performed by an growth factor may be used to treat early, ag-
ophthalmologist who has experience in ROP. gressive disease.
• If prescribed, have the baby fitted with correc-
tive eyeglasses early.
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(continued )
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PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
B. Retinopathy of Prematurity (continued)
Family’s understanding Families may have difficulty accepting that their Denial of the baby’s Counsel the family that keeping examination,
of the disease and inter- baby may be at risk for vision impairment. condition by the family treatment, and follow-up appointments is
action with their baby or being inadequately essential for optimal preservation of the
informed about the con- baby’s sight.
dition and the impor-
tance of follow-up
C. Gastroesophageal Reflux
Weight Babies with gastroesophageal reflux may regurgitate Lack of weight gain Consider using formula/milk thickeners.
so much that they do not satisfactorily gain weight.
Medications Babies with gastroesophageal reflux are sometimes • More reflux events Consult regional perinatal center staff.
given medications to improve gastric emptying and • Increased apnea/
gastrointestinal motility. bradycardia
D. Short Bowel Syndrome
Weight (every day) An increase in weight is a sign of adequate nutri- Decrease in weight • Assess the baby’s caloric intake.
tional intake and absorption. A decrease in weight is • Assess the number of stools or the volume
a sign of nutrient malabsorption. of ostomy output, stool pH levels, electro-
lytes, and serum urea nitrogen levels.
Formula-fed babies who have more stools or Increase in output • Assess the baby for malabsorption of car-
increased ostomy output may develop nutrient bohydrates by checking the pH levels of the
malabsorption. stool. A pH level , 6 suggests carbohy-
drate malabsorption.
• Give the baby half-strength formula or
clear liquids temporarily.
(continued )
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Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
D. Short Bowel Syndrome (continued)
Electrolytes and serum Babies with increased fluid losses through the • Decreased sodium • Increase the sodium intake in the baby’s diet.
urea nitrogen levels intestines may develop electrolyte abnormalities. level • Increase the potassium intake in the
• Decreased potassium baby’s diet.
level • Assess the baby for signs of dehydration
• Increased serum urea and consider administering intravenous
nitrogen levels fluids.
Family understanding The family must be educated about ostomy care, or • Lack of instruction • Teach the family about the importance of
of the baby’s condition care of the buttocks, and taught warning signs, such • Lack of interest their care and observations.
as increase in stools or ostomy output. • Observe the family’s ability to provide all
details of care for their baby.
E. Seizures
Anticonvulsant drugs As the baby grows and gains weight, the anticonvul- Increase in seizure activ- Discuss with your regional perinatal center
sant dose may need to be increased. ity staff the requirement for:
After administering a loading dose to achieve sup- • Drug level monitoring

UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

pression of seizures, use a maintenance dosage of • Adjustment of anticonvulsant dosing
3.5–5.0 mg/kg/day of phenobarbital.
Measure serum levels periodically. Adjust the dose
as necessary to maintain a serum level of 20–30
mcg/mL, in consultation with a pediatric neurolo-
gist.
F. Hydrocephalus
Head circumference Worsening hydrocephalus or a malfunctioning shunt The head circumference • Perform cranial ultrasonography.
(daily) will cause the baby’s head circumference to increase. increases . 1.25 cm/wk • Consult regional perinatal center staff.
(.0.5 in/wk) or 0.25
cm/d (0.1 in/d), over
several days.
Signs of infection Babies with shunts in place may develop infections • Irritability • Obtain blood cultures, complete blood cell
around or within the shunts. • Lethargy counts, etc.
171

• Vomiting • Consult regional perinatal center staff.

• Fever
• Tense fontanels
(continued )
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PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
G. Poor Head Growth
Head circumference Provide continued surveillance of babies with severe Head circumference • Assess the baby’s caloric intake and
(weekly) perinatal compromise. does not increase at weight gain.
least 0.5 cm/wk (0.2 in/ • Monitor the baby’s developmental progress.
wk) for several weeks. • Perform cranial ultrasonography.
• Discuss your concerns with the family.
• Consult regional perinatal center staff.
H. Poor Parent-Baby Attachment
Number of visits/phone Sick or preterm babies are more frequently • Few visits Make time to listen to parents, counsel
calls neglected than healthy, term babies. • Few phone calls parents, and teach parenting and caregiving
skills (eg, feeding, bathing).
Interaction among fam- The care of sick babies may lead to disagreements Excessive friction • Involve your hospital’s social service
ily members amongst family members. among family members department.
• Consult your local public health
department.
Parenting skills • Substance users • Poor parenting skills • Consult a psychiatrist if family problems
• Young, single, first-time parents • Inadequate resources are severe.
• Indigent parents • Detain the baby until family/social prob-
lems are resolved or the situation is stable
enough for the baby to be discharged.
Readiness of the No readiness in the Arrange frequent follow-ups with a visiting
family’s home home for the baby nurse and regular follow-ups with the baby’s
physician.
I. Congenital Heart Disease
Heart rate Worsening CHF or hypoxia will affect the baby’s • Increase in heart rate • Assess the baby for CHF.
heart rate. • Decrease in heart rate • Assess the baby for hypoxia.
Weight (every day) Worsening CHF will result in fluid retention and ex- • Weight gain .20–30 • Assess the baby for increasing CHF (in-
cessive weight gain. g/day (.7/10–1 oz/day) creased rales, increased hepatosplenomegaly).
• Weight loss • Consider an increase in diuretic dose.
• Assess the baby for inadequate caloric
intake.
(continued )
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Table 7.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued )
Monitoring Reason for Monitoring Abnormality Action
I. Congenital Heart Disease (continued)
Hematocrit value A low hematocrit value may cause CHF. • ,30% • Look for the cause for anemia.
A high hematocrit value may mean chronically • .60% • Assess the baby for increasing CHF.
worse hypoxia in a cyanotic baby. • Consult regional perinatal center staff.
Medications Babies with heart disease may be given medications
for which the dose will need to be increased with
growth and weight gain.
Diuretics Diuretics help prevent fluid retention resulting from Worsening CHF Increase the dose appropriately for the baby’s
CHF. weight.
Electrolytes (every Diuretics may cause excessive loss of sodium, Decrease in sodium level Carefully increase the dose of sodium supple-
week) potassium, chloride, or calcium (or any combination ment, but consider that a decrease in the se-
of those). rum sodium level in the presence of weight
gain may indicate worsening CHF.
Decrease in potassium Increase the potassium supplementation.

UNIT 7: CONTINUING CARE FOR AT-RISK BABIES

level
Decrease in chloride Increase the chloride supplementation (usu-
level ally as potassium chloride) or decrease the
diuretic dose.
Hypercalciuria Monitor the baby for renal calculi with uri-
nalysis and possibly renal ultrasonography.
Chest radiography Observe the baby for signs of CHF or pneumonia. Lung infiltrates or en- • Increase the diuretic dose.
larging heart size (or • Consider starting antibiotics.
both)
Electrocardiography or Babies with heart disease may develop worsening • Increasing left or Consult regional perinatal center staff.
echocardiography right or left ventricular hypertrophy or demonstrate right ventricular
arrhythmias. hypertrophy
• Development of
arrhythmias
173

Physical examination Worsening CHF will cause increased rales, hepato- • Increased rales • Adjust the dosage of any medications
splenomegaly, and a gallop rhythm of the heart. • Increased hepato- according to the baby’s weight.
splenomegaly • Consult regional perinatal center staff.
• Presence of a gallop
5/29/21 8:08 AM

Abbreviations: CHF, congestive heart failure; CLD, chronic lung disease; Fio2, inspired oxygen concentration; ROP, retinopathy of prematurity.
 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Self-test C
Now answer these questions to test yourself on the information in the last section.
C1. Name 2 types of congenital heart disease.
________________________________________________________________________________________
________________________________________________________________________________________
C2. True False A baby with seizures appears normal at the time of discharge. In spite of this, the
child should be assessed later for the appearance of developmental delay.
C3. Babies with hydrocephalus may require insertion of a __________________________ to prevent the
accumulation of excess cerebrospinal fluid.
C4. True False Babies who require supplemental oxygen for months generally recover and can be
discharged from the hospital.
C5. True False Visual impairment from retinopathy of prematurity may range from slight impair-
ment to total blindness.
C6. Babies with cyanotic congenital heart disease may require monitoring for
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
C7. Two major problems with shunts used to treat hydrocephalus are ____________________________
and _____________________________.
C8. When babies with chronic lung disease become ill, it is usually with
______________________________ or _____________________________.
C9. Babies with acyanotic congenital heart disease are frequently given medications for
________________________________________________________________________________________
C10. The dose of anticonvulsant drugs should be adjusted according to the
A. Length of the baby
B. Weight of the baby
C. Head circumference of the baby
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.

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CONTINUING CARE FOR AT-RISK BABIES

Recommended Routines
All the routines listed below are based on the principles of perinatal care presented in the unit
you have just finished. They are recommended as part of routine perinatal care.
Carefully read each routine and decide whether it is standard operating procedure in your
hospital. Check the appropriate blank next to each routine.

Procedure Standard Needs Discussion Recommended Routine

in My Hospital by Our Staff
______________ ______________ 1. Establish the following policies for babies who
require continuing care:
______________ ______________ • Maintain the baby in an incubator until the
baby weighs approximately 1,600 to 1,700 g
(3 lb 8 oz to 3 lb 12 oz).
______________ ______________ • Feed the baby with tube feedings until the
baby reaches 32 to 34 weeks’ postmenstrual
age; demonstrates a gag reflex; can coordinate
sucking, swallowing, and breathing; and dem-
onstrates feeding cues.
______________ ______________ • Weigh the baby daily.
______________ ______________ • Measure the baby’s head circumference and
length weekly.
______________ ______________ • Monitor the baby for apnea until
______________ ______________ – The baby weighs 1,800 g (3 lb 151/2 oz)
______________ ______________ – The baby reaches a postmenstrual age of
35 weeks
______________ ______________ – The baby has been apnea free for 5 to 8 con-
secutive days (start the countdown at least
5 days after the last dose of caffeine or with
a subtherapeutic level)
______________ ______________ • Periodically measure the baby’s hematocrit
value. Discharge the baby with an iron-forti-
fied formula or supplemental iron (or both),
unless there are contraindications.
______________ ______________ • Start assessment of the home environment and
begin to teach caregiving skills as soon as a
baby is admitted.
______________ ______________ • Record the family’s visiting patterns and per-
formance of caregiving skills.
______________ ______________ 2. Develop a predischarge checklist to review for all
babies who require continuing care.
______________ ______________ 3. Develop a system for periodically communicating
with the regional perinatal center staff regarding
the progress of any baby with special problems
who requires continuing care.
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Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.

Self-test A
A1. Any 2 of the following reasons:
• Additional weight gain
• Monitoring of special problems
• Physiological maturation to improve functions such as temperature control, regular
respirations, and feeding
A2. Any 7 of the following components:
• Temperature control
• Feeding
• Assessment of growth
• Apnea monitoring
• Monitoring for anemia
• Assessment of family
• Administering immunizations
• Screening of hearing
• Screening for retinopathy of prematurity
• Accustoming the baby to being in a supine (on the back) sleep position
• Predischarge cranial ultrasonography
A3. Weight
Head circumference
Length
A4. Preterm babies who need continuing care should be monitored for apnea until they weigh
more than 1,800 grams (3 lb 151/2 ounces), have reached a postmenstrual age of 35 weeks,
and have had no apneic spells for 5 to 8 consecutive days.
A5. True
A6. False. Reason: A feeding tube should not be inserted during or shortly after a feeding.
Doing so may cause the baby to vomit and thus increase the risk that the baby will
aspirate some of the feeding contents.
A7. Yes No
  X         Place a stocking cap on the baby’s head.
        X   Begin antibiotics.
        X   Give the baby at least 25% more calories.
  X         Wrap the baby in extra blankets.
A8. If a baby’s head grows more rapidly than normal, the baby may be developing
hydrocephalus.
A9. The baby is cold.
Caloric intake is inadequate.
The baby is acidotic.
The baby is infected (septic).
A10. Continuous electronic heart and respiratory rate monitoring
Checking the blood level of the medication

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A11. True
A12. False. Reason: Prior to discharge, babies should be apnea free for 5 to 8 consecutive days
after the medications have been stopped and the baby’s blood has been tested and
been shown to be drug free (except in very rare circumstances when home monitor-
ing may be used and careful follow-up is ensured).
A13. A baby should be evaluated for possible hydrocephalus if the head circumference grows
more than 1.25 cm/wk (0.5 in/wk).
A14. A normal weight gain is 20 to 30 g/d (7⁄10 to 1 oz/d).
A15. Caffeine
A16 A 1,900-g (4 lb 3 oz) baby has an apneic spell. The baby should be monitored until
no apnea has occurred for 5 to 8 consecutive days.
A17. Any 3 of the following signs:
• Sustained heart rate faster than 160 beats/min
• Sustained respiratory rate faster than 60 breaths/min
• Onset of or increase in apneic spells
• Poor feeding and poor weight gain
A18. Any 3 of the following ways:
• Record the telephone calls and visits made by the baby’s parents.
• Record caretaking activities taught to the parents and performed by them.
• Assign one nurse to be the primary nurse communicating with the family.
• Have regular, frequent discussions among the nurses, physicians, and social workers
concerning parent-baby attachment and family interactions.
• Start assessment early, so there is time to address any problems or provide adequate
teaching before the baby is ready to be discharged home.
A19. Day
Week
Week
A20. Any 3 of the following reasons:
• Blood taken for laboratory tests
• Iron deficiency
• Normal decrease in hemoglobin level and hematocrit value that occurs in all babies in the
weeks after birth
• Lower hematocrit values of babies born preterm
A21. Yes No
  X   Unlimited visiting hours
  X   Adapting care routines for parents who wish to provide “kangaroo care”
  X   Many nurses caring for the baby and talking with the family
  X   Involvement of social service in special cases
  X   Teaching the parents how to bathe and feed their baby
A22. Any baby born at 30 weeks’ gestational age or less or with a birth weight of 1,500 g
(3 lb 5 oz) or less
Any baby with a birth weight of 1,500 g to 2,000 g (3 lb 5 oz–4 lb 6½ oz) with an
unstable course and thought to be at high risk for retinopathy of prematurity
A23. True

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A24. False. Reason: Diphtheria, tetanus, acellular pertussis; Haemophilus influenzae type b con-
jugate; enhanced inactivated poliovirus; and pneumococcal conjugate vaccines
should each be given in the usual dose of 0.5 mL for preterm and term babies.
A25. True
Self-test B
B1. False. 
Reason: Babies requiring medication should have their conditions stabilized and
their response to any new medication assessed before being discharged.
B2. True. However, babies with signs of anemia should not be discharged.
B3. Evaluate the parents’ readiness and ability to care for their baby at home.
• Observe the parents taking care of their baby (feeding, bathing, changing diapers, etc).
Encourage the parents to visit for several hours or days (or both). Assist them in making
these arrangements.
• Ask the parents what preparations they have made at home for the baby.
• Determine a system for medical follow-up of the baby.
• Find out what questions or misunderstandings (or both) the parents have about their
baby. Provide them with the correct information.
• Contact a social service, public health department, etc, if additional assistance or follow-
up care is needed.
B4. Any 5 of the following activities:
• Plan ahead.
• Determine if the baby is medically ready for discharge.
• Review the parental visiting record and interactions with the baby.
• Assess the parents’ ability to care for their baby. Solicit and answer their questions and
concerns.
• Assess parents’ ability to give medications or provide special care measures (or both), if
the baby needs any.
• Notify any special individuals or groups involved in the baby’s care; make appointments
for well-baby care and for any special follow-up examinations that may be needed.
• Determine if preparations have been made in the home for the baby. Assess the home
environment.
• Determine what medical or social service follow-up (or both) will be needed and how
this will be achieved.
• Document the baby’s weight, length, and head circumference.
• Perform a detailed physical examination. Prepare this information to send to the baby’s
follow-up and primary care physicians.
• Review the baby’s immunizations; make appointments, as necessary, for follow-up hear-
ing and eye examinations.
• Provide car seat testing and use instructions.
B5. False. 
Reason: Preterm babies are at risk for apneic spells until they reach a weight of
1,800 g (3 lb 151/2 oz) or more and a postmenstrual age of 35 weeks or more.

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Self-test C
C1. Cyanotic (Babies are blue.)
Acyanotic (Babies are pink.)
C2. True
C3. Babies with hydrocephalus may require insertion of a shunt to prevent the accumulation of
excess cerebrospinal fluid.
C4. True
C5. True
C6. Arterial oxygen concentration
Blood level of drugs used to treat their condition
Development of acidosis
“Blue spells,” or times when the baby becomes extremely cyanotic
C7. Two major problems with shunts used to treat hydrocephalus are shunt blockage and shunt
infection.
C8. When babies with chronic lung disease become ill, it is usually with pneumonia or fluid
retention.
C9. Babies with acyanotic congenital heart disease are frequently given medications for
congestive heart failure.
C10. B. Weight of the baby

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Unit 7 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf file
and save it to print later or come back to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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 Unit 8: Biomedical Ethics and Perinatology
Objectives............................................................................................................................ 182
1. How does biomedical ethics apply to neonatology?............................................... 185
2. How does biomedical ethics apply to obstetrics?.................................................... 185
3. What are the principles of biomedical ethics?.......................................................... 186
4. What are some other important biomedical ethics terms?..................................... 187
5. What are some obstetrics applications of biomedical ethics to specific

UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

clinical cases?.............................................................................................................. 189
6. What are some neonatology applications of biomedical ethics to
specific clinical cases?................................................................................................ 192
7. What is unilateral decision making?......................................................................... 195
8. How is withdrawal of life-sustaining measures approached?................................ 197
9. What is the decision-making process for the care of neonates?............................ 198
Figure and Boxes
Figure 8.1. Decision Support Model.............................................................................. 202
Box 8.1. The Components of Choice Talk................................................................. 199
Box 8.2. The Components of Option Talk................................................................ 200
Box 8.3. The Components of Decision Talk.............................................................. 201

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Objectives
In this unit you will learn to
A. Understand the basic principles of biomedical ethics and how they apply to neonates.
B. Define the terms used to describe decision makers in perinatology.
C. Define the terms necessary to understand the application of biomedical ethics to neonates.
D. Recognize how the principles of biomedical ethics are applied to certain cases.
E. Understand how practitioners can make decisions concerning the care of neonates by using
the principles of biomedical ethics.
Note: Whereas other units in this book describe the day-to-day care of women and neonates,
this unit describes important ethical aspects of care that occur across the spectrum of
care. In neonatology, the ethical issues are complex and, in some cases, abstract. This
unit will prepare the reader for biomedical ethical thought to help them be prepared for
when these situations arise in their clinical practice.

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

Unit 8 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them with the answers at the end of the book.
1. True False Parents have full autonomy over their children.
2. True False The principle of respect for autonomy does not apply to newborns.
3. True False Newborns receive more rights than a fetus but less than those of a
toddler.
4. True False All infants born at 22 weeks’ gestation die and should not be
resuscitated.
5. True False The neurological outcome of neonates with trisomy 18 is so poor
that they should not be resuscitated.
6. True False Anencephalic newborns do not have any rights, because they lack
the capacity for eventual higher order thinking.
7. True False Unilateral decisions, when justified, do not need the permission of a
surrogate decision maker.
8. True False Opioid analgesia is appropriate to give in end-of-life scenarios as
long as the intent is to lessen the degree of suffering.
9. Mrs and Mr Francis present to your hospital at 22 weeks and 3 days of gestation.
The estimation of gestational age is accurate, given that this was an in vitro fertil-
ization pregnancy. You are the neonatologist on service. Mrs Francis is currently
stable, but the attending physician for maternal-fetal medicine (MFM) fears she will
deliver in the next 48 hours. This is a much desired pregnancy. Your hospital has a
policy against resuscitation at less than 23 weeks’ gestation, but you think a hospital
across town may offer resuscitation at this gestational age. What is your obligation
to this couple?
A. Discuss the case with the MFM attending physician and advocate for possible
transfer to an institution that would offer resuscitation.
B. Discuss the case with the MFM attending physician and advocate to keep the
patient at your current institution in the hopes that Mrs Francis does not deliver.
C. Emphasize that nothing can be done to save the fetus if born at less than
23 weeks of gestation.
D. Emphasize that, although you will not resuscitate their fetus if born at less
than 23 weeks of gestation, they are free to find a hospital that will offer
resuscitation.
(continued )

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Unit 8 Pretest (continued )

10. You are resuscitating a neonate of unconfirmed gestational age born to a mother
who received no prenatal care. The neonate appears “fetoid” (very immature skin
with fused eyes) and has not responded to intubation and positive pressure ventila-
tion. You are the pediatrician on call, and the neonatologist is en route to the hospi-
tal. You firmly believe further resuscitative interventions will not save this neonate’s
life. You have been resuscitating this infant for 20 minutes without a response. What
is your next best course of action?
A. Proceed with the application of the Neonatal Resuscitation Program (NRP)
algorithm, and place an umbilical catheter and start chest compressions.
B. Wait for further directions from the arriving neonatologist.
C. Ask the parents if they would like you to continue resuscitating.
D. Explain to the family that nothing else can be done to save their neonate but that
comfort care measures will be provided.

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

1. How does biomedical ethics apply to neonatology?

It is impossible to discuss neonatology without also discussing the principles of biomedical
ethics. Despite excellent survival statistics, the care of imperiled newborns bears a dispropor-
tionate amount of biomedical ethical thought. Questions such as, “Should we really be doing
this?” or “What is the point of resuscitating a baby at 22 weeks’ gestation, if they cannot
survive?” are not uncommon. The term neonatology was coined in the early 1960s, and bio-
medical ethics discussions followed soon thereafter. Throughout the evolution of neonatology
as a subspecialty, those at the bedside have strived to make decisions with the best interests of
the baby in mind. The ethical implications of what was being done for (or to) babies became
crystalized in a principlism approach after the dissemination of 2 landmark publications in the
late 1970s. The first was the publication of the Belmont Report by the National Commission
for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont
Report states that 3 biomedical ethics principles ought to govern the approach to human sub-
jects research: autonomy, beneficence, and justice. These 3 principles are discussed further in
the section under objective 3, “What are the principles of biomedical ethics?”
Around the same time, Beauchamp and Childress published their seminal work, Principles of
Biomedical Ethics. Their work laid the foundation for the 4 biomedical ethics principles com-
monly used in discussing the care delivered to patients. In addition to respect for autonomy,
beneficence, and justice, Beauchamp and Childress added nonmaleficence, noting that acting
for the benefit of patients (beneficence) and avoiding harm to a patient (nonmaleficence) are
ethically separate ideas. Also of use for those caring for babies is the idea of the “best-interest
standard for decision making,” a standard embedded in the principle of respect for autonomy.
Therefore, principlism designates an approach to biomedical ethics that uses a framework of
4 universal and basic ethical principles: respect for autonomy, nonmaleficence, beneficence,
and justice. By using these 4 basic principles, many clinical scenarios involving imperiled new-
borns can be approached in a systematic fashion that adheres to biomedical ethics thought.
Importantly, however, principlism, while the most well-known of ethical decision-making
frameworks, represents only one framework ethicists use to approach ethical problem solving.

2. How does biomedical ethics apply to obstetrics?

The field of obstetrics and its relationship to ethics is unique. Much like neonatology, obstet-
rics often finds itself often embroiled in biomedical ethics discussions. Modern medicine is
centered on treating patients as separate, independent entities. In obstetrics, however, the fetus
is linked irrevocably to the mother. Attempts have been made to ethically separate the fetus
and provide it with separate standing as a protected entity. That the fetus is now often re-
garded as an entity separate from the mother is not surprising. Modern medicine affords prac-
titioners the ability to image the fetus with amazing resolution, providing a visual representa-
tion of the contents of the womb. Genetic testing and fetal interventions have also led to the
view that, if something can be done to correct a problem, then the entity for whom something
is being done ought to be considered a patient. To consider the fetus and mother as separate
entities, however, runs the risk of prompting divergent—rather than convergent—interests.
The ethics of care framework acknowledges that the fetus and the mother are intertwined and
that the mother’s relationship to her fetus, as well as her family unit, can inform her decision
making. Failure to recognize the pregnant woman as a person in her own right relegates her
to simply being a vessel for the developing fetus. This would violate a central moral philoso-
phy that a person should never be treated solely as means to an end. Respect for autonomy

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and the ethics of care framework allows physicians to acknowledge the competent pregnant
mother as a decision-maker for her pregnancy.

3. What are the principles of biomedical ethics?

A. Respect for autonomy
The principle of respect for autonomy protects the self-governance of a competent indi-
vidual to make their own decisions concerning their own health care. Because infants
cannot make decisions on their own behalf, their parents have decisional authority over
them. In this instance, parents make decisions on their behalf under the auspices of
the best-interest standard for decision making; this standard requires that those who
are making decisions for others (ie, surrogate decision-makers) will do so in good faith
and consider what a reasonable person would choose.
The surrogate decision-maker is expected to make the decision they view as being in
the best interest of the patient. Typically, they can choose from a broad array of
options. Provided their choice is not fraught with unnecessary burdens, surrogate
decision-makers are given wide latitude in their role.
Decisional authority is defined as the power and obligation to make a decision in a cer-
tain situation. Decisional authority is held to a lower burden of proof for state interven-
tion on the basis of the state’s interests in protecting vulnerable populations. This is called
parens patriae. While subtle, there are differences between authority and autonomy:
We are compelled to respect the autonomy of a competent adult, even if the result
would be withholding a lifesaving procedure or medication. Examples include:
• A competent person has a right to refuse a blood transfusion that would lead to an
improved clinical outcome.
• A pregnant woman retains autonomy over herself when pregnant and can refuse a fe-
tus-saving cesarean delivery. To pursue cesarean delivery over her objection would vi-
olate her autonomy and would be classified as unwanted touching or battery.
A parent’s authority can be challenged by the legal system in cases in which the deci-
sion is clearly not in the best interest of the neonate or in extenuating circumstances.
Examples include:
• Initiating a blood transfusion for an infant whose parents are Jehovah’s Witnesses.
• Performing an emergency surgical procedure that has a high predicted likelihood of
success and survival.
Rarely, the decisional authority of a parent can be challenged, if decisions made by the
parent on behalf of the neonate are made out of fear of legal repercussions. For exam-
ple, if a mother is killed by an intimate partner (eg, by the father of the baby) and the
neonate is delivered alive but is profoundly hypoxic and ill, withdrawal of life-sustain-
ing measures (WLSM) may be appropriate and, perhaps, in the best interest of the im-
periled neonate. If a treatment team recommends WLSM and the father disagrees on
the grounds of not facing an additional homicide charge, his decisional authority can
be challenged. This scenario is incredibly rare but warrants mention.
B. Beneficence
The principle of beneficence refers to actions that bring an overall good to the individ-
ual. Examples include resuscitation of an infant born at 32 weeks’ gestation or the

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

placement of a chest tube in an infant with pneumothorax who has a high chance of
survival. Along with beneficence is the idea of the best-interest standard for decision
making in neonatology. While beneficent actions bring about an overall good for an
individual, they may be associated with a burden to the same individual. If the benefits
of the action outweigh the burdens of the action, the action may be justifiable.
C. Nonmaleficence
As stated previously, the principle of nonmaleficence refers to the avoidance of actions
that harm an individual. Many actions performed in the care of imperiled newborns
can harm them (eg, ventilators may contribute to chronic lung disease, the use of oxy-
gen contributes to retinopathy of prematurity). If, however, an action will lead to an
overall good, despite the harm it produces, it could still be performed. If the burden of
the harmful action is such that it would not be in the best interest of the individual,
however, then it should not be performed. The burdens of a harmful action must be
outweighed by the benefits of the same action.
D. Justice
The principle of justice formally means “to treat equals equally.” For example, if
2 pregnant women present at 23 weeks of gestation with the same predicted outcomes
for their neonates, it would not be just for one woman to receive the option of resusci-
tation for her fetus, while the other woman is not given that option.

Differences in care delivered ought to be related to different aspects of the

patient’s clinical condition that can justify the differences in the clinical approach.

A classic explanation for justice as it pertains to periviability, for example, is the provision of
fetal resuscitation at differing gestational ages, depending on where a mother presents for
care. While it is reasonable for a hospital to have a unilateral policy against resuscitation of
the fetus at certain gestational ages, it is important to note that the only relevant difference
between a neonate who is resuscitated versus one who is not may be their gestational age.
Importantly, even with the most accurate assessments, gestational age assessments may have a
margin of error that ranges from a few days to 2 weeks. Very early ultrasonographic assess-
ments have a margin of error of a few days, and those performed in the second trimester may
have a margin of error of up to 2 weeks.

4. What are some other important biomedical ethics terms?

A. Futility
Futility refers to an action or treatment that will not accomplish the intended physio-
logical goal. This term is problematic, however, because the definition of the word
changes depending on who is using it. While it may be true that providing resuscitation
for a neonate born at 23 weeks’ gestation in a small community hospital would be a
futile endeavor, the definition of why this is so must be expanded upon. Instead of us-
ing a blanket term without a clear definition as it pertains to the individual patient, de-
fining why an action is futile is beneficial. For an infant who is born at 23 weeks’ ges-
tation without the benefit of receiving antenatal steroids and whose estimated fetal
weight is 400 g (14 oz), it may be futile to resuscitate this infant; however, it must be

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elucidated why this is so. For example, the equipment available does not fit into this in-
fant’s trachea, or the infant’s lungs are too underdeveloped to be able to adapt to life
outside of the womb.
B. Obligatory to treat (wrong not to treat)
Benefits of treatment outweigh the burdens of treatment. The balance of nonmalefi-
cence and beneficence are weighted such that life-sustaining treatment is favored.
C. Optional whether to treat (treatment neither required nor prohibited)
Treatment is morally neutral and optional. The presumption of always providing life-
sustaining treatment for the sick and injured does not hold when the treatments may
be involved with burdens that outweigh the benefit.
D. Obligatory not to treat (wrong to treat)
Health care providers have no obligation to provide pointless, futile, or contraindicated
treatment. The burdens can so outweigh the benefits that the treatment is wrong.
E. Harm principle
The harm principle attempts to set the limit for state intervention with regard to a
parent’s decisional authority. It has become an alternative to the best-interest standard
over the past 2 decades. The harm principle indicates that parental decisional authority
should be challenged only if their decision sets the neonate up for an unacceptable
degree of harm. If a parental decision endangers an infant or child, the state can then
intervene on the child’s behalf, in accordance with parens patriae. The harm threshold
for state intervention may be cases in which the harm incurred from a decision would
include loss of life, loss of health, loss of some major interest, and the deprivation of
basic needs.

Self-test A
Now answer these questions to test yourself on the information in the last section.
A1. Which biomedical ethics principle (respect for autonomy, beneficence, nonmaleficence, or justice)
can be considered the most important when making decisions for imperiled newborns?
________________________________________________________________________________________
A2. True False The burden of proof needed to challenge a parent’s authority over decision making
for their child is the same as the burden of proof needed to challenge their own
decision-making autonomy.
A3. The moral duty of a physician to a particular set of patients is dynamic and changes as outcomes
change. What is one group of patients for which the duty to resuscitate is now considered
obligatory?
________________________________________________________________________________________
A4. While it is a commonly used term, what is the biggest concern with the term “futility”?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Check your answers with the list that follows Self-test B. Correct any incorrect answers and review
the appropriate section in the unit.

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5. What are some obstetrics applications of biomedical ethics to

specific clinical cases?
A. Maternal refusal of cesarean delivery (Committee Opinion, The American College of
Obstetricians and Gynecologists, No. 664)
While rare, maternal refusal of cesarean delivery does occur. While the fetus is still
within the uterus, the fetus would have to be accessed through the body of another
individual—the pregnant woman—who has full autonomy over her own decisions.
As long as the woman is fully informed of the risks of not proceeding with a cesarean
delivery that would potentially be lifesaving for the fetus, this is termed informed
refusal and is permissible. Pregnancy does not obviate the requirement for informed
consent, nor does it limit the need for physicians to respect truly informed refusal of an
action. Consideration of the relationship between the mother and fetus is paramount.
• Proceeding with a cesarean delivery over maternal refusal would violate the principle
of respect for autonomy and would constitute unwanted touching or battery.
• While the fetus has certain rights that may expand with increasing gestational age
(and increased chance of survival after birth), the rights of the fetus do not supersede
those of the pregnant woman.
• Cases in which a cesarean delivery has been forcibly performed or a court injunction
has been sought have overwhelmingly been conducted in women of underrepresented
minorities.
• With proper education and counseling, the interests of the fetus and the mother
typically converge on an outcome that is best for both.
• Once the neonate is born, that child is entitled to the full extent of rights granted to
all members of the species Homo sapiens.
B. Maternal-fetal surgery
Cases exist in which a pregnant woman has refused surgery that might potentially save
the fetus. The ability to perform an intrauterine procedure on a fetus is an amazing ad-
vancement in the fields of pediatrics and obstetrics. Importantly, biomedical ethics has
been called upon to address certain dimensions of maternal-fetal surgery. The surgery
was originally termed “fetal surgery” but was renamed “maternal-fetal surgery” in rec-
ognition that to access the fetus, surgery must also be performed on the pregnant
woman. Maternal-fetal surgery has progressed from experimental research to accepted
clinical practice in select conditions. At the crux of maternal-fetal surgery is a balancing
of maternal autonomy and the prospect of beneficence for the fetus as a patient. Before
deciding if maternal-fetal surgery is appropriate, the autonomous woman must make a
decision to continue her pregnancy; by doing so, she decides if the fetus will go on to
become a patient. Fetuses are decidedly patients when there is a reliable chance that a
fetus can go on to develop its own independent moral status. Importantly, as described
previously for maternal refusal of cesarean delivery, pregnant women have no legally
enforceable duties to choose a specific fetal therapy, and they have the right to decline
such interventions. Maternal-fetal surgery can be justified when the following condi-
tions are met:
• Intervention would be lifesaving or would prevent serious or irreversible disease,
injury, or handicap.
• Intervention would have a low mortality risk for the fetus and a low risk of serious
disease, injury, or handicap.

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• Maternal risk of mortality and morbidity must be very low.

Importantly, while it is understood that maternal-fetal surgery may have benefits
for the fetus, there are no medical benefits for the pregnant woman (as opposed to
conditions such as preeclampsia, in which delivery of the neonate leads to medical
improvement of the mother). According to level I evidence, conditions that benefit
from maternal-fetal surgery or fetal therapy, that is, a therapy administered to the
pregnant woman for the benefit of the fetus, include
• Twin-to-twin transfusion syndrome
• Myelomeningocele
• Lower urinary tract obstruction
• Congenital diaphragmatic hernia
According to level II evidence, conditions that may benefit the fetus include the
following fetal therapies:
• Intrauterine transfusion
• Medical therapy for fetal tachycardia
Controversial conditions for which fetal therapy has been attempted include
• Osteogenesis imperfecta
• Aqueductal stenosis
• Fetal heart block
• Twin anemia-polycythemia syndrome
The transition from experimental therapy with the goal of improving the outcome for
the fetus to the standard of care for maternal-fetal surgery must be carefully approached.
Obstetricians ought to counsel the expecting parent or parents on the availability of
options for maternal-fetal surgery or fetal therapy, if deemed appropriate for the fetal
condition present, the gestational age, and the wishes of the parent or parents. Discussions
of maternal-fetal surgery or fetal therapy must include an unbiased presentation of the
uncertainties, complications, and failures of such treatments. Although the pregnant
woman is under no obligation to choose maternal-fetal surgery or fetal therapy, if either
option might be appropriate, it must be discussed. Failure to do so would violate true
autonomous decision making, because the woman’s decision would not truly be informed.
C. Maternal substance use disorder
Currently, women in the United States have an increased proportion of reported opioid
use as well as increased death from opioid overdose. Women of childbearing age are
also affected by the epidemic of opioid use. Importantly, along with the increase in
pregnant women reportedly using illicit substances, there has been an increase in neo-
nates admitted to the neonatal intensive care unit (NICU) with the sequelae of illicit
drug exposure. The rates of admission for neonatal abstinence syndrome, for example,
have almost quadrupled in recent years. The increasing prevalence of maternal sub-
stance use disorder has raised several ethically challenging questions for neonatal and
obstetrics providers.
Responses from professionals such as physicians, lawyers, judges, and law enforcement
officials vary from punitive policies to medication-assisted treatment (MAT) for persons
with substance use disorder. Historically, law enforcement officials and policymakers
have argued that punitive policies will deter pregnant women from continuing illicit
substance use and prompt them to seek MAT. In stark contrast, medical societies argue

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that punitive policies will only serve to prevent pregnant women from seeking out
counseling and MAT. In Tennessee, a law that criminalized maternal illicit substance
use in pregnancy expired and was not renewed. During the law’s existence, concerns
were raised that the criminalization of maternal substance use disorder would deter
women from seeking medical attention, thereby further affecting the potential health
outcome of the fetus.
Despite the presence of few state laws (Tennessee and South Carolina) that criminalized
the maternal use of illicit substances while pregnant, case law demonstrates that crimi-
nal charges of child endangerment, child abuse, and manslaughter have been filed suc-
cessfully in cases of maternal illicit substance use while pregnant. In lieu of criminal
statutes, some states have enacted civil statutes that would penalize a pregnant woman
who uses illicit substances. Importantly, civil law concerns itself with the rights and
duties of persons. Both civil law and criminal law may be punitive. While civil charges
will not lead to incarceration of the mother, they are grounds for cessation of parental
decisional authority. The idea behind all of these examples (both civil and criminal) is
to increase the potential beneficence to the fetus. It has been demonstrated, however,
that punitive policies are unjust, given that they do not account for a woman simply
not being able to access MAT. Additionally, such punitive policies are not evenly
applied across sociodemographic parameters.
Punitive legal approaches concerning mothers who use illicit substances while pregnant
have the following constraints, because they:
• Fail to recognize that all competent adults are entitled to informed consent and
bodily integrity.
• Treat substance use disorder as a moral failing.
• Discourage ongoing prenatal care.
• Apply said punishments unjustly to the most vulnerable women.
• Lay the groundwork for the criminalization of legal maternal behavior. For example,
if it is a crime to endanger the fetus by the maternal use of illicit substances and this
is a punishable offense, it is easy to imagine punishing a pregnant woman for not
adhering to her prescribed diet for the treatment of gestational diabetes.
At the crux of the stark differences between medical societies’ responses and policy-
makers’ responses is the interpretation of maternal substance use while pregnant.
Categorizing maternal substance use while pregnant as a moral wrong justifies both
civil and criminal proceedings, per policymakers and law enforcement officials. The
categorization as a medical problem, however, justifies the absence of court proceedings
and the pursuit of counseling and MAT.
The reality of maternal substance use during pregnancy lies somewhere in between. The
National Institute on Drug Abuse defines addiction as a chronic disease that is amena-
ble to therapy. This definition of addiction as a chronic disease, however, does not elim-
inate untoward effects on the fetus and neonate. Given that knowledge of maternal
substance use disorder can change the management of the neonate, medical screening
must take place. The routine testing of every mother for illicit substances is not feasible
and would violate the Fourth Amendment of the United States Constitution, which
prohibits illegal search and seizure. The action of screening for maternal illicit sub-
stance use may encourage a health professional to consider urine drug screening or
screening of neonatal meconium, but parental consent must be obtained from the

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mother. Different states have differing requirements concerning the degree of consent
needed. As several studies have demonstrated, sending urine or meconium samples to
test for maternal illicit substance use without first screening the mother may result in
an explicit or implicit bias against women of color. Importantly, implicit biases occur in
a subconscious manner. Failure to seek maternal consent for testing and to screen
mothers appropriately would violate the principles of justice and respect for autonomy
on behalf of the mother.

6. What are some neonatology applications of biomedical ethics to

specific clinical cases?
A. Periviability
Variations in clinical practice for fetuses of periviable gestational age are largely re-
sponsible for the wide discrepancies in reported neurodevelopmental outcomes and
mortality. The traditional periviable age range was 23 to 25 weeks’ gestation; however,
emerging and reported data suggest that 22 weeks’ gestation may be the current lower
limit for a possible successful trial of resuscitation.
Much of the mortality outcome data for infants born at 22 weeks’ gestation are
reported for all live-born infants. Therefore, careful attention must be given to the
denominator in this instance—it would not make sense to quote survival data for every
infant born at 22 weeks’ gestation. Therefore, the relevant outcome data would be
mortality for infants live-born at 22 weeks’ gestation who received a good-faith effort
of a trial of resuscitation. Reporting only mortality rates for all infants live-born at
22 weeks’ gestation (both those who did receive resuscitation and those who
did not receive resuscitation) represents a framing bias and gives the impression
of a higher mortality rate, because the denominator contains infants born alive who
received a trial of resuscitation as well as with those born alive who did not receive a
trial of resuscitation.
Importantly, it is within the rights of a parent to deny a trial of resuscitation at this
estimated gestational age because it is unclear what a reasonable person might choose
(best interest standard), and the potential harms are significant (harm principle). This
same concept is true of live-born infants at 23 weeks of gestation. However, to say,
“We do not resuscitate infants born at 22 weeks’ gestation because infants born at
22 weeks’ gestation cannot survive” does not take survival data into account and feeds
into a self-fulfilling prophecy.
• Centers that routinely perform a trial of resuscitation on extremely-low-birth-weight
(ELBW) periviable infants have higher survival statistics than centers that take a
more selective approach to resuscitation, given their increased experience with in-
fants born at periviable ages.
• The survival rate for infants live-born at 22 weeks’ gestation ranges from 19% to
61%, depending on the antenatal care delivered to the mother (antenatal steroids
and transfer to a tertiary or quaternary center) and the provision of a trial of resusci-
tation on behalf of the neonate.
While survival statistics are important, the quality of life of the survivor is also im-
mensely important. It is unclear if the rates of neurodevelopmental impairment (NDI)
have improved, stayed the same, or worsened for those infants who fall into the perivi-
able gestational age range at birth. These statistics are dependent on the denominator

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used for data reporting (all live-born infants or only live-born infants for whom resus-
citation was attempted) and the study referenced. Possible reasons for a perceived
worsening of survival rates and outcomes across different studies could be the ability to
save smaller and sicker imperiled newborns who otherwise would have perished. Given
the still-high likelihood of moderate to severe NDI at periviable gestational ages, the
action of providing a trial resuscitation is considered permissible and not obligatory.
• Despite the possibility of survival at 22 weeks’ gestation, these infants still face a
very high likelihood of NDI.
• Parents faced with such a delivery ought to be counseled that while survival is possi-
ble, intact survival (ie, survival with moderate to severe NDI) is less likely.
• The values of the parent or parents must be ascertained when discussing a trial of
resuscitation at any gestation, but especially when dealing with fetuses at
periviable gestational ages.
• Depending on clinical circumstances (eg, the ability to transfer the mother to another
hospital while she is still pregnant), interventions to enhance the survivability of the
neonate at periviable gestational ages ought to be explored.
While 22 weeks’ gestation may be the lower limit of permissible resuscitation,
depending on local and institutional practices, the upper limit of honoring a parent’s
decisional authority concerning a trial resuscitation also seems to be lowering.
Classically, some ethicists have espoused that when the predicted intact survival of an
imperiled neonate exceeds 50% at birth, resuscitation should be performed. In most
cases, this corresponded to a gestational age of 25 weeks. Importantly, however, a
movement beyond gestational age as the sole determining factor in guiding resuscita-
tion practices has been adopted, given the importance of other factors, such as antena-
tal steroids, the sex of the fetus (with female periviable fetuses tending to have better
outcomes than male periviable fetuses), and maternal comorbid conditions. For exam-
ple, in the case of a mother who did not receive antenatal steroids, a hospital policy
may allow the resuscitation of a 25 weeks’ gestation fetus with fetal growth restriction
based solely on gestational age. Importantly, for a 24 weeks’ gestation female fetus that
is well grown, was administered antenatal steroids, and has no other comorbid condi-
tions, the predicted survival rate may be higher than that of the aforementioned
25 weeks’ gestation fetus. However, hospital policies with a unilateral declaration of
not offering resuscitation below a certain gestational age cut-off would not allow resus-
citation in this case. This violates the principle of “justice,” given that the action pro-
vided to the 2 neonates (resuscitation for one fetus and comfort measures only for
another fetus) is different and is not based on their predicted outcomes.
• As much as possible, both survival and morbidity statistics, if wanted by the family,
should be provided; however, they should be clearly differentiated during counseling.
• Failure to differentiate these statistics would put the health professional at risk of a
framing bias, that is, presenting only information that conforms with their own bias.
— For example, if a practitioner feels strongly that all infants born at 24 weeks’
gestation ought to receive a trial of resuscitation, they may only present the
projected survival statistics to the family (which can be as high as 70% in some
cohorts of ELBW infants born at 24 weeks’ gestation) and not the statistics
associated with a high likelihood of NDI even at that gestational age.

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B. Confirmed trisomy 13 or 18
While traditionally thought of as uniformly fatal conditions, newer data suggest that
trisomy 13 and 18 can be survivable conditions in both the short term (to the time of
first hospital discharge) and long term (1 year after birth). While all infants with tri-
somy 13 and 18 will have some degree of congenital anomalies, it must be noted that
not all of their anomalies will result in early death. For example, both trisomy 13 and
18 are associated with limb anomalies that would not affect an infant’s ability to sur-
vive. Most neonates with either trisomy 13 or 18 present with anomalies that do not
require urgent or emergent surgical intervention in the immediate neonatal period.
Despite data on the need for surgical intervention during the first hospitalization,
infants with trisomy 13 and 18 remain at high risk for mortality prior to discharge
from the hospital.
• If possible, a birth plan should be pursued if the fetus has a diagnosis of trisomy
13 or 18.
• While many fetuses will not survive the labor process (and it may not be appropriate
to intervene on behalf of the fetus), approximately 40% of neonates can survive long
enough to be discharged home with feeding support in the form of a nasogastric
tube.
• Infants with trisomy 13 or 18 who are born in the very-low-birth-weight category
have a very high risk of mortality before the time of the first discharge home.
• Most infants with trisomy 13 or 18 who survive long enough to go home do not
require decision making pertaining to surgical intervention in the immediate neonatal
period.
• The death of a neonate with trisomy 13 or 18 after discharge from the NICU is
likely, but if a family’s goal is to spend time with their neonate while they are alive
and decide on what interventions would be appropriate over time, this should be
facilitated.
— For example, it would be reasonable to facilitate a maternal transfer of a
woman whose fetus has trisomy 13 or 18 to a center that is willing to provide
some life-prolonging or lifesaving therapies.
C. Anencephaly
The care of the anencephalic fetus and neonate brings several aspects of the designation
of human rights to the forefront of biomedical ethical thought. Some philosophers have
advocated that the designation of rights is based on an individual’s capacity to interact
with their environment. Human rights (such as the right to be treated with dignity and
respect) would be assigned based on someone’s ability to interact with others who also
have the ability to interact with them. For example, Person A can interact with Person
B in a meaningful way, such as smiling or talking to one another. Person B can also in-
teract with Person A in a meaningful way. Given their interaction with each other, they
would be afforded human rights. By this definition, then, anencephalic infants would
not receive the same human rights as an older infant would, because anencephalic in-
fants cannot interact in a meaningful way with another individual. Importantly, this
may also limit the rights of neonates who do not yet possess the ability to perform such
actions as the social smile, for example. Also included, from a standpoint of adult med-
icine or pediatrics outside of the NICU, would be the patient in a persistent vegetative
state or the comatose patient. If such patients can no longer communicate, are they no
longer deserving of their rights? Other philosophers have advocated that the genetic

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makeup of an individual grants them the rights inherent to that species. For example, a
Homo sapiens child (regardless of the method of conception) is deserving of the rights
enjoyed by all Homo sapiens, given their unique genetic makeup. By following this
logic, then, it would be reasonable to assume that neonates with anencephaly are de-
serving of the rights afforded to all neonates. Although organ donation from neonates
with anencephaly is not common, the topic has recently been revisited. This would not
be within the purview of a referring institution, but some parents will discuss organ
donation and may seek transfer to a facility that is willing to provide such a service.
Importantly, the right of the anencephalic neonate to not be subjected to painful proce-
dures for the benefit of another patient must be respected. While it is unclear what de-
gree of pain neonates with anencephaly can experience, it cannot be said they do not
have the capacity to experience pain, given the varying degree of higher brain matter
present in reported autopsy cases.
• Parents may request or inquire about organ donation if their fetus receives a diagno-
sis of anencephaly.
• Organ donation from neonates is technically challenging, but not impossible.
• Hesitancy to procure organs from neonates also exists, given the inability to diag-
nose brain death definitively (instead relying on circulatory determination of death).
D. Profound encephalopathy
Regardless of the cause of a neonate’s profound encephalopathy at birth, cases exist in
which an unrecoverable insult has occurred. Examples of insults that can lead to such a
profound presentation include umbilical cord prolapse, maternal cessation of circula-
tion, uterine rupture, and maternal illicit drug overdose that causes death. The standard
of care for moderate to severe encephalopathy includes therapeutic hypothermia (see
Unit 6, Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy, in
this book). This is typically performed at a level 3 or 4 nursery and may require transfer
from the birth institution. Along the spectrum of infants with severe encephalopathy,
there are neonates who will undoubtedly have severe NDI. It is challenging to predict
which infants will be severely affected and receive little benefit from therapeutic hypo-
thermia. Within the scope of treatment for neonates with severe encephalopathy is the
idea of withdrawing life-sustaining measures, namely withdrawing respiratory support.
Neonates with severe respiratory depression resulting from encephalopathy often have a
degree of recovery that enables them to spontaneously breathe on their own, with little
to no respiratory support. In some of these cases, however, neurological outcomes are so
poor that the alternative (ie, death) would be preferable. This thought process appeals to
the notion of mercy and the avoidance of unnecessary suffering. Discussion with a level
3 or 4 receiving NICU concerning the appropriateness of transfer in select, profoundly
severe cases of encephalopathy, is reasonable. Transferring a neonate with an unrecover-
able insult who might die shortly after transport is not ideal, because the mother may
still be hospitalized or other loved ones may not be able to visit the dying neonate.

7. What is unilateral decision making?

While the intent of neonatology and the resuscitation of a neonate is to promote the survival of
the neonate, survival is not always possible, despite a good-faith effort on behalf of those provid-
ing resuscitation. In cases in which survival is physiologically impossible or highly unlikely, a phy-
sician has the unalienable right to either cease resuscitative efforts or refuse to provide them. The
right of the physician to make this choice in this situation is termed unilateral decision making.

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The right of the physician to cease resuscitative efforts or refuse to provide them in the event
of physiologically impossible or highly unlikely survival stems from several well-established
codes of professional conduct, as well as from the biomedical ethics literature. Simply put, if
a physician does not believe a treatment or intervention will work, they are not obligated to
provide it. This is true even if a family requests for an intervention to be performed. For exam-
ple, if a neonate is born at a previable gestational age or has a congenital malformation that
is unequivocally not compatible with life, a physician is under no obligation to provide life-
prolonging or life-sustaining therapies. Of course, the comfort of the neonate must be attended
to with the utmost care and consideration. Many hospitals also have policies in place to pro-
tect physicians from providing care they deem futile. Importantly, the definition of the word
“futile” must be clearly defined to the family and others involved in the care of the patient. As
much as possible, the word “futile” should be avoided, and those providing care in such cir-
cumstances must clearly elucidate the aspect of care that is not being provided and why such
care is inappropriate.
While the idea of making a decision unilaterally—without the permission or explicit input from
a caregiver—may seem paternalistic, such actions are morally justified. Less justifiable would
be the provision of a half-hearted attempt of resuscitation, the so-called slow code. If a neonate
cannot benefit from a trial of resuscitation or therapeutic modality, the resuscitation or modal-
ity should not be provided. To feign an effort for the benefit of others (or oneself) is to use the
neonate as a means to another’s end and may subject the neonate to unjustifiable pain and suf-
fering. Even the most intractable differences of opinion concerning the resuscitation status of a
neonate can often be remedied with continued counseling and education. Unilateral end-of-life
decision making ought to be reserved for very select cases and based only on the physiological
reality that a treatment is not working.
A different but also challenging task is making resuscitation decisions for neonates who
are predicted to survive a resuscitation, even though their survival will be associated
with severe comorbidities. Neurological comorbidities are not uncommon in neonates,
especially those born at periviable gestational ages. Some neurological comorbidities may be
predicted to be so severe that they would cause the physician to question whether resuscita-
tion is in the best interests of the patient. For example, a neonate with bilateral grade 4 intra-
ventricular hemorrhage (ie, periventricular hemorrhagic infarction) that is severe or an infant
with severe encephalopathy who is unresponsive may survive a trial of resuscitation; however,
their ultimate outcome would likely include a poor neurological prognosis. Under these cir-
cumstances, the physician should be hesitant to make a unilateral resuscitation decision and,
if resuscitation is not in the best interest of the patient, instead should counsel the family
accordingly.
In the midst of counseling in cases in which the physician believes that resuscitation is not in
the best interest of the neonate but the physician does not want to make a unilateral decision,
they can suggest a plan of care to the family and give the family an opportunity to disagree
with the plan. For example, in cases of renal agenesis with concurrent pulmonary hypoplasia,
the physician can suggest a trial of intubation and application of supplemental oxygen but
can also offer that no medications be given to increase the heart rate (eg, epinephrine). This
is termed informed non-dissent, and authorization is inferred from the absence of veto of the
family, rather than from the presence of an explicit agreement. Although this method is not
ideal, it can spare a patient potentially harmful treatments that would have very little benefit,
especially in the face of a poor neurological prognosis.

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8. How is withdrawal of life-sustaining measures approached?

Despite the best efforts of physicians and nurses, continuing to provide life-sustaining interven-
tion is not always in a neonate’s best interest. This is challenging for the health care team and
the parent or parents to reconcile. But it must be understood that the infant is deserving of
mercy. Another term for a “do-not-attempt” resuscitation decision is “allow natural death.” In
essence, without the continuation of life-sustaining measures, the health care team at the bed-
side would allow the patient to die naturally and comfortably, unencumbered by technology.
WLSM is justified in select cases in which the neonate’s survival would be associated with a sig-
nificant burden (to the neonate) and allowing natural death would be the more merciful choice.
The most common way neonates die in the NICU is as a result of WLSM. This withdrawal typ-
ically occurs within the first 72 hours after birth. While there are no moral differences between
WLSM and the non-initiation of life-sustaining measures, it must be understood that health
care providers often perceive WLSM as being different. A potential reason for this is that, for
the act of withdrawal, a negative action occurs. This means that something—for example, a
ventilator attached to an endotracheal tube—is removed from the care of the neonate, and this
allows death to occur. This is in contrast to the potentially more passive inaction of allowing a
neonate who is not predicted to have a good outcome to die naturally, without any interven-
tion. In the latter example, there are no positive or negative actions—only inaction. Although
the nature of WLSM can be uncomfortable, this ought not to be a barrier when it is in the best
interest of the patient.
In contrast to making a unilateral decision concerning resuscitation, WLSM typically requires
the permission of a surrogate decision maker (ie, the parent or parents, in most NICU cases).
Many hospitals have policies concerning both resuscitation and the provision of treatment
when it is not predicted to work. Hospitals also have policies about WLSM for when life-
prolonging treatment is no longer indicated. These policies are in place to protect patients from
receiving non-beneficial treatment. This is different from a treatment that cannot work. For
example, if a patient is no longer responding to epinephrine boluses during a resuscitation,
the physician can decide to cease the resuscitation. This is different than caring for a medically
stable patient who is profoundly incapacitated but is dependent upon the ventilator for con-
tinued life. In this instance, although the patient may survive a resuscitation, WLSM may be in
their best interest if their hope for recovery is nonexistent.
If an intractable difference of opinion concerning WLSM exists between a patient’s surrogate
decision makers and the medical team, some hospital policies describe a process by which the
physician can still remove life-sustaining measures over the objection of the surrogate deci-
sion maker. Such policies typically elucidate the necessary procedures to pursue such an action
in detail and can only be enacted when further life-prolonging therapy is very much not in
the best interests of the patient or is overtly burdensome. The surrogate decision makers are
usually given a period of time to find a hospital willing to provide the care deemed no longer
beneficial and, at the end of this time period (10–14 days), assuming all other procedures have
been followed, the medical team can withdraw life-sustaining measures over the objection of
the surrogate decision maker. In addition to sparing patients nonbeneficial care, the goal of
such policies is to foster communication at the end of a neonate’s life. These policies should be
used as a last resort.
When a neonate is deemed appropriate for WLSM, care must be taken to ensure the comfort
of the neonate. If available, palliative care should be provided upon the admission of a neonate
who is expected to have a life-limiting condition. Importantly, palliative care should not be

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viewed as only end-of-life care; the services of a palliative care practitioner should be sought to
help facilitate goals of care discussions and to ensure patient comfort. Knowing that adults are
medicated for dyspnea at the end of life, it follows then that the comfort of the dying neonate
must also be ensured. While opioid analgesics are respiratory depressants in neonates, they also
mitigate any pain and/or discomfort felt by the neonate at the end of life. The physician should
feel free to use such medications, despite their potential side effects, on the basis of the doctrine
of double effect.
The doctrine of double effect dictates that, while a treatment may have an unwanted side
effect, as long as the intended primary effect was morally justified, the provision of the treat-
ment is also justified. For example, the provision of morphine at the end of life may cause
respiratory depression, but it is given for the morally justifiable reason of decreasing pain and
dyspnea at the end of life. The side effect of respiratory depression is not the intended effect of
the provision of morphine, but it is a known possibility.
The provision of a medication to actively end the life of a neonate is prohibited in the United
States. While certain states permit physician-assisted suicide, currently this practice does not
extend to the neonate. A protocol exists in the Netherlands for the active euthanasia of a neo-
nate in the case of hopeless and unbearable suffering. This protocol, which was developed in
2004 at the University of Groningen, is called the Groningen Protocol. Importantly, this pro-
tocol is not acted upon in a unilateral fashion by physicians in the Netherlands. Parent permis-
sion must be sought. Possible justification for this protocol is the prevention of a long death
by withdrawing the provision of artificial nutrition. Importantly, the withdrawal of artificial
nutrition is not an act of assisted suicide but rather the cessation of medical therapy.
As previously mentioned, most neonates die as a result of WLSM—typically the discontinua-
tion of respiratory support. There are some neonates who have the capacity to breathe on their
own but for whom death would be in their best interest. An example of such a patient may be
a neonate with severe encephalopathy who has recovered brainstem activity but is incapable
of interaction with their environment. One possible course for this infant would be the provi-
sion of artificial nutrition via a gastrostomy tube, if they cannot manage oral feedings. While
the neonate’s ability to interact with the environment would not change, they would be kept
alive by the receipt of artificial nutrition. Accepting that artificial nutrition is a medical treat-
ment, it follows that it too can be withdrawn, similar to a ventilator or an inotrope. In theory
this is true, but many persons at the bedside of imperiled newborns have difficulty accepting
the prospect of withdrawing artificial nutrition and hydration. Potential reasons for having
difficulty with accepting the withdrawal of artificial nutrition include the societal expectation
of providing food for a baby, as well as fears of suffering compounded by death resulting from
starvation. However, data extrapolated from the adult literature indicate that the fear of suffer-
ing compounded by starvation is unfounded, given the evidence from pain scores at the end of
life for adults, as well as symptom scores and self-reports.
In all instances of the provision of end-of-life care, regardless of the means of death, the com-
fort of the neonate must be of paramount importance. Palliative care services may help guide
the dying process. In addition to providing comfort for the neonate, it is also important to
provide as much support as possible to the family.

9. What is the decision-making process for the care of neonates?

Any decision made on behalf of the neonate must have their best interests in mind and, with
rare exception, must be made by their surrogate decision makers. Their surrogates are, by

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

default, their parent or parents. The process of making a decision on behalf of a neonate with
input from the family is termed shared decision making. Parental decisional authority must be
balanced with beneficence, nonmaleficence, and justice in pursuit of what is in the neonate’s
best interest. Similar to decision making for the neonate, decision making for the pregnant
woman must also be under the auspices of shared decision making. The balance for the preg-
nant woman is more complicated, given the presence of the fetus. And, as discussed previously,
the pregnant woman can refuse therapies that would be beneficial to the fetus.
The concept of shared decision making is based on a 3-step model: introducing a choice,
describing options, and helping patients make decisions through decision talk (explained
later in this section). This model is based on the basic tenets that, through deliberation and
understanding, patients can make decisions based on what matters most to them and to the
degree they want information conveyed to them. It is through good shared decision making
that patients are said to achieve informed preferences in care. An informed preference extends
beyond informed consent and is based on the optimal accurate expectations of both positive
and negative consequences of an action (eg, trial of resuscitation for a neonate born at
22 weeks’ gestation). It is through shared decision making that neonatologists can afford
agency to parents, in which agency refers to the capacity to act independently and make free
and informed choices. Agency is afforded to parents by providing information and supporting
the decision-making process. This same agency is afforded to a pregnant woman whose auton-
omy is respected in the face of refusing an intervention.
Shared Decision-Making Model (J Gen Intern Med. 2012;27:1361–1367)
A. Choice talk
Choice talk is the step of making sure patients and/or their surrogates know reasonable
options are available (eg, trial of resuscitation vs comfort care). Choice talk is consid-
ered a planning step toward shared decision making (Box 8.1).

Box 8.1. The Components of Choice Talk

1. Step back. Provide an up-front summary statement, such as, “Now that we have identified
you are at risk for delivering at 23 weeks’ gestation, we have to think about what to
do next.”
2. Offer choices. Present the options as they exist in the particular circumstance. For example,
“I’d like to discuss some information with you that may help explain how the different
options at this gestational age are different from one another.”
3. Justify choice. Emphasize the role of individual preferences (eg, the parent may not accept
the risk of having a child with severe neurodevelopmental impairment [NDI]) and the
amount of uncertainty in the information provided.
a. Personalizing preferences. Explain that different issues matter more to some people than
others. For example, “A trial of resuscitation at this gestational age is associated with a
high likelihood of severe NDI. That is very important for some parents. Other parents are
less concerned with NDI and value life at all costs.”

(continued )

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Box 8.1. The Components of Choice Talk (continued )

b. Uncertainty. Emphasize the deficits in data, where they exist. Parents may be unaware of
the degree of uncertainty in making predictions surrounding fetuses at periviable gesta-
tional ages, for example. This uncertainty may also extend to decisions about resuscita-
tion or whether a woman opts for a cesarean delivery at a periviable fetal age due to
fetal bradycardia, instead of delivering vaginally without fetal heart rate monitoring. For
example, despite offering a trial of resuscitation, the neonatologist may not be surprised
by a neonate’s failure to respond to intubation and positive pressure ventilation, but par-
ents may find it shocking.
4. Check the reaction. The discussion of the choices presented may be disconcerting to
parents. Pause to determine the state of mind of the parent or parents by using phrases
such as, “Shall we go on?” or “Shall I tell you more about the options?”
5. Defer closure. Some parents may react by placing the decision on the neonatologist or
obstetrician. In these instances, the neonatologist or obstetrician may say, “I am happy to
share my views on this scenario and help you make an informed decision. Before I do so,
may I describe the options in more detail, so that you truly understand what is at stake?”

B. Option talk
Further detailed discussion about the informed preferences the patients or their surro-
gates may choose from appears in Box 8.2.

Box 8.2. The Components of Option Talk

1. Check knowledge. Check the parent’s or parents’ prior knowledge of the subject being
discussed. Ask, “What have you heard about infants born at 23 weeks’ gestation?” or “What
have you heard about the outcomes of maternal-fetal surgery?”
2. List options. Make a clear list—in writing—of the options available to the parent or parents,
and say, “Let me list the options before we go into more detail.” Use terms such as, “a
trial of resuscitation” as opposed to “resuscitation.” Use the term “maternal-fetal surgery”
instead of “fetal surgery.”
3. Describe options. Describe the options in practical terms as much as possible. Point out the
clear differences between the available options. Point out that some decisions are reversible,
while others are not.
• Harms and benefits. Be as clear as possible about the potential pros and cons of the
available options. Use effective risk communication, and provide risk data in relative and
absolute terms.
4. Provide patient decision support. Where available, use tools to enhance communication and
understanding of available options. Additional study is needed on the use of visual aids in
periviable counseling needs to determine their true effect on parental understanding. Before
using a decision support tool for periviable counseling, consider the health literacy of the
patient or their surrogate.
5. Summarize. Use the “teach-back” method. That is, list the options again and assess the
parent’s or parents’ understanding by asking them to summarize what you said.

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

C. Decision talk
Decision talk supports the work of considering preferences and deciding what is best
(Box 8.3).

Box 8.3. The Components of Decision Talk

1. Focus on preferences. Guide the parent or parents or their surrogates to focus on pref-
erences. Use phrases such as, “From your point of view, what matters most to you?”
Elaborate on this phrase by discussing morbidity versus survival.
2. Elicit a preference. Give the parent or parents or their surrogate more time to think about it,
if they wish for it and if circumstances allow.
3. Moving to a decision. Try checking for the need to either defer a decision (time permitting)
or make a decision. Use phrases such as, “Are you ready to decide?”, “Do you want more
time? Do you have more questions?” or “Are there more things we should discuss?”
4. Offer review. Remind the parent or parents that decisions may be reviewed, where feasible.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

D. Model figure (Figure 8.1)

Deliberation
Initial Informed
Preferences Preferences

Choice Option Decision

Decision
Talk Talk Talk

Decision Support
Brief as well as Extensive

A process whereby patients become aware of choice,

understand their options, and have the time and
support to consider what matters most to them. This
Deliberation
may require more than one clinical contact (not
necessarily face-to-face) and may include the use of
decision support and discussion with others.

Initiated by either a patient or a clinician

Choice talk Conveys awareness that a choice exists
May occur before the clinical encounter

Patients are infomed about treatment options in more

Option talk
detail.

After having been informed, patients are supported in

Decision talk
exploring what matters most to them.

Takes two forms: (1) a brief type that is used by the

Decision clinician and patient together and (2) a more extensive
support type (eg, print materials, DVD, online resource), designed
to be used by the patient either before or after clinical
encounters.

Initial Awareness of options leads to the development of initial

preferences preferences, based on existing knowledge. The goal is to
arrive at informed preferences.

Personal preferences based on what matters most to

Informed
patients, predicated on an understanding of the most
preferences
relevant benefits and harms.

Figure 8.1. Decision Support Model

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

Self-test B
Now answer these questions to test yourself on the information in the last section.
B1. What are some of the important facts to remind yourself of when presented with a laboring mother
whose fetus has trisomy 18?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
B2. Health professionals who feel powerless when faced with the provision of life-prolonging care they
no longer believe to be beneficial should take what steps?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
B3. True False Withdrawal of life-sustaining measures can only occur with surrogate permission,
while non-initiation of intensive care does not require surrogate permission.
B4. True False The doctrine of double effect protects the provision of pain medications at the end
of life in all instances.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.

Self-test A
A1. When making decisions for imperiled newborns, none of the principles can be considered
more important than the others. What matters in a case is the relative weight assigned to
each principle. For example, if a parent refuses a treatment for their child, nonmaleficence
and beneficence would both hold equal weight in terms of their importance to whether or
not parental authority could be challenged. That said, the weights assigned to both nonma-
leficence and beneficence would be different, based on the potential burdens and benefits of
the treatment in question.
A2. False.  Reason: The burden of proof to challenge authority is less than the burden of proof
to challenge one’s autonomy. This is rooted in the idea of parens patriae, or the
state’s duty to protect the incompetent. An autonomous person can decide against a
lifesaving therapy if they are competent to do so; however, provided the burdens to
the child are insubstantial or are outweighed by the benefits, they cannot decide sim-
ilarly for their child. This is not to say that a parent must accept lifesaving therapy
for their child in absolutely all circumstances. For example, when the potential out-
come is uncertain, the parent ought to retain decisional authority.
A3. The most striking example of a change in patient populations for whom resuscitation is con-
sidered obligatory is for infants 25 weeks’ gestation and older. These infants represent a
population for whom the survival and predicted morbidity are such that resuscitation ought
to be provided, even against the wishes of the parents. There is less uncertainty related to the
outcomes of these infants when compared to infants born at 22 weeks’ gestation—and,
therefore, resuscitation is performed.
A4. Without qualifiers, “futility” is a meaningless term. While the chances of success for a resus-
citation may be dismal because of the physiological realities of the infant, simply saying,
“Resuscitation is futile” does not provide adequate information to the family about your
clinical reasoning. The word “futile” only has clinical meaning if there are qualifiers attached
to it in discussion with the family.
Self-test B
B1. Chiefly, it must be recognized that trisomy 18 is not a universally fatal diagnosis. In the
absence of a definitive birth plan (eg, a mother presents in labor at a community hospital),
life-prolonging interventions should be attempted to stabilize the infant and allow the family
to make a decision about ongoing provision of life-prolonging therapies. Contrary to popu-
larly held beliefs, many neonates with trisomy 18 will not need cardiac surgery during their
first admission.
B2. Under the auspices of shared decision making, every attempt should be made to reach a
joint conclusion that is in the best interests of the family. When disagreements exist, the hos-
pital ethics committee can serve as a resource to help navigate further complex discussions
with the family; the palliative care service can also serve as such a resource. Importantly,
some states allow for withdrawal of life-sustaining measures over the objection of a surro-
gate decision maker as long as certain protocols are followed. Health professionals should
familiarize themselves with state laws and hospital policies.

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 UNIT 8: BIOMEDICAL ETHICS AND PERINATOLOGY

B3. False. 
Reason: As described previously, withdrawal can occur without permission in select
cases. Non-initiation of intensive care (or a trial of resuscitation) can only occur uni-
laterally when the patient in question is not expected to survive initiation of inten-
sive care or is not expected to survive a trial of resuscitation. In all other instances,
this decision ought to be arrived at under the auspices of the shared decision-making
model.
B4. False. 
Reason: The doctrine of double effect only applies to pain medications administered
for the explicit reason of promoting comfort at the end of life and alleviating pain.
The doctrine does not protect those who would deliver pain medications in an
attempt to facilitate the death of the patient. Separate laws in some states and coun-
tries define the legality of physician-assisted suicide. Generally, such laws are not
applicable to neonates.

Unit 1 Posttest
After completion of each unit, there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15) and pass the test at 80% or greater to earn continuing education
credits. Only start the PCEP book examination if you have time to complete it. If you
take the book examination and are not connected to a printer, either print your certifi-
cate to a .pdf file and save it to print later, or come back to www.cmevillage.com at
any time and print a copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book examination are as follows: Book 1: 14.5 credits;
Book 2: 16 credits; Book 3: 17 credits; and Book 4: 9 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.

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08_Unit8_BKIV_PCEP_181-206.indd 206 5/29/21 8:08 AM
 PCEP
Perinatal Continuing Education Program

Pretest Answer Key

Book 4: Specialized Newborn Care

Unit 1: Direct Blood Pressure Measurement

1. C. Severe anemia 5. True
2. True 6. A. Baby’s heart
3. True 7. D. Measurement of acid-base balance
4. False

Unit 2: Exchange, Reduction, and Direct Transfusions

1. True  ​8. True
2. True  ​9. False
3. False 10. False
4. False 11. D. Tachypnea
5. C. Blood is not given 12. A. A 30-weeks’ gestation baby who is
6. A. 1 to 10 days appropriate for gestational age
7. True 13. B. 18 mL

Unit 3: Continuous Positive Airway Pressure

1. A. Intravenous fluids 6. B. 4 to 8 cm H2O pressure
2. D. Preterm baby with respiratory 7. A. Decrease the Fio2 to 40% to 50%, and
distress syndrome decrease the nasal CPAP to 6 cm H2O
3. False pressure.
4. False
5. C. Increase the baby’s arterial oxygen
concentration.

Unit 4: Assisted Ventilation With Mechanical Ventilators

1. E. Expiratory resistance 5. D. Ventilatory rate should be faster.
2. B. Capillary Po2 6. C. High pH level
3. A. End-expiratory pressure should
be higher
4. B. A 1,500-g (3 lb 5 oz) baby with respira-
tory distress syndrome who is breathing
80% oxygen and has a Pao2 of 45,
Paco2 of 65, and pH level of 7.28

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Unit 5: Surfactant Therapy

1. A. Contains phospholipids and proteins  ​6. A. Bolus instillation into the trachea
2. C. Will have a direct effect on alveolar  ​7. False
stability  ​8. True
3. A. It is the cause of respiratory distress  ​9. True
syndrome. 10. False
4. D. Mother is infected with HIV. 11. True
5. B. Lower

Unit 6: Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic

Encephalopathy
1. B. A cord blood gas analysis with a base of 5. A. Avoid hyperthermia.
16 or base excess of deficit of –16. 6. C. The temperature goals for pre-transport
2. D. Hypotonia cooling are 33°C to 34°C (91.4°F–93.2°F).
3. C. Before 6 hours of age
4. B. A baby born at 33 weeks’ gestation with
severe encephalopathy

Unit 7: Continuing Care for At-Risk Babies

1. A. Urine pH level  ​6. True
2. Yes No  ​7. False
X Request consultation from  ​8. False
social service department  ​9. True
staff. 10. False
X Call the parents and chat 11. False
with them about their baby. 12. False
X Begin making plans for the 13. False
baby to be sent to a foster 14. C. Bronchopulmonary dysplasia
home. 15. B. Feed the baby as much as he or she
3. B. A 1,000-g (2 lb 3 oz), preterm baby will take by nipple while a feeding tube
requiring assisted ventilation is in place, and then give the remainder
4. D. All preterm babies with a Pao2 greater of the feeding through the tube.
than 100 mm Hg will develop retinopa- 16. D. Adjusting the room temperature to a
thy of prematurity. neutral thermal environment during
5. Yes No the weaning period
X Measure the baby’s head 17. Yes No
circumference once a week. X Blood electrolytes
X Start the baby on X Volume of urine output
phenobarbital. X Stool pH level
X Weigh the baby daily. X Hematocrit value
X Administer iron dextran X Weight gain
intramuscularly. X Blood calcium level
X Check the baby’s hemato-
crit value at least once a
week.
X Attach the baby to a cardiac
or respiratory monitor.

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 PRETEST ANSWER KEY

Unit 8: Biomedical Ethics and Perinatology

  ​1. False Reason: Parents have decisional authority over their children. Their decisions, in very
rare cases, can be challenged. Decisions of a fully competent person cannot be challenged.
  ​2. False Reason: All 4 basic principles apply to all patients. While most newborns will one
day be capable of being autonomous, decisions made on their behalf are made by surro-
gate decision makers—typically parents.
  ​3. False Reason: Upon birth, the neonate is entitled to the same rights as any other human.
  ​4. False Reason: Some infants born at 22 weeks’ gestation will survive—some even neurolog-
ically intact. It would be a self-fulfilling prophecy to not resuscitate infants born at
22 weeks’ gestation because it is believed that none of them survive.
  ​5. False Reason: While the predicted neurological outcome of infants with trisomy
18 remains poor, the decision of whether to resuscitate should be discussed under the
auspices of shared decision making.
  ​6. False Reason: Anencephalic newborns, regardless of method of conception, are human
beings and therefore deserve rights afforded to all humans. Similar logic would dictate
that those who have lost the capacity for higher thought should also retain their rights,
given that they are still human beings.
  ​7. True Unilateral decisions, when justified, are protected by medical organizations.
Physicians have no obligation to provide a treatment they do not believe will work.
  ​8. True The provision of opioid analgesia at the end of life is intended to lessen suffering
(a good intent that is morally justifiable) and not cause the cessation of breathing (a possi-
ble outcome or side effect but not the intent of the provision of opioid analgesia).
  ​9. A. Discuss the case with the maternal-fetal medicine attending physician, and advocate for
possible transfer to an institution that would offer resuscitation. If a hospital has a unilat-
eral policy against resuscitating a fetus at a certain gestational age, provisions ought to be
in place for transfer, when possible, of parents to receive the care they desire for their
fetus, if morally justifiable.
10. D. Explain to the family that nothing else can be done to save their neonate, but comfort
care measures will be provided. A practitioner trained in the Neonatal Resuscitation
Program (NRP) can determine whether further resuscitative efforts are warranted. In
this case, the resuscitating physician firmly believes further efforts would not benefit the
patient, and the patient is not responding to even the most basic of interventions.
Additionally, this resuscitation has been occurring for 20 minutes, a time frame beyond
the recommended time set forth by NRP. This, in conjunction with the unknown gesta-
tional age, justifies the cessation of resuscitative efforts.

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 Glossary
ABO incompatibility: A condition that may lead to neonatal hemolytic disease. The pregnant woman
has group O red blood cells and antibodies to group A and B red blood cells. These antibodies are trans-
ferred to the fetus and cause destruction of fetal red blood cells. While this process is similar to Rh in-
compatibility, the hemolytic disease resulting from ABO incompatibility is less severe than the disease
caused by Rh incompatibility. Unlike Rh incompatibility, ABO incompatibility cannot be prevented by
giving the mother Rh immune globulin.
Acidosis: Abnormally low pH of the blood. The range of blood pH in a healthy neonate is between 7.25
and 7.35. A blood pH of 7.20 or lower is considered severe acidosis. Acidosis may result from metabolic
disturbances in which the serum bicarbonate is low or inadequate respiratory efforts in which serum
carbon dioxide is high. Often metabolic and respiratory factors simultaneously influence the blood pH.

BOOK 4: SPECIALIZED NEWBORN CARE/GLOSSARY

Acidotic babies are usually lethargic and may have mottled or grayish colored skin. If extremely acidotic,
babies typically take deep, regular gasping breaths. If a baby is gasping, the pH is probably 7.00 or less.
Acidosis should be corrected promptly, most commonly with assisted ventilation when due to inadequate
respiratory effort or occasionally by administration of sodium bicarbonate if due to metabolic factors.
Acoustic stimulation: A test in which fetal response to a sound when produced by a device placed
against the maternal abdomen and triggered to give a loud, 1-second buzz is used as an estimate of fetal
well-being. This test may be used during a nonstress test or labor.
Adrenaline: Official British Pharmacopoeia name for epinephrine. The trademark name for epinephrine
preparations is Adrenalin.
AGA: See Appropriate for gestational age.
Age, adjusted: See Age, corrected.
Age, chronological: Number of days, weeks, months, or years that have elapsed since birth.
Age, conceptional: Time elapsed between the day of conception and day of delivery. Note: The term
conceptual age is incorrect and should not be used. Conceptional age may be used when conception
occurred as a result of assisted reproductive technology, but should not be used to indicate the age of a
fetus or newborn. See also Age, gestational.
Age, corrected: Chronologic age in weeks or months reduced by the number of weeks born before
40 weeks of gestation. It is used only for children up to 3 years of age who were born preterm. It is
the preferred term to use after neonatal hospitalization, and should be used instead of adjusted age.
Example: A 24-month-old child born at 28 weeks’ gestation has a corrected age of 21 months.
Age, gestational: Number of completed weeks between the first day of the woman’s last menstrual
period and the day of delivery (or the date an assessment is performed if the woman has not yet
delivered). If pregnancy was achieved using assisted reproductive technology and, therefore, the date of
fertilization or implantation is defined, gestational age may be calculated by adding 2 weeks to the con-
ceptional age.
Age, postmenstrual: Weeks of gestational age plus chronologic age. It is the preferred term to describe
the age of preterm infants during neonatal hospitalization. Note: Postconceptional age should not be
used. Example: A baby born at 331/7 weeks with a chronologic age of 54/7 weeks has a postmenstrual
age of 385/7 weeks.
AIDS: Symptomatic stage of the illness caused by HIV.
Albumin: The major protein in blood.
Alkalosis: Abnormally high pH of the blood. Range of blood pH in a healthy neonate is between 7.25
and 7.35. Alkalosis may result from a high serum bicarbonate or, more commonly, when the carbon
dioxide concentration in a baby’s blood is lowered by hyperventilation (assisting the baby’s breathing at
an excessively fast rate). Babies who are alkalotic may not respond to stimulation intended to increase
their breathing efforts until their blood carbon dioxide level rises toward the reference range.

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 PCEP BOOK 4: SPECIALIZED NEWBORN CARE

Alpha fetoprotein: A normal fetal serum protein. When a fetus has an open neural tube defect, such as
anencephaly or meningomyelocele, increased amounts of this protein pass into the amniotic fluid and the
pregnant woman’s blood, thus providing the basis for an antenatal screening test. Low or high maternal
serum alpha fetoprotein levels may also indicate certain other fetal chromosomal defects or congenital
malformations.
ALT: Alanine transaminase. The serum level of this enzyme is used as a measure of liver function. When
liver cells are destroyed by disease or trauma, transaminases are released into the bloodstream. The
higher the ALT, the greater the number of destroyed or damaged liver cells.
Alveoli: The numerous, small, saclike structures in the lungs where the exchange of oxygen and carbon
dioxide between the lungs and blood takes place.
Amniocentesis: A procedure used to obtain amniotic fluid for tests to determine genetic makeup, health,
or maturity of the fetus. Using ultrasound guidance, a needle is inserted through a pregnant woman’s
abdominal wall and into the uterus where a sample of amniotic fluid is withdrawn, usually at 16 to
20 weeks’ gestation. If done earlier (11–13 weeks), there is often insufficient amniotic fluid and the
complication rate is higher.
Amnioinfusion: Infusion of fluid into the amniotic cavity. Amnioinfusion may be done by either of the
following procedures: after membranes have ruptured, by passing a catheter through the cervix and into
the uterus and infusing physiologic (normal) saline solution or otherwise by infusing saline through an
amniocentesis needle placed through the maternal abdominal wall and into the uterus. Amnioinfusion
may be used to reduce cord compression (as indicated by variable fetal heart rate decelerations) during
labor when oligohydramnios is present.
Amnion: The inner membrane surrounding the fetus. The amnion lines the chorion but is separate from
it. Together these membranes contain the fetus and amniotic fluid.
Amniotic fluid: Fluid that surrounds the fetus and makes up the “water” in the “bag of waters.” It
provides a liquid environment in which the fetus can grow freely and serves as insulation, protecting
the fetus from temperature changes. It also protects the fetus from a blow to the uterus by distributing
equally in all directions any force applied to the uterus. Amniotic fluid is composed mainly of fetal urine,
but also contains cells from the fetus’s skin and chemical compounds from the fetus’s respiratory passages.
Amniotic fluid analysis: Evaluation of various compounds in the amniotic fluid that relate to fetal lung
maturity and fetal health. Fetal skin cells that normally float in the amniotic fluid may also be obtained
with amniocentesis and grown in a culture to allow determination of fetal chromosomal status.
Amniotic fluid embolism: Amniotic fluid that escapes into the maternal circulation, usually late in labor
or immediately postpartum. Rather than causing a mechanical blockage in the circulation as emboli of
other origin might do, amniotic fluid embolism is thought to cause an anaphylactic-type response in sus-
ceptible women. This response is dramatic and severe, with sudden onset of hypoxia and hypotension.
Seizures or cardiac arrest may occur. If a woman survives the initial phase, disseminated intravascular
coagulation often follows. Although rare, it is associated with a high maternal mortality rate.
Analgesia: Relative relief of pain without loss of consciousness. Administration of specific medications is
the most common way to provide analgesia.
Anemia: Abnormally low number of red blood cells. The red blood cells may be lost because of bleeding,
destroyed because of disease process, or produced in insufficient numbers. Anemia is determined by
measuring the hemoglobin or hematocrit.
Anencephaly: A lethal congenital defect of neural tube development in which there is partial or complete
absence of the skull and brain.
Anesthesia: Total relief of pain, with or without loss of consciousness. Usually requires more invasive
techniques than that required for analgesia. General inhalation anesthesia produces loss of conscious-
ness, while major conduction anesthesia, such as spinal or epidural injection of long-lasting local anes-
thetics, produces total loss of pain in a specific area of the body without loss of consciousness.

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Anomaly, congenital: Malformation resulting from abnormal development during embryonic or fetal
growth. For example, a cleft lip is a congenital anomaly, as is gastroschisis, anencephaly, and countless
others. Used synonymously with congenital malformation.
Antenatal: Period during pregnancy before birth. Synonymous with prenatal.
Antenatal testing: Techniques used to evaluate fetal growth and well-being prior to the onset of labor.
Examples include nonstress test, biophysical profile, and ultrasonography.
Antepartum: Period of pregnancy before delivery. Most often used for period of pregnancy preceding
the onset of labor. (Intrapartum is used to refer to the time during labor.) Used in reference to the
woman.
Antibody: A type of blood protein produced by the body’s lymph tissue in response to an antigen
(a protein that is foreign to the bloodstream). Each specific antibody is formed as a defense mechanism
against a specific antigen.
Antibody screening test: A test of maternal serum against a large variety of blood group antigens as a
screening test for possible blood group incompatibility between a pregnant woman and her fetus. If the
antibody screening test result is positive, the individual blood group incompatibility should be identified.
See also Coombs test.
Antibody titers: A test used to indicate the relative concentration of a particular antibody present in a
person’s blood. Example: A high rubella titer indicates a person has been exposed to rubella (German
measles) and formed a significant amount of antibody against the rubella virus and, therefore, will most
likely be able to ward off another attack of the virus without becoming ill.
Anticonvulsants: Drugs given to prevent the occurrence of seizures (convulsions). The most
common anticonvulsants used in infants are phenobarbital and phenytoin (Dilantin). Anticonvulsant
therapy, with certain medications, for a pregnant woman with a seizure disorder may affect health
of the fetus.
Antiphospholipid antibody syndrome (APS): Development of antibodies to naturally occurring phospho-
lipids in the blood, causing abnormal phospholipid function. Antiphospholipid antibodies may be
present in healthy women but are more commonly associated with a generalized disease (eg, lupus
erythematosus). They have a strong association with recurrent miscarriage, fetal growth restriction, pre-
eclampsia, and other factors adversely affecting fetal or maternal health.
Aorta: Main artery leaving the heart and feeding the systemic circulation. It passes through the
chest and abdomen, where it branches into smaller arteries. In a newborn, an umbilical arterial
catheter passes through one of the arteries in the umbilical cord and into the abdominal section of
the aorta.
Apgar score: A score given to newborns and based on heart rate, respiratory effort, muscle tone, reflex
irritability, and color. The score is given 1 minute after the baby’s head and feet are delivered (not from
the time the cord is cut) and again when the baby is 5 minutes of age. If the 5-minute score is less than
7, additional scores are given every 5 minutes for a total of 20 minutes. The 1-minute Apgar score indi-
cates a baby’s immediate condition; the 5-minute score reflects the baby’s condition and effectiveness of
resuscitative efforts. A low 5-minute score is a worrisome sign. It is not, however, a certain indicator of
damage. Likewise, a high score is not a guarantee of a healthy baby. The score is named for Dr Virginia
Apgar, who developed it. The 5 letters of her name may also be used to signify the 5 components of the
score: A 5 appearance (color), P 5 pulse (heart rate), G 5 grimace (reflex irritability), A 5 activity
(muscle tone), and R 5 respirations.
Apnea: Stoppage of breathing for 15 seconds or longer, or stoppage of breathing for less than 15 seconds
if also accompanied by bradycardia or cyanosis.
Appropriate for gestational age (AGA): Refers to a baby whose weight is above the 10th percentile and
below the 90th percentile for babies of that gestational age.
APS: See Antiphospholipid antibody syndrome.

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Arrhythmia: Abnormal rhythm of the heartbeat. Fetal arrhythmias are rare. One of the more common
ones is congenital heart block, which occurs almost exclusively with maternal systemic lupus erythema-
tosus, although it is uncommon even in that situation. With a maternal arrhythmia, the more persistent
the arrhythmia and farther the rate is from normal (either faster or slower), the more likely it is there
will be a deleterious effect on maternal cardiac output and, thus, on blood flow to the uterus.
Artery: Any blood vessel that carries blood away from the heart.
Asphyxia: A condition resulting from inadequate oxygenation or blood flow and characterized by
low blood oxygen concentration, high blood carbon dioxide concentration, metabolic acidosis, and
organ injury.
Aspiration: (1) Breathing in or inhaling of a fluid (eg, formula, meconium, or amniotic fluid) into the
lungs. Aspiration usually interferes with lung function and oxygenation. If inhaled, meconium is irritat-
ing as well as obstructing, resulting in meconium aspiration syndrome, which often causes serious and
sometimes fatal lung disease. (2) Removal of fluids or gases from a cavity, such as the stomach, by
suction. Example: A nasogastric tube is inserted and an empty syringe is attached to the tube and used
to suck out or aspirate air and gastric juices from the stomach.
Assisted ventilation: Use of mechanical devices to help a person breathe. Bag and mask with bag
breathing, endotracheal tube with bag breathing, or a respirator machine may each be used to assist
ventilation.
AST: Aspartate transaminase. The serum level of this enzyme is used as a measure of liver function. As
with alanine aminotransaminase, liver damage causes transaminases to be released into the bloodstream.
Atelectasis: Condition in which lung alveoli have collapsed and remain shut.
Atony: Loss of muscle tone or strength. Uterine atony is a leading cause of postpartum hemorrhage.
Axillary: Refers to the axilla, or armpit.
Bacteriuria: Presence of bacteria in the urine.
Bag breathing: Artificially breathing for a person by inflating the lungs with a resuscitation bag and
mask or resuscitation bag and endotracheal tube.
Ballooning of lower uterine segment: A sign of impending labor, either term or preterm. The process
leading to labor produces thinning of the lower uterine segment of myometrium, so that the lower seg-
ment “balloons out” into the anterior fornix of the vagina. The ballooned segment may be seen during
speculum examination or palpated during digital examination.
BCG: Bacille Calmette-Guérin. Vaccine made from the Calmette-Guérin strain of Mycobacterium bovis
for immunization against tuberculosis.
Beneficence: Acting for the benefit of a patient.
b-human chorionic gonadotropin (b-hCG): A hormone produced by trophoblastic cells of the chorionic
villi. It is the first biochemical marker of pregnancy and produced in increasing amounts until maximal
levels are reached at 8 to 10 weeks. When b-hCG is present in the blood or urine of a woman, she is
pregnant. High titers are found with multifetal gestation and erythroblastosis fetalis; extremely high
titers may be seen with hydatidiform mole and choriocarcinoma, while declining or low levels are
found with spontaneous abortion and ectopic pregnancy.
Betamimetic: A drug that stimulates b-adrenergic receptors of smooth muscle, such as the myometrium
(uterine muscle), causing decreased contractions. Used to suppress the onset of premature labor. A
betamimetic drug is also called a b-adrenergic receptor agonist. An example is terbutaline.
Bilirubin: A substance produced from the breakdown of red blood cells. High blood bilirubin level
causes the yellow coloring of the skin (and sclera) that is termed jaundice.
Biophysical profile (BPP): A combination of measures used to evaluate fetal well-being. Each of the
5 components (nonstress test, ultrasound evaluation of amniotic fluid volume, fetal body movements,

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muscle tone, and respirations) is scored. Each measure is given 2 points if present, zero if absent (there is
no score of 1). The scores are added together for the final BPP score.
Biparietal diameter (BPD): Diameter of the skull, measured as the distance between the parietal bones,
which lie just above each ear. Ultrasonography is used to determine BPD of the fetal skull. Serial BPD
measurements are used to assess fetal growth and estimate fetal gestational age.
Bishop score: A system that scores cervical dilation, effacement, consistency, and position, as well as
station of the presenting part to assess the “readiness” of a cervix for labor. Scores correlate with the
likelihood that an attempt at induction of labor will be successful.
Blood gas measurement: Determination of the pH and concentration of oxygen, carbon dioxide, and
bicarbonate in the blood.
Blood glucose screening test: Any of several commercially available, small, thin, plastic reagent strips
designed to estimate blood glucose level with a single drop of blood. A color change caused by a drop
of blood placed on the reagent pad provides an estimate of the blood glucose level. In addition, several
handheld devices are designed to draw in a tiny amount of blood and give a digital readout of the
glucose level.
Blood group: Numerous blood groups are in humans, each defined by their antigenic responses. The
major blood groups are A, B, AB, and O, which are then further defined by their Rh type, positive or
negative, as well as various other minor antigens. Note: Every person is exposed to the major blood
group antigens (A and B) soon after birth, because the antigens are found in air, food, and water. Each
person who lacks one or both of the major blood group genes (A or B) will make antibodies against the
antigens they lack. Thus, persons with blood group O develop anti-A and anti-B antibodies and keep
them throughout life. If given a blood transfusion with group A or B blood, a person with group O
blood will have a transfusion reaction, which may in some cases be fatal. Similar reactions occur when
a person with group B blood is given group A blood, or vice versa. Group “AB” persons do not make
antibodies against either A or B because they have both antigens on their red blood cells. Persons with
group AB blood can receive blood from people with any major blood group, but AB blood should be
transfused only into persons with AB blood. Persons with group O blood should receive only blood
transfusions with O blood, but O blood may be used to transfuse a person with any major blood group.
This is why a person with AB blood is called a universal recipient and a person with O blood is called a
universal donor.
Blood pressure, diastolic: Lowest point of the blood pressure between heartbeats, when the heart is
relaxed.
Blood pressure, mean: The diastolic blood pressure plus one-third of the difference between the systolic
and diastolic blood pressure.
Blood pressure, systolic: Highest point of the blood pressure. The blood pressure during the heartbeat,
when the heart is contracted.
Blood smear: A thin layer of blood spread across a glass slide and studied under a microscope to
determine the types of blood cells present.
Blood type: See Blood group.
Bloody show: Bloody mucus passed from the vagina in late pregnancy, usually associated with cervical
effacement. It often heralds the onset of labor and is a normal finding. Any bleeding in pregnancy,
however, should be investigated.
BPD: See Biparietal diameter.
BPP: See Biophysical profile.
Brachial plexus nerve injury: Paralysis of the arm that results from injury to the upper brachial plexus. Is
associated with shoulder dystocia or a difficult breech delivery when traction is applied to the shoulder,
stretching the nerve trunks exiting from the cervical spinal cord (brachial plexus). However, about one-
half of these injuries occur in children in whom there was no evidence of either shoulder dystocia or

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breech delivery. The injury, therefore, may be initiated before birth by deformation of the neck
and shoulder by abnormal positioning of the fetus. Many such palsies will recover within the first
few years after birth.
Bracht maneuver: A method of delivering breech presentations in cases in which delivery is imminent
and neither a practitioner skilled in vaginal breech delivery nor cesarean delivery is immediately available.
Bradycardia: Slow heart rate. (1) Fetal: Considered to be a baseline heart rate of less than 110 beats/min
for 2 minutes or longer. Bradycardia alone may or may not indicate fetal distress. (2) Neonatal: Consid-
ered to be a sustained heart rate less than 100 beats/min.
Breech presentation: The feet- or buttocks-first presentation of a fetus. (1) Frank: Buttocks presenting,
with the fetus’s legs extended upward alongside the body. (2) Footling: One foot can be felt below the
buttocks. (3) Double footling: Both feet can be felt below the buttocks. (4) Complete: Buttocks present-
ing, with the knees flexed.
Bronchopulmonary dysplasia (BPD): Also called chronic lung disease. A form of chronic lung disease
sometimes seen in infants who have required ventilator therapy for any of a variety of lung problems,
including respiratory distress syndrome and meconium aspiration syndrome. Bronchopulmonary
dysplasia is thought to result from the combined effects of oxygen free-radical injury of premature
lungs and trauma to the lungs produced by high airway pressures generated by ventilators.
Brow presentation: The brow (forehead) of the fetus is the presenting part. On vaginal examination, the
anterior fontanel can be felt, but the posterior fontanel cannot. Management depends on whether the
presentation stays brow or changes to face or the baby’s neck flexes and the presentation becomes vertex.
Caput succedaneum: Edema of the fetal scalp that develops during labor. This swelling crosses suture
lines of the skull. Caput succedaneum may occur with a normal, spontaneous vaginal delivery, but a
lengthy labor or delivery by vacuum extraction increases the risk of occurrence.
Cardiac massage: See Chest compressions.
Cardiac output: Output of the left ventricle in milliliters per minute.
Central nervous system depression: Condition in which the body is less reactive than normal to stimuli,
such as a pinprick. Central nervous system depression may be characterized by delayed reflexes, lethargy,
or coma. It may result from a variety of causes, including certain drugs, certain metabolic disorders, or
asphyxia.
Cephalhematoma: Also called cephalohematoma. Hematoma under the periosteum of the skull and
limited to one cranial bone (does not cross suture lines) of the newborn. It is usually seen following
prolonged labor and difficult delivery, but may also occur with uncomplicated birth. Delivery with
forceps or vacuum extraction increases the risk of occurrence.
Cephalopelvic disproportion (CPD): See Fetopelvic disproportion.
Cerclage of the cervix: The procedure of placing a suture around the cervix to prevent it from dilating
prematurely. There are several different techniques for placing the suture. Cervical cerclage is used as a
treatment for incompetent cervix.
Cervix: The lower, narrow end of the uterus, which opens into the vagina.
Cesarean delivery: Surgical delivery of the fetus through an abdominal incision. The uterine incision may
be classical (vertical, cutting through both the contractile and non-contractile segments) or confined to
the non-contractile lower uterine segment (either vertical or transverse incision).
Chest compressions: Artificial pumping of blood through the heart by a bellows effect created from
intermittent compression of the sternum, over the heart, during resuscitation.
Chickenpox: See Varicella-zoster virus.
Chlamydia: A type of microorganism with several species. Capable of producing a variety of illnesses,
including eye infection, pneumonia, and infection of the genitourinary tract.

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Choanal atresia: Congenital blockage of the nasal airway. Because babies breathe mainly through
their noses, a baby with choanal atresia will have severe respiratory distress at birth. The immediate
treatment is insertion of an oral airway. Surgical repair when the baby is stable is required for permanent
correction.
Chorioamnionitis: Inflammation of the fetal membranes, also known as intra-amniotic infection, or IAI.
The fetus may also become infected.
Chorion: Fetal membrane that surrounds the amnion, but is separate from it, and lies against the
decidual lining of the uterine cavity (endometrium). During embryonic development, the chorion gives
rise to the placenta.
Chorionic villus sampling (CVS): A highly specialized technique in which a tiny portion of the chorionic
villi, which contain the same genetic material as the fetus, is obtained in a manner similar to a needle
biopsy. The cells obtained may be analyzed for chromosomal defects. Chorionic villus sampling may
be done as early as 10 weeks’ gestation, with preliminary results available within as little as 2 days,
allowing earlier and more rapid detection of chromosomal disorders than is possible with amniocentesis.
The incidence of complications is similar to the risks associated with amniocentesis.
Chromosome: The material (DNA protein) in each body cell that contains the genes, or information
regarding hereditary factors. Each normal cell contains 46 chromosomes. Each chromosome contains
numerous genes. A baby acquires one-half of chromosomes from the mother and one-half from the
father. A chromosomal defect results from an abnormal number of chromosomes or structural damage
to the chromosomes. Example: Each cell in the body of a baby with Down syndrome (trisomy 21)
contains 47 instead of 46 chromosomes.
Chronic lung disease (CLD): See Bronchopulmonary dysplasia.
Circulatory system: The system that carries blood through the body and consists of the heart and blood
vessels. The systemic circulatory system carries blood to and from the head, arms, legs, trunk, and
all body organs except the lungs. The pulmonary circulatory system carries blood to the lungs, where
carbon dioxide is released and oxygen is collected, and returns the oxygenated blood to the systemic
circulatory system.
Cirrhosis: Chronic degeneration of the hepatic cells, replacing them with fibrosis and nodular tissue and
resulting in liver failure. Chronic hepatitis and alcoholism are common causes.
CLD: Chronic lung disease. See Bronchopulmonary dysplasia.
CMV: See Cytomegalovirus.
Coagulation: The process of blood clot formation.
Colon: The large intestine, which is between the small intestine and rectum.
Colonization: Persistent, asymptomatic presence of bacteria in a particular area of the body. If symptoms
develop, it becomes an infection. Example: Many women have vaginal or rectal colonization with group
B b-hemolytic streptococci but are entirely without symptoms, although maternal group B b-hemolytic
streptococci colonization poses a risk for life-threatening neonatal infection.
Compliance (of lung): Refers to elastic properties of the lungs. Babies with certain lung diseases have
decreased compliance (stiff lungs) and thus cannot expand their lungs well during inhalation.
Comprehensive ultrasound: Detailed ultrasound examination designed to review all parts of fetal anatomy.
Done when congenital malformations are suspected.
Condyloma: Warty growth of skin in the genital area caused by human papillomavirus.
Congenital: Refers to conditions that are present at birth, regardless of cause. Congenital defects may re-
sult from a variety of causes, including genetic factors, chromosomal factors, diseases affecting the preg-
nant woman, and drugs taken by the woman. The cause, however, of most congenital defects is un-
known. Note: Congenital and hereditary are not synonymous. Congenital means present at birth.
Hereditary means the genetic transmission from parent to child of a particular trait, which may be the

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trait for a specific inheritable disease and associated malformations. Some defects are congenital and
hereditary, but many are simply congenital with no genetic link.
Congenital rubella syndrome: A group of congenital anomalies resulting from an intrauterine rubella
infection. Anomalies commonly include cataracts, heart defects, deafness, microcephaly (abnormally
small head), and intellectual disability.
Congestive heart failure: A condition that develops when the heart cannot pump as much blood as it
receives. As a result, fluid backs up into the lungs and other tissues, causing edema and respiratory
distress. Congestive heart failure may result from a diseased or malformed heart, severe lung disease, or
too much fluid given to the patient.
Conjugation of bilirubin: Process that occurs in the liver and combines bilirubin with another chemical
so it may be removed from the blood and pass out of the body in the feces. Failure of bilirubin conjuga-
tion is one cause of jaundice.
Conjunctivitis: Inflammation of the membrane that covers the eye and lines the eyelids. Certain genital
tract infections, particularly Chlamydia and gonorrhea, in a pregnant woman can cause severe conjuncti-
vitis and eye damage in a newborn, unless proper neonatal treatment is given.
Continuous positive airway pressure (CPAP): A steady pressure delivered to the lungs by means of a
special apparatus or mechanical ventilator. Continuous positive airway pressure may be used for babies
with respiratory distress syndrome to prevent alveoli from collapsing during expiration.
Contraction stress test (CST): Termed oxytocin challenge test when oxytocin is used to induce contrac-
tions. A brief period of uterine contractions (either spontaneous or induced with nipple stimulation or
intravenous oxytocin administration) during which the fetal heart rate and uterine contractions are
monitored with an external monitor. It is a test used in certain high-risk pregnancies to assess fetal
well-being.
Coombs test: Test to determine the presence of antibodies in blood or on red blood cells. There are
2 forms of the test. The direct Coombs test detects antibodies attached to the red blood cells; the indirect
Coombs test detects antibodies within the serum. Example: The direct test is used to detect antibodies
present on the red blood cells of Rh-positive babies born to Rh-negative sensitized women. The indirect
test is used on a woman’s blood to detect antibodies to fetal Rh-positive cells. See also Antibody screen-
ing test.
Cord presentation: Also referred to as funic presentation. A situation in which the umbilical cord lies
against the membranes over the cervix, beneath the fetal presenting part. This poses a risk for cord
injury or prolapse when the membranes rupture.
Cordocentesis: See Percutaneous umbilical blood sampling.
Corticosteroids: Refers to any of the steroids of the adrenal cortex. Betamethasone and dexamethasone
are artificially prepared steroids that may be given to a woman to speed up the process of lung matura-
tion in her fetus when preterm delivery is unavoidable.
COVID-19: Coronavirus disease 2019, the clinical illness caused by infection with SARS-CoV-2
(severe acute respiratory syndrome coronavirus 2), a novel coronavirus that caused a global pandemic
beginning in late 2019.
CPAP: See Continuous positive airway pressure.
CPD: Cephalopelvic disproportion. See Fetopelvic disproportion.
Creatinine: A chemical in the blood excreted in urine and used as an indication of renal function.
Cryoprecipitate: A concentrated form of plasma. In a much smaller volume, it contains fibrinogen, coag-
ulation factor VIII, and some, but not all, of the other coagulation factors found in fresh frozen plasma.
Used in the treatment of severe disseminated intravascular coagulation.
CST: See Contraction stress test.

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CVS: See Chorionic villus sampling.

Cyanosis: Bluish coloration of the skin. (1) Central cyanosis: Bluish coloration of the skin and mucous
membranes due to inadequate arterial blood oxygen concentration. Sometimes babies with central
cyanosis are described as appearing dusky. (2) Acrocyanosis: Cyanosis of the hands and feet only, which
is generally not associated with low blood oxygen concentration.
Cytomegalic inclusion disease: An infection with cytomegalovirus. Maternal infection may go unnoticed,
but fetal infection, especially early in gestation, can damage every organ system. The disease commonly
causes an enlarged liver and spleen, encephalitis, microcephaly, intracranial calcification, and visual or
hearing defects.
Cytomegalovirus (CMV): The virus that causes cytomegalic inclusion disease.
Debridement: Removal of dead tissue and foreign matter from a wound.
Deceleration: See Fetal heart rate deceleration.
Decidua: Endometrium that has been modified by the hormonal effects of pregnancy; the endometrium
during pregnancy.
Deflexed head: The fetal head is not round. It is longer from front to back (occipitomental diameter is
approximately 13.5 cm at term) than it is from side to side (biparietal diameter is approximately 9.5 cm at
term). When the fetal head is well flexed with the chin on the chest, the top of the head, with a maximum
diameter of 9.5 to 10 cm, is presented to the pelvis. In most cases, the pelvis is larger than this, allowing the
head (largest part of the fetus) to pass through it. When the head is deflexed, as it is in brow and face presen-
tations, the farther the chin is from the chest, the larger the diameter is presented to the pelvis. These presen-
tations make vaginal delivery difficult or impossible without risk of serious damage to the fetus or woman.
Deformation: Structural defect of a fetus caused by mechanical force, rather than abnormal embryonic
development or an inherited disease. External factors, such as uterine fibroids or amniotic bands, may
produce a deformity by compressing parts of the fetus. Prolonged oligohydramnios can also cause defor-
mities, due to lack of the amniotic fluid cushion normally provided to a growing fetus. Sometimes these
deformities, such as an angulated spine or flattened head, resolve spontaneously over time. In other
cases, cosmetic surgery will be needed for correction. Malformation and deformation are not synony-
mous. Malformation is the term used when a congenital anomaly is due to abnormal development of
the fetus. Deformation is the term used when a congenital anomaly is due to external mechanical force
applied to a growing fetus.
Dehiscence: Separation of an incision that had been surgically united. The separation may be partial,
involving only the outer layer, or complete through all tissue layers. In perinatal care, this term is most
commonly applied to the postoperative separation of an abdominal incision or development of an
opening in a uterine scar from a previous cesarean delivery.
Diabetes, gestational: Also called glucose intolerance of pregnancy or gestational diabetes mellitus.
Disturbance of glucose metabolism that mimics diabetes mellitus and first appears during pregnancy and,
in many cases, disappears after delivery. Women with this condition are more likely than the general
population, however, to develop insulin-dependent diabetes later in life. Because normal control of blood
glucose during pregnancy is important for fetal well-being, and because this metabolic problem is fairly
common, screening tests for abnormal glucose tolerance are recommended for every prenatal patient.
Diabetes mellitus: A metabolic disorder in which the body’s ability to use glucose is impaired because of
a disturbance in normal production of or response to insulin. This leads to high blood glucose levels and
other metabolic imbalances. Diabetes mellitus during pregnancy places the woman and fetus at risk for
certain serious problems and may affect health of the newborn.
Diaphragm: The primary muscle of breathing that separates the chest cavity from the abdominal cavity.
Diaphragmatic hernia: A defect in the diaphragm through which abdominal organs slip and enter
the chest, where they compress the lungs. If abdominal organs enter the chest cavity early in gestation,
development of one or both of the lungs can be severely inhibited.

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DIC: See Disseminated intravascular coagulation.

Digital examination: Examination of the cervix and, during labor, the presenting part of the fetus, with a
gloved hand inserted in the vagina (examination is done using your fingers, or digits), as opposed to a
speculum examination to view the cervix.
Digitalis: A drug that increases the contraction force of the heart while at the same time decreasing the
rate at which the heart beats. Sometimes used to treat congestive heart failure.
Dilation: The condition of being stretched beyond normal dimensions. In perinatal care this most com-
monly refers to the degree of opening in the cervical os.
Dipstick: Thin, narrow paper or plastic strip (or “stick”) with chemical reagents that change color in the
presence of certain conditions in the liquid being tested. Different types of dipstick test for different sub-
stances, and some dipsticks have several reagent patches to test for several substances on the same stick.
Dipsticks are used to test body fluids, such as vaginal secretions, gastric aspirate, and urine. Examples of
their use in perinatal care include testing vaginal secretions for pH to help identify rupture of the mem-
branes and urine for protein in women with hypertension.
Disseminated intravascular coagulation (DIC): An acquired disturbance of the body’s blood coagulation
processes in which coagulation factors are consumed, leaving the blood incapable of coagulating. Certain
serious illnesses may trigger the onset of DIC in neonates or adults. Most commonly in neonates, DIC
may accompany severe sepsis, hypoxia, acidosis, or hypotension. In pregnant women, DIC may accom-
pany placental abruption, retained dead fetus syndrome, or sepsis. Blood platelets and coagulation
factors are activated abnormally by the release of thromboplastic substances into the circulation. As a
result, numerous fibrin clots are formed in the capillaries. Red blood cells may be broken down as blood
flow pushes the cells through the clogged capillaries, which may lead to hemolytic anemia. In addition,
oozing from puncture sites, surgical incisions or other wounds, and easy bruising may occur as the plate-
lets and coagulation factors are consumed by the fibrin clots and are no longer available to maintain
normal blood coagulation. Neonates with DIC, especially preterm babies, are also at risk for pulmonary
or intracranial hemorrhage. Treatment, which is complex, is directed at correcting the underlying disease
process and providing emergency management to correct the coagulation deficit.
Diuretics: Drugs (eg, furosemide, thiazides, spironolactone) given to prevent or decrease fluid buildup in
the lungs and body by increasing urine output.
DNA testing: Also called genetic testing. Samples of tissues (eg, blood, urine, skin) are treated, using a
highly technical process, to extract the DNA of chromosomes (and mitochondria). Tests can then reveal
defective genes that cause specific diseases. Most disease-causing genes, however, have not yet been
identified.
Dolichocephalic: Long headed; typically refers to the elongated head of a fetus in breech position when
ultrasonography is used to measure the fetal skull biparietal diameter. This head shape reduces the
accuracy of biparietal diameter measurements.
Doppler instrument: A device used to detect changes of blood flow through a blood vessel. A Doppler
instrument may be used to detect fetal heartbeats.
Double setup: A vaginal examination performed in an operating room, with everything in readiness for
either a vaginal or cesarean delivery. Used in cases of suspected placenta previa during labor, in which
the examination itself may trigger such profuse hemorrhage that immediate surgery is required.
Down syndrome: Also called trisomy 21. A chromosomal abnormality resulting in a typical facial
appearance, intellectual disability, and sometimes other congenital defects, particularly cardiac defects.
Individuals with Down syndrome have 47 instead of the normal 46 chromosomes, with one additional
copy of chromosome 21 in each cell.
Ductus arteriosus: A blood vessel in the fetus that connects the pulmonary artery and aorta. This
allows less blood to go to the fetal lungs and more blood to go to the systemic and placental circulation.
Normally this vessel closes shortly after birth, thus redirecting blood flow to the lungs. A patent ductus
arteriosus means the ductus arteriosus persistently remains open after birth. As a result, and with

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 GLOSSARY

changes in pressure that occur within the circulatory system once placental circulation is eliminated,
blood may flow from the aorta into the pulmonary artery, resulting in too much blood directed to the
lungs. This may cause congestive heart failure in the baby.
Dusky: See Cyanosis.
Dye test: In perinatal care, this usually refers to a test done to determine if the amniotic membranes are
ruptured. There is no indication for a dye test unless there is reason to suspect that rupture of mem-
branes has occurred, other tests are negative, and the diagnosis of ruptured membranes will affect clini-
cal management. Amniocentesis is done under ultrasound guidance. If indicated, a sample of amniotic
fluid is withdrawn for testing. A dye, usually indigo carmine, is then introduced through the amniocente-
sis needle. A sterile gauze pad (4 3 4 in) is placed high in the woman’s vagina. If no dye appears on the
pad after 20 to 30 minutes of sitting or walking, it is most likely that the membranes are intact and have
not ruptured.
Dyspnea: Difficult breathing, labored. This may accompany any variety of disease states or be a result of
physical exertion in a healthy person.
Dystocia: Difficult labor. (1) Uterine: Abnormal labor, particularly prolonged. Used to refer to weak or
ineffective uterine contractions. Usually used to describe a labor that has ceased progressing such that a
cesarean delivery is necessary. (2) Shoulder: Situation in which the shoulders of a baby in vertex presen-
tation become trapped after delivery of the head. This is an emergency, requiring immediate intervention
to avoid severe fetal hypoxia.
ECG: See electrocardiograph.
Eclampsia: Term used to describe the condition in which convulsions or coma develop in a pregnant
or postpartum woman with pregnancy-related hypertension. The condition of preeclampsia becomes
eclampsia whenever seizures or coma develop.
EDD: Estimated date of delivery. See Pregnancy due date.
Edema: Swelling due to an excessive amount of fluid in the tissues.
Effacement: The process of thinning of the cervix prior to and after the onset of labor.
Electrocardiograph: Also called electrocardiogram, electronic cardiac monitor. A device used for
recording the heart’s electrical activity.
Electrolyte: A substance that dissociates into ions when in solution (and thereby makes the solution
capable of conducting electricity). Commonly refers to sodium, potassium, chloride, and bicarbonate
in blood.
Embolus: A blood clot or other plug (eg, an air bubble) carried by the blood from a larger to smaller
blood vessel, where it lodges and obstructs the blood flow. Plural: emboli.
Embryo: Term used for the product of conception, from the time a fertilized egg is implanted until all
major structures and organs are defined. In humans, this is the first 8 weeks of development after con-
ception (10 weeks after the last menstrual period). After 8 weeks and until birth, the term fetus is used.
Endocrine system: Refers to organs that release hormones into the blood.
Endometritis: Infection of inner lining of the uterine cavity, the endometrium.
Engagement, engaged: Term applied during late pregnancy or in labor that indicates that the largest
diameter of the presenting part is at or below the smallest diameter of the pelvis. Usually the presenting
part is the fetal head, which is said to be engaged when a vaginal examination reveals the head to be at
or below the ischial spines.
Environmental oxygen: See Inspired oxygen.
Epidural: A technique for providing anesthesia during labor. A hollow needle is inserted between 2 verte-
brae in the woman’s spine, and a catheter is threaded through the needle and into the epidural space of

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the spinal column. A local anesthetic is then injected through the catheter into the epidural space. This
eliminates all sensation for the nerve roots that the drug contacts. The greater the volume of anesthetic
medication injected, the greater the number of nerve roots affected and, therefore, the larger the area of
body that is anesthetized. By anesthetizing only some of the spinal nerve roots, epidural anesthesia pro-
vides pain relief during labor but, at the same time, may also permit walking. As with spinal anesthesia,
the anesthetic medication also blocks the sympathetic nerves leaving the spinal cord. Because of this,
blood pressure of the woman may decline and requires careful monitoring. (For this reason, a loading
dose of 500–1,000 mL of physiologic [normal] saline solution may be given intravenously prior to intro-
duction of the anesthetic.)
Epigastric: Area immediately below the tip of the sternum in the center of the upper abdomen. Pain felt
here is usually related to liver or gallbladder disease. Of most importance in pregnant women with
preeclampsia, the onset of epigastric pain indicates swelling of the liver capsule. This often precedes the
onset of the first convulsion of eclampsia.
Epiglottis: The flap of cartilage that overlies the larynx. The epiglottis is open during breathing and
closes over the larynx during swallowing to prevent food from entering the trachea.
Epinephrine: A natural body hormone that is released by adrenal glands into the blood during stress. It
may also be used as a drug during resuscitation to constrict blood vessels and increase blood pressure,
and to increase heart rate and volume of blood pumped.
Erb palsy: The most common form of brachial plexus nerve injury in newborns.
Erythema: Redness of the skin produced by dilation of the smallest blood vessels. Example: The redness
that occurs around an infected wound.
Erythroblastosis fetalis: Hemolytic anemia resulting from the passage of antibodies between the pregnant
woman and the fetus across the placenta during pregnancy. Red blood cell alloantibodies may develop in
a woman when fetal red blood cells enter the maternal circulation during a prior pregnancy (most com-
monly at the time of delivery), or as a result of a blood transfusion (less common). The placenta transfers
immunoglobulin G antibodies from mother to fetus during pregnancy. If the fetal red blood cells exhibit
the specific antigen to which the mother has an alloantibody, the interaction between the antibody and
antigen leads to breakdown (hemolysis) of the fetal red blood cells. As the fetal blood-forming organs
produce red blood cells more rapidly than normal to replace those undergoing hemolysis, immature fetal
red blood cells (erythroblasts) are released into the fetal circulation. The consequences of untreated fetal
hemolytic anemia can include fetal hydrops and stillbirth.
Esophagus: The muscular tube that connects the throat and stomach.
Etiology: The cause of anything. Example: Sepsis may be the etiology of hyperbilirubinemia in a
newborn.
Exchange transfusion: Process during which a baby’s blood is removed and replaced with donor blood
so that when the exchange transfusion is completed, most of the baby’s blood has been replaced by
donor blood. Most often, exchange transfusions are used as a treatment for severe hyperbilirubinemia.
Expiration: (1) Period during the breathing cycle when the person is breathing out or exhaling.
(2) The end of a period of usefulness, validity, or effectiveness, such as the expiration date for a
product or medication, after which time the item should not be used. (3) Death.
Face presentation: The face is the presenting part. The chin (mentum) is the reference point, and it may
rotate either anteriorly (mentum anterior), in which case vaginal delivery is likely if the pelvis is normal
in size, or posteriorly. When the chin rotates posteriorly into the hollow of the sacrum (mentum poste-
rior), vaginal delivery is impossible unless the forces of labor or use of obstetric forceps are successful in
rotating the chin to the anterior position. Cesarean delivery is usually performed for mentum posterior
position.
FAD: See Fetal activity determination.
FAE: See Fetal alcohol effects.

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Familial: Used to describe a disease or defect that affects more members of a family than would be
expected by chance.
FAS: See Fetal alcohol syndrome.
Fat, brown: Fat tissue that has a rich blood and nerve supply. Babies have proportionally more brown
fat than do adults and metabolize or “burn” it as their main source of heat production, while adults
produce heat mainly by shivering. Extra oxygen and calories are used when brown fat is metabolized.
Fat, white: Type of fat that has few blood vessels and appears whitish. It is used mainly for insulation
and as a reserve supply of energy and is not nearly as metabolically active as brown fat.
Fatty acids: Substances resulting from the breakdown of fat. Fatty acids decrease binding of bilirubin to
albumin, thus increasing the chance of brain damage from hyperbilirubinemia.
Femoral pulse: Pulse felt in the groin, over the femoral artery.
Fern test: A test for amniotic fluid in the vagina, used when rupture of membranes is suspected. When
there is a pool of fluid in the vagina, a drop of it is smeared on a glass slide and allowed to dry in the
air. Salt content of the amniotic fluid will dry in a typical pattern, resembling a fern, while other fluids
(eg, urine) will not. If a fern pattern is seen, the membranes are ruptured.
Fetal activity determination (FAD): A noninvasive means to monitor fetal well-being that may be used by
either low- or high-risk pregnant women. Approximately 80% of gross fetal movements observed on
ultrasound are felt by the pregnant woman. Beginning at approximately 28 weeks’ gestation, a pregnant
woman records fetal activity daily according to one of several accepted protocols. Any significant
decrease in activity warrants prompt (the same day) investigation of fetal condition.
Fetal alcohol effects (FAE): The effects of maternal alcohol ingestion during pregnancy may be seen in a
baby without the baby having all the findings typical of fetal alcohol syndrome.
Fetal alcohol syndrome (FAS): Constellation of findings, including intellectual disability, that may occur
in fetuses of women who ingest alcohol during pregnancy, especially early in gestation.
Fetal echocardiogram: An ultrasonographic technique that shows movements of the walls and valves of
the beating heart of a fetus. Certain valvular and other abnormalities of the fetal heart may be seen.
Used only when there is some reason to suspect that the fetus may have an abnormal heart.
Fetal heart rate, baseline: Approximate average fetal heart rate during any 10-minute period that is free
of accelerations, decelerations, and marked variability (.25 beats/min). The reference baseline range is
between 110 and 160 beats/min.
Fetal heart rate acceleration: Abrupt increase (at least 15 beats/min) in fetal heart rate (onset to peak rate
occurs in ,30 seconds) that lasts at least 15 seconds but less than 2 minutes.
Fetal heart rate deceleration: A decrease in the fetal heart rate that then returns to baseline. There are
3 types of decelerations (early, late, and variable), which are defined by their shape and relationship to
uterine contractions.
Fetal heart rate variability: Fluctuations in baseline fetal heart rate that are irregular in amplitude and
frequency. Visual inspection is used to classify the peak-to-trough beats per minute difference as absent
(no detectable change from baseline), minimal (fluctuation of #5 beats/min), moderate (fluctuation of
6–25 beats/min), or marked (fluctuation of $25 beats/min).
Fetal lung maturity: Analysis of a sample of amniotic fluid for the presence of surfactant components.
The lecithin to sphingomyelin ratio is one such test. See also Pulmonary maturity.
Fetal membranes: The amnion and chorion.
Fetal monitoring, external: Refers to continuous electronic monitoring using a device strapped to the
woman’s abdomen to detect the fetal heart rate, periodic rate changes, and timing of the uterine
contractions.

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Fetal monitoring, internal: Refers to continuous electronic monitoring using a wire attached to the fetal
presenting part to detect fetal heart rate and a pressure transducer placed inside the uterus to detect
onset and intensity of uterine contractions.
Fetal pole: A term used to describe the appearance of either end of the fetal body when the fetus is so
small the head cannot be distinguished from the breech.
Fetopelvic disproportion (FPD): Condition in which the internal size of the maternal pelvis is too small
or the fetal head is too large to allow vaginal delivery. Because exact measurements of the fetal head and
maternal pelvis cannot be made, this is a relative term.
Fetoscope: A specially constructed stethoscope used to listen to fetal heart rate.
Fetus: After development of organ systems (after the first 8 weeks from conception/10 weeks from the
last menstrual period), an embryo is called a fetus until delivery.
Fio2: Fractional inspired oxygen. The percentage of oxygen being inhaled. An environmental oxygen
concentration of 55% may also be written Fio2 5 55%. The Fio2 of room air is 21%.
Flaccid: Limp.
Flexion: Bending of a body part. Example: Flexion of the arm occurs when the elbow is bent. By contrast,
extension means the straightening of a body part.
Flip-flop phenomenon: Flip flop is caused by lowering the environmental oxygen concentration too
rapidly, or allowing a baby requiring oxygen therapy to breathe room air for even a short period. In
response, the arteries to the lungs constrict, thus limiting the amount of blood that can be oxygenated in
the lungs. The baby then requires an environmental oxygen concentration even higher than that breathed
previously to achieve the same arterial blood oxygen concentration.
Foramen ovale: The opening between the 2 upper chambers (atria) of the heart in the fetus. It consists of
redundant tissue in the interatrial wall that results in a functional closure of the opening when left atrial
pressure exceeds right atrial pressure shortly after birth.
Forceps: Obstetric forceps are 2 metal instruments, made in mirror image of each other, curved laterally
to follow the shape of the fetal head and vertically to fit the curve of the maternal pelvis. Used to assist
vaginal delivery of the fetal head and shorten the second stage of labor, for either maternal or fetal
reasons. They are made in a variety of sizes and shapes, including forceps designed to help deliver the
after-coming head in breech presentations. When forceps are used, the delivery is classified as midforceps,
low forceps, or outlet forceps, depending on fetal station and position when the forceps are applied.
FPD: See Fetopelvic disproportion.
Fundal height: During pregnancy, the fundus of the uterus can be felt higher and higher in the maternal
abdomen. The distance between the fundus and symphysis pubis (front pelvic bone) is the fundal height.
It is used as an estimate of gestational age of the fetus. Consistency in the technique used (preferably by
the same examiner) throughout pregnancy is important for accurate results.
Fundus: The broad top two-thirds of the uterus.
Gastroschisis: A defect of the abdominal wall during embryonic development, allowing abdominal or-
gans to protrude into amniotic fluid. As opposed to omphalocele, no peritoneal sac covers the organs
with gastroschisis.
GBS: See Group B b-hemolytic streptococcus.
GDM: Gestational diabetes mellitus. See Diabetes, gestational.
General inhalation anesthesia: An anesthetic technique that produces loss of consciousness. The patient is
usually given barbiturates or narcotics to induce anesthesia, followed by paralyzing drugs, endotracheal
intubation, and artificial ventilation. Anesthetic gases are used to continue the anesthetic state until the
surgical procedure is completed. Because the gases are quickly cleared from the blood by the lungs, the

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 GLOSSARY

patient “wakes up” within a few minutes after the anesthetic gases are stopped. With this type of anes-
thesia, the drugs and gases used can cross the placenta and may depress a fetus. Anesthesia provided
to an obstetric patient must consider the unique physiological state of a pregnant woman as well as the
potential effect drugs given to her may have on the fetus.
Geneticist: A physician who specializes in knowing how genes are inherited by children from their
parents and the association between certain genetic abnormalities and specific physical characteristics.
Genitourinary tract: Pertaining to the reproductive organs and urinary organs.
Gestational diabetes mellitus (GDM): See Diabetes, gestational.
Glottis: The vocal cords and opening between them that leads to the trachea.
Glucose tolerance test (GTT): A test for abnormal glucose metabolism. A fasting patient is given a stan-
dard dose of glucose orally, with the blood level of glucose determined at standard intervals.
Glycogen: Main storage form of glucose in the body. It is changed to glucose and released to the
bloodstream as needed.
Glycosylated hemoglobin (hemoglobin A1C): Reflects circulating blood glucose for the previous 3 months.
It is used as an indicator of long-term glucose control.
Gonorrheal ophthalmia, neonatal: Eye infection in newborns that results from gonorrhea bacteria
acquired by a baby during the birth process, if the woman has gonorrhea. Silver nitrate drops or
erythromycin ointment placed in the baby’s eyes shortly after delivery prevents the development of this
potentially damaging infection.
Gram stain: A specific stain for bacteria that separates gram-positive bacteria (which stain blue) from
gram-negative bacteria (which stain red). These 2 categories of bacteria vary in the types of disease they
cause and their antibiotic sensitivity. Gram stain of an infected body fluid (eg, urine, pus, amniotic fluid)
may identify the type of organism causing the infection and allow appropriate antibiotic therapy to
begin before culture and sensitivity studies can be completed.
Gravidity: Number of pregnancies a woman has had, regardless of pregnancy outcome. With her first
pregnancy, a woman is a primigravida. With her second pregnancy, a woman is, technically, a secundi-
gravida, and with her third or subsequent pregnancies, a multigravida. In practice, however, secundigrav-
ida is rarely used and multigravida is used to refer to any woman with her second, or subsequent,
pregnancy. See also Parity.
Group B b-hemolytic streptococcus (GBS): A type of streptococcal bacteria that can cause serious or
fatal neonatal illness. Some women, without evidence of infection, have chronic GBS vaginal or rectal
colonization, which may infect the fetus before delivery or the baby at the time of delivery.
Growth restriction: Describes fetuses that, on serial examination, are significantly smaller than would be
expected, with their growth falling below the 10th percentile for their gestational age.
Grunting: A sign of respiratory distress in a neonate. The grunt or whine occurs during expiration as a
result of the baby exhaling against a partially closed glottis. The baby grunts in an attempt to trap air
in the lungs and hold open the alveoli. Grunting sometimes may be normal immediately following birth;
after 1 to 2 hours it is always abnormal.
GTT: See Glucose tolerance test.
HBIG: Hepatitis B immune globulin. Administration of HBIG soon after delivery is part of the treatment
for newborns whose mothers are hepatitis B surface antigen–positive (test for hepatitis B).
HBsAg: See Hepatitis B surface antigen.
HCT: See Hematocrit.
Heart murmur, functional: A heart murmur that does not result from disease or an abnormality of the
heart. A functional heart murmur is not associated with abnormal functioning of the heart.

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HELLP syndrome: Hemolysis, elevated liver enzymes, low platelet count occurring in association with
preeclampsia. An uncommon and severe form of pregnancy-related hypertension.
Hematocrit (Hct): A blood test showing the percentage of red blood cells in whole blood. Example: An
Hct of 40 means that 40% of the blood is red blood cells and 60% is plasma and other cells.
Hemoglobin (Hgb): (1) Blood test showing the concentration of Hgb in blood. (2) Oxygen-carrying part
of red blood cells.
Hemoglobinopathy: A genetic disorder that causes a change in the molecular structure of hemoglobin in
the red blood cells and results in certain typical laboratory and clinical changes, frequently including
anemia. Sickle cell disease is one type of hemoglobinopathy.
Hemolysis: Breakdown of red blood cells. Hemolytic anemia, therefore, is anemia that results from the
destruction of red blood cells, rather than loss of blood or inadequate production of red blood cells.
Hemorrhage: Bleeding; most often used to indicate severe bleeding.
Heparin lock: A technique used to prevent blood clot formation in an arterial or venous catheter, when a
continuous infusion of fluids is not being used. A solution of intravenous fluids with a specific concentra-
tion of heparin is flushed through the catheter and then the stopcock is closed to the catheter.
Hepatitis: Serious inflammation of the liver usually caused by a viral infection. There are several forms
of hepatitis, depending on the specific causative agent and mode of transmission. Infection may be acute
or chronic.
Hepatitis B surface antigen (HBsAg): Term for protein on the surface of the hepatitis B virus. Screening
all prenatal patients for this antigen identifies women who are carriers for hepatitis B, and therefore at
risk for passing the virus to their fetuses before birth. Such newborns should be given hepatitis B immune
globulin and hepatitis B vaccine soon after birth.
Hepatosplenomegaly: Enlargement of the liver and spleen.
Hereditary: Used to describe a condition that is transmitted by the genes, from parents to their children.
Example: Cystic fibrosis is a hereditary disease, and eye color is a hereditary trait.
Heredity: Genetic transmission from parent to child of traits and characteristics. Example: A baby with
brown eyes can be said to have that color of eyes as part of his or her heredity.
Herpes: Refers to diseases caused by herpesvirus. Maternal herpes may have serious consequences for
the newborn.
Hgb: See Hemoglobin.
HIE: See Hypoxic-ischemic encephalopathy.
HIV: The virus that causes AIDS, which attacks and eventually overcomes the body’s immune system.
HPV: Human papillomavirus.
Hyaline membrane disease: Older name for neonatal respiratory distress syndrome.
Hydatidiform mole: A pregnancy characterized by grossly abnormal development of the chorionic villi,
which eventually form a mass of cysts. Usually, but not always, no fetus is present. Excessive secretion
from the trophoblast cells leads to very high levels of b-human chorionic gonadotropin. Vaginal bleeding
during the first trimester is common and may be the presenting sign. Uterine size does not usually corre-
spond to expected size for the dates of a pregnancy: larger than expected in about 50% of cases and
smaller than expected in about 30% of cases.
Hydramnios: Also called polyhydramnios. Abnormally large amount of amniotic fluid. It may be associ-
ated with fetal abnormalities (particularly gastrointestinal tract abnormalities that prevent amniotic fluid
from being swallowed into the gastrointestinal tract of the fetus) or certain maternal medical illnesses;
however, in most cases, the cause of hydramnios is unknown.

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Hydrocephalus: Enlargement of the head due to abnormally large collection of cerebrospinal fluid in the
brain. It may be congenital or acquired after birth. Accumulation of cerebrospinal fluid may be caused
by a blockage in the normal flow of fluid around the brain and spinal cord or by a decrease in the
normal absorption of the fluid.
Hydrops fetalis: Edema in the entire body of a fetus, accompanied by at least one effusion in a body
cavity (pleural, pericardial, or peritoneal). Usually a result of severe hemolytic anemia caused by Rh dis-
ease or other alloimmunizations, but may (rarely) be caused by certain other serious in utero conditions
or viral infections. In many cases the cause for hydrops is not clear.
Hyperbilirubinemia: Excess amount of bilirubin in the blood.
Hyperbilirubinemia, physiological: Hyperbilirubinemia due to a baby’s immature liver, which has a
limited ability to excrete bilirubin from the body, rather than hyperbilirubinemia due to a disease
process such as ABO incompatibility.
Hyperkalemia: High blood potassium level.
Hypernatremia: High blood sodium level.
Hyperosmolar: Used to describe a liquid with a higher concentration of particles than found in a physio-
logical fluid. For example, an intravenous solution may be hyperosmolar compared to blood, or formula
may be hyperosmolar compared to human (breast) milk.
Hypertension: High blood pressure. In adults, generally defined as higher than 130/80 mm Hg.
Hyperthermia: High body temperature; fever. In adults, generally defined as greater than or equal to
38.0°C (100.4°F).
Hypertonic: Used to describe a solution that is more concentrated than body fluid and therefore will
draw water out of the body’s cells, causing the cells to shrink.
Hypocalcemia: Low blood calcium level.
Hypoglycemia: Low blood glucose level.
Hypotension: Low blood pressure.
Hypothermia: Low body temperature.
Hypovolemia: Low blood volume.
Hypoxemia: Low concentration of oxygen in the arterial blood.
Hypoxia: A deficiency of oxygen and perfusion in the body tissues resulting in compromised metabolism
and injured tissue.
Hypoxic-ischemic encephalopathy (HIE): Neonatal brain injury that presents at birth and is caused by a
newborn experiencing a hypoxic and/or ischemic event around the time of delivery.
IAI: See Intra-amniotic infection.
Icterus: See Jaundice.
Ileitis: Inflammation of the ileum, the distal portion of the small bowel (between the jejunum and
cecum). Usually represents Crohn disease, a chronic inflammation of the intestinal tract, most often
affecting the terminal ileum (may also involve the colon). Cause is unknown, complications are frequent
(eg, abscess, obstruction, fistula formation), and recurrence after treatment is common.
Ileus: Obstruction of the intestines. Commonly used to refer to a dynamic or functional ileus in which
there is an absence of peristalsis resulting from postsurgical inhibition of bowel motility but frequently
not associated with a mechanical blockage of the intestines.
Immune thrombocytopenic purpura (ITP): A disease of unknown cause in which the body destroys its
own platelets, causing thrombocytopenia and resulting in coagulation disorders and easy bruising. The

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fetus of a woman with ITP may also have thrombocytopenia. Formerly called idiopathic thrombocytope-
nic purpura.
In utero: Latin for “inside the uterus.”
In utero resuscitation: Term applied to measures taken to improve fetal oxygenation when there is a
non-reassuring fetal heart rate pattern during labor. These measures include provision of 100% oxygen
by mask to the woman, correction of maternal hypotension (turn woman on her side or from one side
to the other, give fluids, or elevate legs), and reduction of uterine activity (stop oxytocin; consider use of
tocolytics).
Incompetent cervix: A condition in which the cervix (lower part of the uterus and entrance to the birth
canal) dilates prematurely, causing a spontaneous abortion or preterm delivery. A woman with an incom-
petent cervix is at risk for a preterm delivery with each pregnancy. See also Cerclage of the cervix.
Infant death rate: Number of babies that die within the first year after birth (365 days) per 1,000 live births.
Infective endocarditis: An infectious inflammatory process in which the infecting bacteria form growths
on the heart valves or endocardium. The process may have an acute or subacute course. Diagnosis is usu-
ally made during the subacute, longer-lasting stage. Heart tissue is permanently damaged, and the infec-
tion can be difficult or impossible to treat effectively. Patients with heart valve malformations are particu-
larly prone to developing these infective growths on the abnormal valves and surrounding endocardium.
Inferior vena cava: The major vein returning blood from the lower body to the right side of the heart.
Infiltration of intravenous fluids: Occurs when an intravenous catheter or needle in a peripheral vein
perforates the wall of the vein and the intravenous fluids infuse into the surrounding tissue instead of
bloodstream. Swelling and tenderness develop near the tip of the catheter. An infiltrated intravenous
catheter should be removed immediately because some intravenous fluids can cause severe tissue damage.
Infusion pump: A machine used to push fluid at a controlled, preset rate into an artery or vein. All
neonatal infusions should use a pump so the volume infused can be controlled precisely. Some pumps
infuse fluids by means of small, regular pulses, while other pumps, particularly syringe pumps, infuse
continuously.
INH: Isoniazid hydrazide. Generic name for an antituberculosis medication.
Insensible water loss: Body fluid lost through the skin and respiratory passages.
Inspired oxygen: The oxygen concentration that is being inhaled (not the concentration in the blood).
Also called environmental oxygen.
Intra-amniotic infection (IAI): Formerly known as chorioamnionitis, or infection of the fetal membranes,
which puts the fetus at risk for also becoming infected with the same organism.
Intra-arterial infusion: An infusion of fluid into an artery (eg, via a peripheral or an umbilical arterial
catheter).
Intracardiac: Inside the heart.
Intrapartum: Period of pregnancy during labor.
Intrauterine: Inside the uterus.
Intubation, endotracheal: Insertion of a hollow tube (endotracheal tube) into the trachea to suction for-
eign matter, such as meconium, from the trachea or deliver air or oxygen under pressure directly into the
lungs by assisted ventilation.
Iron: A mineral important for the formation of red blood cells. Iron deficiency is a common cause
of anemia.
Isosmolar: Of the same particle concentration as body fluid.
ITP: See Immune thrombocytopenic purpura.

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 GLOSSARY

IUGR: In utero growth restriction. See Growth restriction.

Jaundice: Also called icterus. Yellow coloration of the skin and mucous membranes resulting from
hyperbilirubinemia.
Karyotype: The complete set of chromosomes of the nucleus of a cell. Also used to refer to the photomi-
crograph of the chromosomes arranged in a standard order. The process of identifying a karyotype uses
a technique that stops cells in their reproductive cycle and causes the individual chromosomes to swell,
thus allowing each chromosome to be identified and counted. This technique is used to identify condi-
tions, such as Down syndrome (trisomy 21) or Turner syndrome (monosomy X), that are caused by an
excess or deficiency of one or more chromosomes. The technique cannot identify individual genes that
comprise each chromosome.
Lactic acid: A by-product from one of the body’s metabolic pathways. During periods of poor oxygenation,
metabolism may be incomplete and lactic acid may build up, thus resulting in low blood pH or acidosis.
Large for gestational age (LGA): Refers to an infant whose weight is above the 90th percentile for
infants of that gestational age.
Laryngoscope: An instrument used to visualize the glottis during endotracheal intubation.
Larynx: The area containing the vocal cords and located between the base of the tongue and the trachea.
Leopold maneuvers: A method of systematically palpating the abdomen of a pregnant woman to deter-
mine fetal presentation and position.
Lethargy: Condition of diminished activity due to drowsiness, medication, or illness.
LGA: See Large for gestational age.
Lie: Relationship of the long axis of the fetus’s body with that of the maternal spine (transverse, oblique,
or longitudinal).
Lightening: The feeling of decreased abdominal distension a pregnant woman has as the fetus and uterus
descend into the pelvic cavity during the last 4 weeks of a term pregnancy.
Macrosomia: Large body size. A newborn weighing more than 4,000 g (8 lb 13 oz) at birth is considered
macrosomic.
Maladaptation: Failure to adapt to stresses of the environment.
Malformation, congenital: A defect that occurs during embryonic or fetal development. Used synony-
mously with congenital anomaly but not deformation. See also Deformation.
Maternal serum alpha fetoprotein (MSAFP): See Alpha fetoprotein.
Maternal-fetal medicine (MFM): The subspecialty of obstetrics and gynecology that deals specifically
with the care of high-risk pregnancies.
Maximum vertical pocket (MVP): A way of estimating the relative volume of amniotic fluid using ultrasound
identification and measurement of the single deepest pocket of amniotic fluid of at least 1 cm in width.
McRoberts maneuver: Used to relieve shoulder dystocia by elevating and flexing the woman’s legs so her
knees and thighs are held as closely as possible against her abdomen and chest. This extreme flexion of
the maternal hips rotates the pelvis in such a way that there is more room for the anterior shoulder to
slip under the symphysis pubis, allowing delivery.
Meconium: The dark green-brown sticky material that makes up a baby’s first stools. It is formed by the
fetus in utero from intestinal secretions and swallowed amniotic fluid. The rectum may relax and release
meconium into the amniotic fluid in post-term gestations and during periods of fetal stress. Meconium-
stained amniotic fluid may therefore be a worrisome sign but does not always indicate fetal jeopardy.
Meningitis: Inflammation of the membranes that surround the brain and spinal cord.

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Meningomyelocele: Congenital defect of the spinal column. Part of the spinal cord and surrounding
membranes protrude through an opening in the spine and form a sac on the baby’s back. The sac may be
large or small, and located anywhere along the baby’s spine. There may be various degrees of neurologic
impairment occurring below the level of the meningomyelocele. It may be detected in the fetus by assess-
ment of maternal serum alpha fetoprotein.
Metabolism: All the physical and chemical processes that produce and maintain body tissue.
Methimazole: A mercaptol-imidazole compound used to treat hyperthyroidism.
MFM: See Maternal-fetal medicine.
Morbidity: Any complication or damage that results from an illness.
Mortality: Death.
Motility: Movement.
MSAFP: Maternal serum alpha fetoprotein. See Alpha fetoprotein.
Multifetal gestation: More than one fetus. Multifetal gestation may be used to describe a pregnancy
involving twins, triplets, quadruplets, quintuplets, or more.
Multigravida: Precise term for a pregnant woman who has had 2 or more previous pregnancies.
Commonly used, however, to refer to a pregnant woman who has had one or more previous pregnancies.
(Secundigravida is the precise term for a woman in her second pregnancy.)
MVP: See Maximum vertical pocket.
Myometrium: The muscular wall of the uterus.
Naloxone hydrochloride (Narcan): A drug that counteracts the depressant effects of narcotics. Naloxone
may be given to a depressed baby whose mother received narcotic pain medication shortly before deliv-
ery. Adequate oxygenation with assisted ventilation, as necessary, should be provided before time is
taken to give this drug. Naloxone should be used with caution if maternal drug addiction is suspected.
Narcan: See Naloxone hydrochloride.
NAS: See Neonatal abstinence syndrome.
Nasal flaring: A sign of neonatal respiratory distress. Edges of the nostrils fan outward as the baby
inhales.
Nasogastric tube: A pliable tube that is inserted through the baby’s nose, down the esophagus, and into
the stomach. It is used for feeding or to decompress the stomach by intermittent or constant suctioning
of air or gastric juices out of the stomach.
NEC: See Necrotizing enterocolitis.
Necrotizing enterocolitis (NEC): A serious disease in which sections of the intestines are injured and may
die. Medical treatment may result in complete resolution, but in some cases portions of the intestines
must be surgically removed. It occurs more often in preterm infants, but the cause is unclear.
Neonatal: Refers to the time period from delivery through the first 28 days.
Neonatal abstinence syndrome (NAS): Constellation of findings, including jitteriness, irritability,
hypertonia, seizures, sneezing, tachycardia, difficulty with feedings, or diarrhea, often occurring in babies
born to women who used heroin or methadone during pregnancy. These findings result from the baby’s
sudden withdrawal from maternal drugs following delivery.
Neonate: Baby from birth through the first 28 days of age.
Neonatal opioid withdrawal syndrome (NOWS): A condition that results from newborns being exposed
to opioids in the womb. NOWS symptoms can include tremors, excessive crying and irritability, and
problems with sleeping, feeding, and breathing.

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Neonatologist: A pediatrician who specializes in caring for newborns, particularly at-risk and sick
babies.
Nephrosis: General term used for any noninfectious disease of the kidney.
Neural tube defect: Used to describe any congenital defect in the brain or spinal cord (structures
that developed from the neural tube of the embryo), including anencephaly, encephalocele, and
meningomyelocele.
Neutral thermal environment: The very narrow environmental temperature range that keeps a baby’s
body temperature normal, with the baby having to use the least amount of calories and oxygen to
produce heat.
Nitrazine: Trade name for phenaphthazine.
Nonhemolytic jaundice: Hyperbilirubinemia not resulting from an excessive breakdown of red
blood cells.
Nonmaleficence: Avoiding harm to a patient.
Nonstress test (NST): One of several measures used to assess fetal well-being in high-risk pregnancies,
during which spontaneous fetal heart rate accelerations in relation to fetal activity are monitored with
an external electronic monitor. The pregnant woman is resting during the procedure and receives no
medication.
NOWS: See Neonatal opioid withdrawal syndrome.
NST: See Nonstress test.
OCT: Oxytocin challenge test. See Contraction stress test.
Oligohydramnios: An abnormally low amount of amniotic fluid. It may be associated with abnormalities
of the fetal kidney, ureter, or urethra (fetal urine is the primary component of amniotic fluid); certain fe-
tal chromosomal defects; fetal growth restriction; uteroplacental insufficiency; positional deformities
(due to prolonged uterine pressure in the absence of a fluid cushion); and umbilical cord compression
(particularly during labor). Oligohydramnios may also result from early, prolonged rupture of membranes.
Omphalocele: A congenital opening in the abdominal wall allowing the abdominal organs, covered with
a peritoneal membrane, to protrude and form a sac outside the abdominal cavity. See also Gastroschisis.
Ophthalmia: General term for any disease of the eye.
Oral airway: A device that allows babies with blocked nasal passages to breathe through their mouths. It
is inserted into the mouth and keeps the tongue forward, preventing it from obstructing the airway.
Orogastric tube: A pliable tube that is inserted through the baby’s mouth, down the esophagus, and into
the stomach. It is used for the same purposes as a nasogastric tube.
Orthopnea: Shortness of breath while lying down. It is usually caused by heart or lung failure and is
characterized by the patient sitting up to sleep.
Osmolarity: Concentration of particles in a solution. Synonymous with osmolality.
Ovulation: Release of an egg, ready for fertilization, from an ovary.
Ovum: Female reproductive cell that, after fertilization and implantation, becomes an embryo.
Oximeter: A device that reads the color of blood and reports the percentage saturation of hemoglobin
with oxygen (Spo2). The probe of an oximeter emits a light that is sensed by a detector. See also Pulse
oximetry.
Oxygen hood: Also called oxyhood. A small plastic box with a neck space designed to fit over a baby’s
head and allow precise control of a baby’s inspired (environmental) oxygen concentration.
Oxyhemoglobin saturation: Hemoglobin is the oxygen-carrying component of red blood cells. The
amount of oxygen attached to hemoglobin is measured as percent saturation and called oxyhemoglobin

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saturation (commonly shortened to “% sat” or “O2 sat”). The degree of saturation can range from
0% to 100%.
Oxytocin: A hormone occurring naturally in the body and also used to induce labor, enhance weak
labor contractions, and cause contraction of the uterus after delivery of the placenta.
Oxytocin challenge test (OCT): See Contraction stress test.
Paco2 or Pco2: Concentration of carbon dioxide in the blood (a specifies arterial blood).
Palate: Roof of the mouth. The structure that separates the oral and nasal passages. A cleft palate is one
that is split from front to back, sometimes with an opening so deep that the mouth and nasal passages
are connected.
Pao2 or Po2: Concentration of oxygen in the blood (a specifies arterial blood).
Parens patriae: The duty of the state to protect the vulnerable or incompetent.
Parenteral: Taking something into the body in a manner other than through the digestive canal (which is
enteral).
Parity: The condition of a woman with respect to having had one or more pregnancies reach a gestational
age of viability. Parity is determined by the number of pregnancies that reached viability, whether the
fetuses were live-born or stillborn, and not the number of fetuses. Twins, triplets, or more do not
increase a woman’s parity. Nulliparity is the condition of having carried no pregnancies to an age of
viability; primiparity, of having carried one pregnancy to an age of viability; secundiparity, of having
2 pregnancies reach viability; and multiparity, of having had 3 or more pregnancies reach viability. In
practice, however, secundiparity is rarely used and multiparity is used for any woman who has had 2 or
more pregnancies reach an age of viability. Example: A woman whose first pregnancy ended in stillborn
twins at 30 weeks’ gestation, second pregnancy ended in a single, healthy fetus born at 39 weeks, and
third pregnancy ended in spontaneous abortion at 10 weeks has a parity of 2. She is now pregnant for
the fourth time, at 32 weeks’ gestation, and therefore has a gravidity of 4. She may be described as a
gravida 4, para 2. When she delivers the current pregnancy, she will become a G4 P3.
Pelvis, contracted: Smaller than normal-sized pelvis. The pelvis may be too small to allow the vaginal
birth of a baby.
Percutaneous umbilical blood sampling (PUBS): Also called cordocentesis. A highly specialized technique
during which a needle is inserted through a pregnant woman’s abdominal wall into the uterus and then
directly into an artery or vein of the umbilical cord, usually near the base of the cord at the placenta.
Ultrasound visualization of the fetus, placenta, and umbilical cord is used throughout the procedure. A
sample of fetal blood is obtained. Percutaneous umbilical blood sampling may be used to detect congeni-
tal infections, isoimmune diseases, and chromosomal defects (for chromosomal defects, fetal blood can
yield results in a few days, while amniotic fluid cell culture may take several weeks). Percutaneous umbil-
ical blood sampling may also be used to give a direct blood transfusion to a fetus in cases of severe anemia.
Perfusion: The flow of blood through an organ or tissue.
Pericarditis: Inflammation of the pericardium, the sac of fibrous tissue surrounding the heart. Pericarditis
is sometimes caused by infection and other times by an inflammatory, noninfectious disease such as sys-
temic lupus erythematosus.
Perinatal: The time surrounding a baby’s birth. The perinatal period begins at 22 completed weeks and
ends 7 completed days after birth.
Perinatologist: Technically, a subspecialist physician who cares for the fetus and neonate. Often used,
incorrectly, to refer to an obstetrician with subspecialty training in maternal-fetal medicine.
Perinatology: Now more commonly referred to as maternal-fetal medicine, perinatology is a subspecialty
of obstetrics and gynecology that focuses on the care of patients with complicated pregnancies and the
diagnosis and care of conditions that affect the fetus before birth.

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Periodic heart rate changes: Fetal heart rate accelerations and decelerations. Their occurrence and rela-
tionship to fetal activity or uterine contractions is used as an estimate of fetal well-being, for antenatal
testing, and during labor.
Peripheral: The outward and surface parts of the body. Example: Peripheral circulation is the blood flow
in the skin, arms, and legs.
pH level: Refers to the acidity or alkalinity of a liquid. A blood pH level outside the reference range indi-
cates metabolic or respiratory disturbance.
Pharynx: Throat above the esophagus and below the nasal passages.
Phenaphthazine (Nitrazine): A pH-sensitive dye embedded in paper that, when dipped into fluids, esti-
mates pH of the fluid. Used primarily to distinguish amniotic fluid (which has an alkaline pH) from
urine or vaginal secretions (which are acidic) in pregnant patients with symptoms of premature rupture
of the membranes.
Phototherapy: Use of fluorescent, tungsten-halogen, or fiberoptic lights to treat hyperbilirubinemia in ne-
onates by breaking down bilirubin accumulated in the skin. The color of phototherapy lights ranges
from nearly white to deep blue, depending on the type and brand of lights.
Pierre Robin syndrome: A group of congenital anomalies that include a small jaw, a cleft palate, and
backward displacement of the tongue. Babies with Pierre Robin syndrome may have great difficulty
breathing or eating.
Placenta: Organ that joins the woman and fetus during pregnancy. The umbilical cord is implanted on
one side, while the other side is attached to the uterus. Maternal and fetal blood does not mix directly,
but nutrients and waste products are exchanged across a thin membrane that separates maternal and
fetal blood.
Placenta accreta: Term used to describe a rare condition of implantation in which the implanting tropho-
blasts not only penetrate the endometrium but continue into the myometrium as well. This eliminates the
normal cleavage plane in the decidua (endometrium during pregnancy) that allows normal spontaneous
separation of the placenta following delivery. Attempts to remove a placenta accreta by manual separa-
tion usually result in excessive hemorrhage. Hysterectomy may be the only way to remove the placenta,
as separation from the myometrium may be impossible, and emergency surgery may be required if heavy
bleeding begins.
Placenta previa: Abnormally low implantation of the placenta in the lower segment of the uterus. As the
placenta grows with pregnancy, it spreads so that it partially or completely covers the internal cervical os
at term. The resultant position of the placenta is in front of the fetus. Thus, a vaginal delivery would re-
quire delivery of the placenta before the fetus. Painless vaginal bleeding during the third trimester is the
most common sign of placenta previa. If not identified earlier, severe hemorrhage with maternal and fetal
compromise may occur as the cervix dilates during labor. Whether placenta previa is identified prenatally
or not until after labor has begun, cesarean delivery is required for the health of the woman and fetus.
Note: Early in gestation a placenta may appear to be low lying, but not be later in pregnancy. A diagno-
sis of placenta previa cannot be made until after 20 weeks’ gestation and should be reconfirmed at 26 to
28 weeks.
Placental abruption: Premature separation of a normally placed placenta. Placental separation can occur
at any time during pregnancy, but is most likely to occur during late pregnancy and before the onset
of labor. Several risk factors are associated with placental abruption, but usually the cause is unknown.
Depending on the degree of separation, bleeding may be slight or severe. If severe, both the woman and
fetus may go into shock. Bleeding, even severe bleeding, can be completely hidden behind the placenta.
In the most severe cases, the uterus is tense, boardlike, and tender. The woman’s blood pressure may fall,
and symptoms of shock or disseminated intravascular coagulation may develop. Fetal distress is com-
mon, and fetal death may occur. Placental abruption requires an emergency response.
Placental perfusion: Blood from the uterine artery flows into the intervillous space, bathing the placental
villi that protrude into this space with nutrients and oxygen. Flow of blood through the intervillous

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space allows perfusion of nutrients and oxygen into the fetus from the maternal blood and waste prod-
ucts of fetal metabolism to pass from the fetus to the maternal circulation. Fetal and maternal blood
does not mix. Nutrients and waste are exchanged across the thin membrane of the placental villi.
Pneumonia: Inflammation of the lungs. Neonatal pneumonia has many possible causes, such as bacterial
infection, aspiration of formula, or aspiration of meconium.
Pneumothorax: Rupture in the lung that allows air to leak outside the lung, form a collection of air
between the lung and chest wall, and thereby compress the lung so it cannot expand fully. Often when
a pneumothorax develops, a baby suddenly becomes cyanotic and shows signs of increased respiratory
distress. There are decreased breath sounds over the affected lung. Insertion of a tube or needle into
the chest is required to remove the air pocket and allow the lung to re-expand. Plural: pneumothoraces
(rupture in both lungs).
Polycythemia: Abnormally high number of red blood cells. It is more common in infants of diabetic
mothers and in newborns small for gestational age.
Polyhydramnios: Synonymous with hydramnios, although hydramnios is now the preferred term for this
condition.
Position, fetal: Relationship of the fetal-presenting part to the maternal pelvis. In vertex presentations,
the posterior fontanel is the reference point. With breech presentations, it is the tip of the fetal sacrum;
with face presentations, the chin; and with brow presentations, the anterior fontanel. Position is not the
same as presentation. A fetus in vertex presentation may be in any of several positions. Example: Left
occiput anterior position indicates that the fetal occiput, as determined by position of the posterior
fontanel, is located on the left side of the anterior part of the woman’s pelvis.
Positive-pressure ventilation: Artificial breathing for a person by forcing air or oxygen into the lungs under
pressure by bag and mask, bag and endotracheal tube, T-piece resuscitator, or mechanical ventilator.
Post-term: Refers to a fetus or baby whose gestation has been longer than 42 completed weeks.
Postnatal: The time after delivery, used in reference to the baby.
Postpartum: The time after delivery, used in reference to the mother.
Potter syndrome: A rare, fatal congenital malformation with characteristic facial appearance and absent
or hypoplastic kidneys. Oligohydramnios may be noted in the mother. These babies are often born at
term, are frequently small for gestational age, and may have hypoplastic lungs.
Preconceptional: Before conception. Refers to counseling women or families before conception regarding
the risks of various problems during pregnancy. This is particularly important when a woman has a dis-
ease known to affect pregnancy or fetal development or a family history of such problems or pregnancy
carries increased risks for a woman because of an illness or condition she has.
Preeclampsia: New-onset hypertension in pregnancy with excretion of protein into the urine, with or
without other laboratory abnormalities or symptoms.
Pregnancy due date: Expected date for the onset of labor. On average, the date of delivery will occur
280 days, or 40 weeks, after the first day of the last menstrual period. The reference range of variation is
2 weeks before or after the calculated due date. Babies delivered between 37 and 42 weeks’ gestation are
considered term. Babies delivered prior to the onset of the 37th week are designated preterm, and those
delivered after 416/7 weeks are considered postterm. Inaccuracies can occur with calculating the due date
because the date of the menstrual period may not be recalled correctly or there are variations in
the length of the preovulatory phase of a menstrual cycle. In some women with irregular periods, the
preovulatory phase may be prolonged several weeks or even months.
Premature rupture of membranes (PROM): Rupture of the membranes (“bag of waters”) before the
onset of labor.
Prenatal: The time during pregnancy and before birth of the baby. Synonymous with antenatal.

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Presentation: Refers to that part of the fetus that is in the birth canal and will deliver first. The normal
presentation, near term and during labor and delivery, is vertex (headfirst). Any other presentation at
that time is considered abnormal.
Preterm: Refers to that part of pregnancy between 200/7 weeks and 366/7 weeks (eg, preterm labor,
preterm rupture of the membranes, or an infant born before 37 weeks’ gestation).
Primary infection: First episode of a given infection. Some infections, such as cytomegalovirus or herpes,
remain latent, without symptoms, in a person but may recur from time to time. The primary infection,
however, is the most severe and likely to be the most damaging to a fetus or newborn. Other infections,
such as syphilis or gonorrhea, may be cured, but if reinfection occurs, it will be as severe as the first
infection.
Primigravida: A woman pregnant for the first time. See also Gravidity.
Primipara: A woman who has had one pregnancy carried to viability. See also Parity.
Prodromal labor: Refers to a patient having contractions but without sufficient cervical changes to make
the diagnosis of true labor.
Prodrome: The time before a disease or process reaches its full strength. Example: The prodrome of
a herpes infection may be mild itching in the area where the vesicles will later appear. This could be
described as prodromal itching.
Prognosis: A forecast of the most likely outcome of an illness.
Prolapse: Falling out of a viscus. For example, an umbilical cord that slips through the cervix ahead of
the fetus is a prolapsed cord, or a uterus that falls partially or completely into the vagina has prolapsed.
Prolapsed cord: Premature expulsion of the umbilical cord during labor and before the fetus is delivered.
This is an emergency situation because a prolapsed cord is likely to be compressed, which may cause se-
vere fetal compromise.
PROM: See Premature rupture of membranes.
Propylthiouracil (PTU): An antithyroid agent used to treat hyperthyroidism during the first trimester of
pregnancy.
Proteinuria: Condition in which proteins from the blood are present in the urine. Also called albuminuria.
Psychosis: Any major mental disorder in which a person loses contact with reality and is unable to process
information rationally.
PTU: See Propylthiouracil.
PUBS: See Percutaneous umbilical blood sampling.
Pudendal block: Nerve block by injection of local anesthetic into the area of the pudendal nerve. Used
primarily for anesthesia of the perineum for delivery.
Pulmonary: Refers to the lungs.
Pulmonary hypoplasia: Underdevelopment of the fetal lungs, usually related to in utero compression of
the fetal chest or lungs that prevents appropriate growth. This is seen with diaphragmatic hernia and
with severe oligohydramnios, such as may occur with Potter syndrome.
Pulmonary maturity: Refers to relative ability of the fetal lungs to function normally if the fetus were
to be delivered at the time a test for pulmonary maturity is performed. As the lungs mature, various
chemicals produced by the fetal lungs appear in the amniotic fluid. Lecithin to sphingomyelin ratio,
phosphatidyl glycerol detection, or lamellar body count may be performed on a sample of amniotic fluid
to assess fetal lung maturity.
Pulse oximetry: Uses a noninvasive device that allows continuous measurement of the saturation of he-
moglobin with oxygen. Hemoglobin changes color from blue to red as it becomes increasingly saturated

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with oxygen. A pulse oximeter uses a tiny light to shine through the skin and a light detector to measure
the color of light coming through the skin. The color of light coming through the skin is determined by
the amount of oxygen carried by hemoglobin in the red blood cells. From this the percentage of satura-
tion is calculated (Spo2). The percentage of saturation is not the same as a Pao2 value, which measures
the amount of oxygen dissolved in plasma.
Quickening: The first time fetal movements can be felt by the pregnant woman. This usually occurs be-
tween 16 and 20 weeks of gestation. Quickening generally occurs later in pregnancy for a primigravida
than a woman who has had a previous pregnancy.
Radiant warmer: A servo-controlled heating device that is placed over a baby and provides radiant heat
to keep body temperature normal.
RDS: See Respiratory distress syndrome.
Respiratory distress syndrome (RDS): Formerly called hyaline membrane disease. A disease mainly affect-
ing preterm infants, due to immaturity of the lungs and lack of surfactant. Without surfactant, the alve-
oli collapse during exhalation and are difficult to open with the next breath.
Resuscitation: The process of restoring or supporting cardiac function, blood pressure, and respiration so
as to provide adequate oxygenation and perfusion to a baby, child, or adult who is apparently dead or
near death. For newborns, resuscitation is needed most often in the delivery room; for adults, resuscita-
tion may be needed after any of a number of life-threatening events.
Resuscitation team: This concept refers to the fact that more than one person is needed to provide resus-
citation. At least 2, preferably 3, health care professionals, skilled in the techniques of resuscitation, are
needed for each resuscitation.
Reticulocyte count: Estimation of the number of newly formed red blood cells (reticulocytes) in a blood
sample.
Retinopathy of prematurity (ROP): Abnormal blood vessel growth in the eye that may lead to detach-
ment of the retina and partial or complete blindness. Blood vessel changes may result from many factors,
including excessively high arterial blood oxygen concentrations for a period that can be as short as a few
hours. The more preterm a baby, the more likely the baby is to develop ROP. Often ROP resolves spon-
taneously, but if permitted to proceed unchecked, scarring may occur and the retina may detach. It is
critical that babies with ROP be followed by an ophthalmologist trained in examining babies so that
laser therapy may be used to check the progression.
Retractions: A sign of respiratory distress. These occur with each breath as the skin is pulled inward
between the ribs as a baby tries to expand stiff lungs.
Retrolental fibroplasia (RLF): Scarring phase of retinopathy of prematurity.
Rh alloimmunization: Formerly referred to as Rh sensitization. (1) Development of antibodies by an
Rh-negative woman pregnant with an Rh-positive fetus. The antibodies cross the placenta into the fetus’s
blood, thus causing hemolysis of the fetus’s red blood cells. (2) Development of antibodies against the
Rh-positive red blood cells following a transfusion of Rh-positive blood unintentionally given to an
Rh-negative person.
Rh blood type: Besides the major blood groups of A, B, O, and AB, there are a number of minor groups,
of which the Rh system is the most important for perinatal care. Prevalence of the Rh factor varies by
ethnic and racial groups. In the white population, 85% have the Rh antigen and are said to be Rh posi-
tive, while 15% lack the Rh antigen and, therefore, are Rh negative. Regardless of ethnic or racial heri-
tage, persons who lack a blood antigen can make antibodies against that blood group. This means that
Rh-negative persons can make antibodies against Rh-positive blood, if their immune system has been ex-
posed to that blood (from external transfusion or transplacental transfer). Persons who have developed
such antibodies are said to be alloimmunized, or sensitized to that blood group. See also Rh alloimmuni-
zation and Erythroblastosis fetalis.
Rh disease: See Erythroblastosis fetalis.

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RhIg: Rh immune globulin (RhoGAM is one commercial name for Rh immune globulin products). The
antibodies from sensitized Rh-negative persons can be harvested, purified, and prepared for safe injection
into another Rh-negative, but unsensitized, woman. The product is called Rh immune globulin, or RhIg.
The injected antibodies contained in RhIg prevent alloimmunization by reacting with the antigens on the
few Rh-positive blood cells that may have escaped from the fetus into the maternal circulation. Rh-nega-
tive, unsensitized women should receive RhIg at 28 weeks’ gestation and again following delivery. Rh-
negative, unsensitized women should also receive RhIg within 72 hours of an abortion or an episode of
vaginal bleeding during pregnancy. Protection lasts for 12 weeks. Therefore, depending on the course of
the pregnancy, subsequent doses may also be needed. Use of RhIg protects fetuses in future pregnancies
from Rh disease.
Rhinitis: Inflammation of mucous membranes of the nasal passages, causing a characteristic runny
or stuffy nose. Although generally uncommon in newborns, rhinitis is frequently found in babies with
congenital syphilis.
RLF: See Retrolental fibroplasia and Retinopathy of prematurity.
ROP: In neonatal care, retinopathy of prematurity. In obstetric care, an abbreviation for a specific posi-
tion (right occiput posterior) of a vertex presentation during labor. See also Retinopathy of prematurity.
Rotation (of the fetal head): Gradual turning of the fetus during labor for the fetal head to accommo-
date size and shape of the maternal pelvis as the fetus descends through it.
Rubella: A mild viral infection, also called German measles. A rubella infection in a pregnant woman
during early pregnancy may result in infection of the fetus and cause rubella syndrome.
SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2, a novel coronavirus that caused a global
pandemic of COVID-19 (coronavirus disease 2019), beginning in late 2019.
Scalp stimulation test: Test in which fetal heart rate response to mechanical stimulation of the fetal scalp
(by examiner’s gloved finger or sterile instrument) is assessed. Used as an estimate of fetal well-being
during labor.
Scaphoid abdomen: Sunken or hollow-looking abdomen, occurring when there is a diaphragmatic her-
nia, which allows the intestines to slip from the abdomen through a hole in the diaphragm and into the
chest cavity.
Secondary infection: Recurrent infection. See also Primary infection.
Sepsis: Infection of the blood. Also referred to as septicemia.
Serum bicarbonate: Also called blood or plasma bicarbonate. Concentration of bicarbonate in the blood.
Bicarbonate is the main body chemical responsible for the acid-base balance of the blood.
Serum urea nitrogen: A blood chemistry test of renal function. The higher the serum urea nitrogen, the
more urinary excretion has been impaired.
Servo control: A mechanism that automatically maintains skin temperature at a preset temperature. A
thermistor probe is taped to the baby, registers the skin temperature, and in turn activates a radiant
warmer or incubator to continue to produce heat, or to stop heating.
Sexually transmitted infection (STI): An infection that is transmitted from one partner to another during
sexual activity. Many infections can be transmitted in this way, but certain STIs can have significant
effect on the fetus or newborn, including syphilis, gonorrhea, Chlamydia, and HIV.
SGA: See Small for gestational age.
Shock: Collapse of the circulatory system due to inadequate blood volume, cardiac function, or vasomo-
tor tone. In babies, the causes are most often hypovolemia, sepsis, or severe acidosis. Symptoms are
hypotension, rapid respirations, pallor, weak pulses, and slow refilling of blanched skin. In pregnant
women, the cause is most often hemorrhage. Because of the expanded blood volume of pregnancy and
vasoconstrictive capabilities of most (young, healthy) pregnant women, blood loss may be severe before

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symptoms of shock (hypotension, weak and rapid pulse, rapid respirations, anxiousness or confusion,
and cold, clammy, pale skin) become evident.
Short bowel syndrome: A syndrome of weight loss and dehydration related to having less than the nor-
mal length of intestine. The less intestine a baby has, the less well nutrients can be absorbed. Short bowel
syndrome may result from a baby being born with an abnormally short bowel or may be the result of a
portion of the intestines having been removed for treatment of certain types of bowel disease.
Shoulder dystocia: Situation in which the baby’s shoulders become wedged between the maternal
symphysis and sacrum after delivery of the fetal head. The head may be pulled back against the
perineum as the woman relaxes her push that delivered the head (the “turtle sign”). Various procedures
may be tried to free the shoulders. Severe asphyxia or fetal death can occur if there is significant delay in
delivery of the shoulders and trunk.
Shunt: A diversion of fluid from its normal pathway. (1) Blood: In some sick babies, blood will be
shunted from the right side of the heart to the left (baby will be blue); in other babies, the shunt will be
from the left side of the heart to the right (baby will be in congestive heart failure). Commonly seen in
babies with congenital heart disease or severe lung disease in which the blood cannot be normally oxy-
genated. (2) Cerebrospinal fluid: An artificial pathway for the flow of cerebrospinal fluid when blockage
is in the normal pathway, resulting in hydrocephalus. Typically, cerebrospinal fluid is shunted through a
one-way valve from the ventricles into a small tube tunneled under the skin and empties into the abdom-
inal cavity. This is called a ventriculoperitoneal, or V-P, shunt.
Sickle cell anemia: A genetic hemoglobinopathy causing chronic anemia. Crises, resulting from infarction
of various body areas clogged by the sickled cells obstructing small blood vessels, may occur periodically.
Management during pregnancy is particularly complicated.
Sickle cell–hemoglobin C disease: A hemoglobinopathy similar to sickle cell anemia.
Sickle cell–thalassemia disease: Sickle cell disease and thalassemia are genetically transmitted anemic
diseases caused by abnormal hemoglobin. See Hemoglobinopathy.
Sims position: The patient rests on one side, with the upper leg drawn up so that the knee is close to
the chest. Often used with an emergency delivery in bed or outside the hospital. This position does not
allow for much assistance by an attendant but has the advantage of placing less tension on the perineum
during delivery and, therefore, may result in fewer lacerations.
SLE: Systemic lupus erythematosus.
Small for gestational age (SGA): A baby whose weight is lower than the 10th percentile for infants of
that gestational age.
“Sniffing” position: Proper position of a baby’s head during bag-and-mask ventilation or endotracheal
intubation. The head and back are in straight alignment, with the chin pulled forward as if sniffing.
This position is different from the one used for endotracheal intubation of an adult because the
relative size and relationship of anatomic structures is different between babies and adults. The
neck is not hyperextended (bent backward to an extreme degree) during endotracheal intubation
in babies.
Sodium bicarbonate: Drug used to counteract metabolic acidosis. After being given to a baby, it rapidly
changes to carbon dioxide and water. Therefore, it should be given only to babies who are breathing
adequately on their own or receiving adequate assisted ventilation. These babies can “blow off” the
excess carbon dioxide formed. If sodium bicarbonate is given to a baby with a high Paco2, it will make
the Paco2 go even higher and thereby worsen the acidosis.
Spinal (block): An anesthetic technique in which a local anesthetic is introduced into the subarachnoid
space of the spinal canal through a hollow needle placed (temporarily) in the spine. It is technically eas-
ier to perform placement of an epidural catheter because spinal fluid in the subarachnoid space will flow
out through the hollow needle and, thereby, identify proper placement of the needle before injection of
the anesthetic. Because the anesthetic also blocks sympathetic nerves leaving the spinal cord, the blood
pressure of the woman may decline. (For this reason, a loading dose of 500–1,000 mL of physiologic

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 GLOSSARY

[normal] saline solution may be given intravenously prior to introduction of the anesthetic.) Spinal anes-
thetics are not ordinarily given until the second stage of labor has begun because the anesthetics used do
not remain effective for longer than 2 hours.
Spo2: The percentage of saturation of hemoglobin by oxygen as detected by a pulse oximeter, which
reads and reports how red the blood is. Fully saturated hemoglobin appears bright red, while desatu-
rated hemoglobin appears blue.
Sterile vaginal examination: Vaginal examination with a speculum, using sterile technique. In this situa-
tion, sterility obviously cannot be ensured. When a woman is pregnant and rupture of membranes is
known or suspected, the goal is to minimize the risk of introducing bacteria during examination.
Sternum: The breastbone. The chest bone that joins the left and right ribs.
STI: See Sexually transmitted infection.
Stopcock: Small device with 3 openings and a lever to close any 1 of the 3 openings. One opening is de-
signed to fit the hub of an intravenous catheter, umbilical catheter, or similar catheter. The other 2 are
designed to connect with a syringe or intravenous fluid tubing.
Stylet: Slender metal probe with a blunt tip that may be inserted inside an endotracheal tube to make the
tube stiffer during intubation. Also, the solid, removable center within certain needles.
Succenturiate lobe of placenta: A malformation of the placenta in which the placenta has a second lobe,
with the umbilical blood vessels traversing membranes between the main placenta and accessory or succen-
turiate lobe. Umbilical vessels between the 2 lobes may lie over the cervical os (creating the condition
known as vasa previa) and can be torn, particularly if the membranes are ruptured artificially. Also, the suc-
centuriate lobe may produce a placenta previa if it lies over the os, even though a previous ultrasound may
have reported a normally placed placenta, which may be accurate for the main portion of the placenta.
Superimposed preeclampsia: Development of preeclampsia in a woman who already has chronic
hypertension. Sometimes it is difficult to tell if the increase in blood pressure is due to poor control
of existing hypertension or development of preeclampsia. If the blood pressure increases and there is
increasing proteinuria, superimposed preeclampsia is most likely. This complication increases the risk of
development of eclampsia.
Supine: Position of a person when he or she is flat on his or her back.
Supine hypotension: In late pregnancy, the enlarged uterus may compress the vena cava when a woman
lies on her back. This reduces return of blood to the heart and, thus, reduces cardiac output. This then
causes a reduction in blood pressure and in the perfusion of body tissues. The woman may feel faint.
Most pregnant women lie on their sides to sleep. During labor it may be helpful to have a woman lie on
her side as much as possible. If supine hypotension develops with a woman resting on her back, uterine
blood flow may be affected, which might result in a non-reassuring fetal heart rate pattern. One measure
to take if a non-reassuring fetal heart pattern occurs during labor is to turn a woman onto her side
(if on her back) or from one side to the other to relieve pressure on the vena cava.
Suprapubic puncture: A technique used to tap the bladder of a newborn. A needle is inserted into
the center of the lower abdomen, above the pubic bone, and into the bladder to obtain a sterile urine
specimen for culture.
Surfactant: A group of substances, including lecithin, that contributes to compliance (elasticity) of the
lungs by coating the alveoli and allowing them to stay open during exhalation. Without surfactant, the
alveoli collapse during expiration and are difficult to open with the next breath.
Symphysis pubis: Connection between the right and left hip bones in front of the body, in the pubic area.
Systemic: Refers to the whole body.
Tachycardia: Rapid heart rate. (1) Fetal tachycardia is considered to be a sustained heart rate faster than
160 beats/min. (2) Neonatal tachycardia is considered to be a sustained heart rate faster than 180 beats/
min while a baby is quiet and at rest.

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Tachypnea: Rapid respiratory rate. In a neonate, tachypnea is considered to be a sustained breathing rate
faster than 60 breaths/min.
Tent: Small cone-shaped device made of material that can expand. Used to dilate an orifice or keep a
wound open. In obstetrics, tents may be used for cervical ripening and may also be called osmotic dilators.
Teratogen: A substance that causes malformations in the developing embryo. Certain medications are
known teratogens and should not be taken during pregnancy. Most congenital malformations, however,
cannot be traced to a teratogen but are instead due to unknown factors (most common) or hereditary
factors.
Thalassemia: Any one of several hereditary hemolytic anemias caused by abnormal hemoglobin.
Thermistor probe: A small sensing device that measures temperature continuously and is able to detect
very small changes. Servo-control devices operate by a thermistor probe attached to the baby and then
the radiant warmer or incubator.
Thrombocytopenia: Abnormally low number of blood platelets.
Thrombophlebitis: Inflammation of a vein associated with the formation of a thrombus. In a superficial
blood vessel, a thin red streak will form in the skin directly over the path of the blood vessel and the
area will feel warm to the touch. Thrombophlebitis may develop at the site of a peripheral intravenous
catheter, in which case the catheter should be removed and the intravenous catheter restarted into an-
other vein. Further treatment is rarely needed. If thrombophlebitis develops in deep veins, however, it is a
serious condition, generally requiring treatment with intravenous heparin.
Thrombosis: The process involved in formation of a thrombus (blood clot in a vessel).
Thrombus: A blood clot that gradually forms inside a blood vessel and may become large enough to
obstruct blood flow. If a thrombus separates from the blood vessel and is carried in the blood, it
becomes an embolus. Plural: thrombi.
Thyroid storm: A sudden worsening of adult hyperthyroidism, usually triggered by trauma or surgery
and characterized by marked tachycardia and fever.
Thyroid-stimulating hormone (TSH): A protein secreted by the anterior pituitary gland that stimulates
thyroid function.
Thyroid-stimulating immunoglobulin (TSI): An antibody produced by lymphocytes that, for unknown
reasons, stimulates the thyroid to release thyroxin. These antibodies may cross the placenta and cause
hyperthyroidism in the fetus.
Tocolysis: Administration of a drug to stop uterine contractions.
Tonus: The amount of continuous contraction of muscle. Uterine tonus refers to how tightly the muscle
of the uterus is contracted between labor contractions. With an internal monitor, it is measured as the
resting pressure in the uterus between contractions. Hypertonus refers to a uterus that remains exces-
sively tense and does not relax normally between labor contractions.
TORCH: Toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex. A specific group of
infections that can cause in utero fetal infection (usually resulting in severe damage) or, in the case of
herpes, life-threatening neonatal infection. The “other” category includes less common, serious infections
such as varicella, coxsackievirus B, and syphilis.
Toxemia: Term formerly used to refer, collectively, to all forms of hypertensive disorders of pregnancy.
Toxoplasmosis: Disease caused by a type of protozoa (a type of microscopic one-cell organism). Toxo-
plasmosis in a woman may go unnoticed but may infect the fetus, thus causing congenital toxoplasmosis.
Congenital toxoplasmosis damages the central nervous system of the fetus and may lead to blindness,
brain defects, or death.
Trachea: The windpipe or tube of stacked cartilaginous rings that descends into the chest cavity from the
larynx and branches into the right and left bronchi, which branch further into smaller bronchioles inside
the lungs.

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Transfusion, fetal-fetal: Situation that may occur, in utero, between fetuses of a multifetal gestation,
when there is a connection between an artery of one fetus and a vein of the other in a monochorionic
placenta. The fetus on the arterial side becomes a chronic blood donor to the fetus on the venous or
recipient side. When born, the donor twin may be pale, severely anemic, and small for gestational age.
The recipient twin may be red, polycythemic, and, occasionally, large for gestational age.
Transfusion, fetal-maternal: Situation that may occur in utero if an abnormal connection develops
between the fetal and maternal circulation in the placenta. The reverse direction of maternal-fetal
transfusion apparently does not occur. The newborn may present with findings similar to the “donor”
fetus described in fetal-fetal transfusion. To diagnose this condition, the woman’s blood can be tested for
the presence of fetal cells with the Kleihauer-Betke test.
Transverse lie: The body of the fetus lies horizontally across the maternal pelvis and hence across the
birth canal entrance. A cesarean delivery is required for safe delivery of a fetus in transverse lie.
Trendelenburg position: A position of the body that may be used for surgery or examination. The
patient lies supine on an inclined surface, with the head lowered below the level of the feet.
Trimester: A period of 3 months. The time during pregnancy is often divided into the first trimester
(first through third month), second trimester (fourth through sixth month), and third trimester (seventh
through ninth month).
Trisomy: Chromosomal abnormality in which there is an extra (third) chromosome of one of a normal
pair of chromosomes. The most common is trisomy 21 (three 21 chromosomes), which is also called
Down syndrome. Other trisomies also occur, such as trisomy 13 (three 13 chromosomes) and trisomy
18 (three 18 chromosomes), both of which have a characteristic set of multiple congenital anomalies.
TSH: See Thyroid-stimulating hormone.
TSI: See Thyroid-stimulating immunoglobulin.
Turner syndrome: A chromosomal abnormality in which there are 45 chromosomes, with the absent
chromosome being one sex chromosome (45,X) instead of the typical 46,XX (female) or 46,XY (male).
These individuals are phenotypically female and may have physical abnormalities including webbed
neck, low hairline, and certain skeletal, urinary tract, lymph system, and cardiac abnormalities. The baby
will have female external genitalia, but the ovaries may be completely absent and sexual development
will be severely impaired.
Twin-twin transfusion: See Transfusion, fetal-fetal.
Twins, conjoined: Twin fetuses joined together, usually at the chest or abdomen but may be at almost
any site, and sharing one or more organs. This results from incomplete separation during the process of
twinning of single ovum (which, if completely split, would have become identical twins). The greater the
degree of organ sharing, the less likely one or both twins can survive surgical separation.
Twins, fraternal: Two fetuses created from the fertilization and implantation of 2 separate ova.
Twins, identical: Two fetuses created from the division of one fertilized ovum.
Ultrasonography (US): A technique used to visualize the fetus and placenta by means of sound waves,
which bounce off of these structures and are turned into a picture outline. Used to assess fetal growth,
fetal well-being, congenital abnormalities, multifetal gestation, placental location, location of structures
during percutaneous umbilical blood sampling and amniocentesis, and volume of amniotic fluid.
Urine drug screening: Commonly available test in which the metabolic breakdown products of recently
taken drugs can be identified in the urine.
US: See Ultrasonography.
Uterine atony: Failure of the uterine muscle (myometrium) to contract in the immediate postpartum
period. A leading cause of postpartum hemorrhage.
Uterine dysfunction: Abnormal progress of labor due to uterine contractions that are inadequate in
strength or occur in an uneven, uncoordinated pattern.

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Uterine fibroids: Tumors of the uterus made up of fibrous connective tissue and smooth muscle. Also
called leiomyomas. These myomas may become very large, occasionally interfering with implantation.
Other risks, although uncommon, include placenta previa, obstructed labor, preterm labor, postpartum
hemorrhage, and endometritis.
Uterine inertia: Inadequate labor caused by uterine contractions that are too short, too weak, and too
infrequent to produce adequate progress.
Uteroplacental: Refers to the uterus and placenta together as a functioning unit.
Uteroplacental insufficiency: An inexact term suggesting a placenta that is functioning poorly, with
inadequate transfer of nutrients and oxygen to the fetus, and used to explain some cases of in utero
growth restriction or fetal distress during labor.
Uterus: A hollow, muscular organ in which the fetus develops, often called the womb.
Vacuum extractor (VE): An instrument used to assist delivery, in which a plastic cup is placed over the
fetal occiput, suction is applied so the cup is sealed to the scalp, and then traction is applied to the cup.
There are risks, benefits, and specific indications for use of vacuum extraction.
Vagus nerve: A major nerve with branches to the heart and gastrointestinal tract. Something that
stimulates one branch of the vagus nerve may also affect another branch. Example: Suctioning deep
in the back of a baby’s throat directly stimulates part of the vagus nerve to the gastrointestinal tract
and indirectly may affect the branch to the heart and cause bradycardia (termed reflex bradycardia).
Varicella-zoster virus: The virus that causes chickenpox in children. Adults who were not infected
as children and, therefore, did not acquire immunity may also develop chickenpox, which, in adults,
can cause life-threatening pneumonia. Infection in a pregnant woman early in pregnancy can cause
severe fetal malformations and serious neonatal illness at term. Note: Reactivated infection in adults is
herpes zoster. This occurs in a small percentage of individuals who had chickenpox as children and
causes pain and the formation of vesicles along specific nerve tracks. These symptoms are known as
shingles.
VariZIG: Varicella-zoster immune globulin. Specific antibodies to the varicella-zoster virus obtained from
persons who have had the disease. Principally used to attenuate infection in the newborn of a mother
who has the infection.
Vasa previa: An abnormality of placental development. Instead of joining together at a point over the
placenta, the vessels that form the umbilical cord join some distance from the edge of the placenta. The
vessels lie on the membranes and, if the vessels lie across the cervical os, are exposed when the cervix di-
lates. This is a dangerous situation because when the membranes rupture or are artificially ruptured, the
vessels may tear open. The fetal hemorrhage that results is often fatal.
Vasoconstriction: Tightening of the blood vessels, allowing less blood flow through the vessels. Example:
When a significant volume of blood is lost, the small blood vessels in the skin will constrict, thus allow-
ing the remaining blood to be directed to the brain and other vital organs.
VBAC: Vaginal birth after cesarean.
VE: See Vacuum extractor.
Vein: Refers to blood vessels that return blood to the heart. In most veins, this blood is dark red because
it has a low oxygen concentration because most of the oxygen from the arterial blood has been trans-
ferred to the body’s cells for metabolism. The pulmonary veins, however, carry oxygenated blood as it
flows from the lungs to the heart.
Vertex: Top of the head. A fetus in vertex presentation is headfirst in the maternal pelvis. This presenta-
tion is identified on vaginal examination by palpation of the posterior fontanel in the center of the
birth canal.
Vital signs: Refers to the group of clinical measures that includes respiratory rate, heart rate, temperature,
and blood pressure.

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Vitamin E: A vitamin important for maintaining red blood cell stability. When a baby is deficient in vita-
min E, the red blood cells may break down more rapidly than normal and the baby may become anemic.
Volume expander: Fluid used to replace blood volume, and thereby increase blood pressure, in cases
of hypotension thought to be due to hypovolemia. Blood or physiologic (normal) saline solution are
examples of volume expanders.
Woods maneuver: Maneuver for management of shoulder dystocia in which the fetus is rotated
180 degrees so the posterior shoulder becomes the anterior shoulder.
Zavanelli maneuver: Maneuver for management of shoulder dystocia in which the fetal head is replaced
into the vagina and a cesarean delivery is done.

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 Index
Page numbers followed by f indicate a figure.
Page numbers followed by t indicate a table.
Page numbers followed by b indicate a box.

A B pretest, 3
Abnormally shaped waveform, 9 Beneficence, 186–187 reference ranges, 6–7
Abnormally wide or narrow pulse Beractant (Survanta), 104 2 general types of, 4
pressure, 9–10 Best-interest standard, 186 Blood pressure waveforms, 4
ABO incompatibility, 24, 25 Biomedical ethics, 181–205 abnormal configurations, 8–9
Absence of breathing. See Apnea application to neonatology, 185, abnormally wide or narrow pulse
Acidosis, 24–25, 30t 192–195 pressure, 9–10
Air bubbles, tubing, 9 application to obstetrics, interpreting, 8–10
Air emboli, 29t 185–186, 189–192 normal configuration, 8
Air leaks beneficence in, 186–187 Blood types, donor, 24
in mechanical ventilation, 85 decision-making process for the Brief resolved unexplained event
in surfactant therapy, 109 care of neonates and, (BRUE), 154
Albuterol, 165t 198–201 Bronchopulmonary dysplasia,
Alkalosis, 24–25, 30t decision support model, 202f 161–162
Alveoli, 102 futility and, 187–188 BRUE. See Brief resolved unex-
Anemia harm principle and, 188 plained event (BRUE)
as complication of exchange justice in, 187
C

BOOK 4: INDEX
transfusion, 31t nonmaleficence in, 187
direct transfusions for signs of, obligatory to treat and, 188 Caffeine citrate, 165t
36–37 optional whether to treat and, Calfactant (Infasurf), 104
in utero, 34 188 Carbon dioxide, 169t
monitoring for, 149–150 other terms in, 187–188 Cardiopulmonary monitoring, 26
partial exchange transfusions in posttest, 205 Cardiorespiratory arrest, 30t
management of, 34–35 pretest, 183–184 Car seat testing, 154
Anencephaly, 194–195 principles of, 186–187 Catheter, clots in, 9, 30t
Anoxia, 119 respect for autonomy in, 186 Central arterial catheter, 27–28
Anticonvulsant drugs, 171t self-test, 188, 203–205 Cesarean delivery, maternal refusal
Aortic regurgitation, 10 unilateral decision making and, of, 189
Aortic stenosis, 10 195–196 CHD. See Congenital heart disease
Aortopulmonary window, 10 withdrawal of life-sustaining (CHD)
Apnea measures and, 197–198 Chest movement in mechanical
continuous positive airway Birth asphyxia, 60, 119 ventilation, 81, 83
pressure (CPAP) for, 60 Birth weight and reference blood Chest radiography, 28, 107, 167t,
mechanical ventilation for, 77 pressure range, 6 173t
monitoring for, 147–149 Blood Chlorothiazide, 166t
Aqueductal stenosis, 190 amount for exchange Choice talk, 199–200, 202f
Arrhythmias, 30t transfusion, 25 Cholestatic jaundice, 163
Arterial blood gases, 169t preparation for exchange Chronic lung disease of prematurity
in continuous positive airway transfusion, 25 (CLD), 161–162,
pressure (CPAP), preservation of, 24–25 165–169t
62–63 types of donor, 24, 25 Citrate phosphate dextrose adenine
in mechanical ventilation, 84 warming of, 25 (CPDA-1), 24
Arterial catheter, 4, 27 Blood emboli, 29t, 37 CLD. See Chronic lung disease of
Arteriovenous fistula, 10 Blood exchange transfusions. See prematurity (CLD)
Asphyxia, birth, 60, 119 Exchange transfusions Clots
Aspiration syndrome, 103 Blood pressure measurement, 3–7. blood, 28
Attachment, parent-baby, See also Transducer blood catheter, 9, 30t
155–156, 172t pressure monitors Coarctation of the aorta, 10
Autonomy, respect for, 186 posttest, 12 Commercial stabilizers, 92–94

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Complications of exchange maintaining nasal, 70 Double volume exchange, 25

transfusion, 29–31 mechanism of, 60 Down syndrome, 33
Confirmed trisomy 13 or 18, 194 perinatal performance guide,
Congenital diaphragmatic hernia, 66–70 E
190 posttest, 64 Echocardiography, 167t, 173t
Congenital heart disease (CHD), preparing baby for, 67–69 Electrocardiography, 167t, 173t
163–164, 172–173t preparing equipment for, Electrolytes, 166t, 171t, 173t
Continuing care, 137–180 66–67 Electronic monitor with waveform
administering immunizations in, pressure level in, 62 display, 4
151–152 pretest, 59 Emboli formation
assessment of baby’s family in, reasons for using, 60 as complication of direct
154–156 surfactant therapy and, 107 transfusion, 37
assessment of growth in, weaning baby from, 62–63 as complication of exchange
144–147 when to administer, 61 transfusion, 29t
for babies with special problems, CPAP. See Continuous positive Endotracheal tube (ETT), 75
161–174 airway pressure (CPAP) blocked or displaced, 85
car seat testing in, 154 CPDA-1. See Citrate phosphate checking/changing position of, 94
defined, 141 dextrose adenine perinatal performance guide,
developmental care in, 156 (CPDA-1) 90–97
discharge of baby from hospital Cranial ultrasound examination, secured with commercial
and, 158–161 154 stabilizer, 92–94
feeding and, 143–144 Cyanotic congenital heart disease, 60 secured without commercial
monitoring for anemia in, Cytomegalovirus, 30t stabilizer, 90–91
149–150 skill unit, 89
monitoring for apnea in, D slipping in too far, 85
147–149 Damped waveform, 8–9 suctioning of, 95–97
posttest, 180 Decisional authority, 186 in surfactant therapy, 109
predischarge cranial ultrasound Decision support, 202f Ethics. See Biomedical ethics
in, 154 Decision talk, 201, 202f ETT. See Endotracheal tube (ETT)
pretest, 139–140 Delayed cord clamping, 32 Exchange transfusions
recommended routines, 175 Deliberation, 202f amount of blood used for, 25
screening for hearing deficits in, Developmental care, 156 babies needing more than one, 29
152 Diabetes mellitus, 103 blood preparation for, 25
screening for retinopathy of Diastolic phase, 8 blood preservation for, 24
prematurity (ROP) in, Dicrotic notch, 8 caring for baby after, 53–55
152–153 Direct blood pressure measurement catheter position, 28
self-test, 156–158, 161, 174, equipment for, 4–5 defined, 23
176–179 method for obtaining, 4 keeping blood mixed during,
sleep positioning and environ- reasons for using, 4 28–29
ment in, 154 Direct transfusions, 36–38 in management of hyperbilirubin­
specific issues involved in, defined, 36 emia, 23–31
141–156 in management of at-risk and methods of exchange, 27–28
temperature control in, 141–142 sick babies, 36–38 monitoring infant before, during,
which babies require, 141 potential complications, 37 and after, 26
Continuous exchange method of procedure for, 37 partial, 31–35
exchange transfusion, 27, reasons for using, 36–37 perinatal performance guide,
28, 34 recommended routines, 39 44–55
defined, 60 Discharge, hospital, 158–161 potential complications, 29–31
Continuous positive airway pressure Disconnected or malfunctioning preparing baby for, 44–53
(CPAP), 57–70 ventilators, 85 reasons for using, 23
adjusting, 69–70 Diuretics, 173t recommended routines, 39
administered via high-flow nasal Doctrine of double effect, 198 record keeping on, 29
cannula, 63 Documentation of exchange skill unit, 43
delivery of, 65 transfusion, 29 steps in performing, 27–29
how to administer, 61–62 Donor blood types, 24, 25 type of donor blood in, 24, 25

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Expiratory time (TE), 79 Hyperglycemia, 128 Lucinactant (Surfaxin), 104

Extremely preterm babies, mechanical Hyperkalemia, 25, 30t Lung development, fetal, 102, 103f
ventilation for, 76–77 Hyperthyroidism, 10
Hypocalcemia, 24, 30t M
F Hypoglycemia, 24, 30t, 128 MAP. See Mean airway pressure
Family assessment in continuing Hypoplastic left side of heart, 10 (MAP)
care, 154–156 Hypothermia, 30t MAT. See Medication-assisted
Feeding Hypovolemic babies, 36 treatment (MAT)
continuing care and, 143–144 Hypoxemia, 119 Maternal diabetes mellitus, 103
continuous positive airway Hypoxia, 119 Maternal-fetal surgery, 189–190
pressure (CPAP) and, 62 Hypoxic-ischemic encephalopathy Maternal refusal of cesarean delivery,
Fetal heart block, 190 (HIE), 116–135 189
Fetal lung development, 102, 103f brain injury after, 122t Maternal steroid administration,
Fetal tachycardia, 190 causes of, 119, 120t 104
Fetal therapy, 190 defined, 119 Maternal substance use disorder,
Fio2. See Inspired oxygen diagnosis of, 121–122 190–192
concentration (Fio2) early management of, 126–129 Mean airway pressure (MAP), 79
Flow-inflating resuscitation bag, 61 recommended routines, 130 Mean pressure, 8
Flow rate risk factors for, 120b Mechanical injury to donor cells, 30t
continuous positive airway Mechanical ventilation, 72–97
pressure (CPAP), 61 I adjusting, 81–84
mechanical ventilation, 79 Immunizations, 151 clinical findings in, 82–84
Framing bias, 193 Indirect blood pressure defined, 75
Furosemide, 166t measurement, 4 endotracheal tube in (See
Futility, 187–188 Infant tubing circuit, 77 Endotracheal tube
Infection [ETT])
G as complication of direct equipment setup, 78–79
Gastroesophageal reflux, 162, 170t transfusion, 37 initial settings in, 79–81
Gestational age and reference blood monitoring for signs of, 171t monitoring during, 85
pressure range, 7 Informed non-dissent, 196 posttest, 88
Growth assessment in continuing Informed preferences, 202f potential complications, 85
care, 144–147 Informed refusal, 189 pretest, 73–74
H Initial preferences, 202f reasons for using, 76
Harm principle, 188 Inspiratory time (TI), 78 self-test, 78, 86–87
Head circumference, 146–147, 171t, Inspired oxygen concentration types of ventilators for, 77
172t (Fio2), 79 when to start, 76–77
Hearing screening, 152 Intrauterine transfusion, 190 Medication-assisted treatment
Heart failure, 10 Intravenous infiltration, 30t (MAT), 190–191
Heart rate, 167t, 172t Intravenous (IV) pump, 5 Medications, monitoring of,
Heated humidifier with thermostat Intravenous solution, 5 165–166t, 170t, 173t
control in circuit, 77 In utero fetal-fetal transfusion, 32 Methylxanthine, 148
Hematocrit value, 25, 32, 166t, 173t In utero maternal-fetal transfusion, Minimum pressure, 8
Hemopericardium, 10 32 Mixing, blood, 28–29
HIE. See Hypoxic-ischemic Iron, supplemental, 150 Myelomeningocele, 190
encephalopathy (HIE) Ischemia, 119
High-flow nasal cannula for CPAP, IV. See Intravenous (IV) pump N
63 Nasal cannula, 63
J
High-pressure tubing, 4 Natural surfactants, 104
Justice, 187
HIV, 30t NBS. See Newborn screening (NBS)
Home apnea monitoring, 149 K findings, continuing
Hospital discharge, 158–161 Kangaroo care, 142 care for
Hydrocephalus, 163, 171t Kinks, tubing, 9 NDI. See Neurodevelopmental
Hyperbilirubinemia, exchange impairment (NDI)
transfusions in L Neonatal encephalopathy, 119
management of, 23–31 Length, baby’s, 147 profound, 195

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 INDEX

Neonatology, 185 Peripheral arterial catheter Pulse pressure, 8

anencephaly and, 194–195 (PAC), 23 abnormally wide or narrow, 9–10
confirmed trisomy 13 or 18 and, Peripheral intravenous (PIV) line, self-test, 10
194 23, 27
periviability and, 192–193 Periviability, 192–193 R
profound encephalopathy and, pH level, 169t RDS. See Respiratory distress
195 Phototherapy for hyperbilirubinemia, syndrome (RDS)
Neurodevelopmental impairment 29, 53 Rebound hyperbilirubinemia, 30t
(NDI), 192–193 PIP. See Peak inspiratory pressure (PIP) Reduction transfusions, 33–35
Newborn screening (NBS) findings, PIV. See Peripheral intravenous potential complications of, 34
continuing care for, 141 (PIV) line procedure for polycythemia,
Non-distensible tubing, 4 Pneumonia, 103 33–34
air bubbles or kinks in, 9 Pneumopericardium, 10 recommended routines, 39
Nonmaleficence, 187 Pneumothorax, 10, 60, 62 Reference neonatal blood pressure
Polycythemia ranges, 6–7
O characteristics of, 32–33 Respect for autonomy, 186
Obligatory to treat, 188 partial exchange transfusions in Respiratory distress syndrome
Obstetrics, 185–186 management of, 31–34 (RDS), 60, 61, 76, 79, 81,
material refusal of cesarean reduction exchange transfusion 103, 104, 107
delivery in, 189 for, 33–34 Respiratory failure, mechanical
maternal-fetal surgery in, Poor head growth, 146–147, 172t ventilation for, 76
189–190 Poractant (Curosurf), 104 Respiratory syncytial virus (RSV),
maternal substance use disorder, Positive end-expiratory pressure 151
190–192 (PEEP), 78 Retinopathy of prematurity (ROP),
Optional whether to treat, 188 Postmenstrual age, 143 152–153, 169–170t
Option talk, 200, 202f reference blood pressure range Rh incompatibility, 24, 25
Osteogenesis imperfecta, 190 and, 7 ROP. See Retinopathy of prematurity
Oxygen concentration Posttests (ROP)
continuous positive airway biomedical ethics, 205 RSV. See Respiratory syncytial virus
pressure (CPAP), 62 blood pressure measurement, 12 (RSV)
mechanical ventilation, 77 continuing care, 180
Oxygen desaturation in surfactant continuous positive airway S
therapy, 109 pressure (CPAP), 64 Safety pop-off valve, CPAP, 61
Oxygen diffusion, 60 mechanical ventilation, 88 Saline, 5
Oxygen saturation, 169t surfactant therapy, 112 Screening
therapeutic hypothermia, 132 hearing, 152
P transfusions, 42 retinopathy of prematurity
Palivizumab, 151–152 Potassium level increase, 25, 37 (ROP), 152–153,
Parasagittal cerebral injury, 122t Preservation of blood, 24–25 169–170t
Parens patriae, 186 Pressure regulation, CPAP, 61 Seizures, 128, 163, 171t
Partial exchange transfusions, 31–35 Pretests Selective cortical necrosis, 122t
defined, 31 biomedical ethics, 183–184 Self-tests
for polycythemia, 32–34 blood pressure measurement, 3 biomedical ethics, 188, 203–205
for severe anemia, 34–35 continuing care, 139–140 blood pressure measurement, 5,
Passive cooling, 133 continuous positive airway 10–11
initiating, 134–135 pressure (CPAP), 59 continuing care, 156–158, 161,
Patent ductus arteriosus (PDA), 10, hypoxic-ischemic encephalopathy 174, 176–179
163–164 (HIE), 117–118 mechanical ventilation, 78, 86–87
PDA. See Patent ductus arteriosus mechanical ventilation, 73–74 surfactant therapy, 105, 110–111
(PDA) surfactant therapy, 101 therapeutic hypothermia, 129,
Peak inspiratory pressure (PIP), 78 transfusions, 21–22 131
Peak pressure, 8 Profound encephalopathy, 195 transfusions, 27, 31, 35, 38,
PEEP. See Positive end-expiratory Pull-push method of exchange 40–41
pressure (PEEP) transfusion, 27, 28, 34 Sepsis, 30t
Perforation of inferior vena cava, 30t Pulse oximetry, 26, 167t Serum hepatitis, 30t

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 INDEX

Severe anemia, partial exchange Surfactant measuring baby’s blood

transfusions in manage- deficiency of, 103–104 pressure, 17
ment of, 34–35 defined, 102 transducer cable, 5
Shared decision making, 199–201 made during fetal development, Transfusions, 19–55
Shock, 10 102, 103f direct, 36–38, 39
Short bowel syndrome, 162, natural vs synthetic, 104 exchange, 23–35, 39, 43–55
170–171t Surfactant therapy, 77, 99–113 partial, 31–35
Skill units administration of surfactant in, posttest, 42
delivery of continuous positive 106 pretest, 21–22
airway pressure, 65 how often to administer recommended routines, 39
endotracheal tubes, 89 surfactant in, 108 reduction, 33–35, 39
exchange transfusions, 43 maternal steroid administration self-tests, 27, 31, 35, 38, 40–41
passive cooling, 133 and need for, 104 Trisomy 13 or 18, 194
surfactant administration, 113 non-intensive vs intensive care Truncus arteriosus, 10
transducer blood pressure settings for, 109 Tube feeding, 143–144
monitoring, 13 posttest, 112 Twin anemia-polycythemia
Skin color during mechanical potential complications, syndrome, 190
ventilation, 83 108–109 Twin-to-twin transfusion syndrome,
Sleep positioning and environment, pretest, 101 190
154 reasons for, 104
Sluggish blood flow, 32 self-test, 105 U
Special problems skill unit, 113 UAC. See Umbilical arterial catheter
cholestatic jaundice, 163 surfactant preparations in, 104 (UAC)
chronic lung disease of which babies to treat and when, Umbilical arterial catheter (UAC), 23
prematurity (CLD), 107–108 Umbilical venous catheter (UVC),
161–162, 165–169t Surgery, maternal-fetal, 189–190 23, 27
congenital heart disease and Synthetic surfactants, 104 positioning of, 28
patent ductus arteriosus, Systolic phase, 8 Unilateral decision making,
10, 163–164, 172–173t 195–196
gastroesophageal reflux, 162, T Urinary tract obstruction, lower, 190
170t Tanning of red blood cells, 31t UVC. See Umbilical venous catheter
how to care for babies with, 164, TE. See Expiratory time (TE) (UVC)
165–173t Temperature control in continuing V
hydrocephalus, 163, 171t care, 141–142 Vaccines, 151
poor head growth, 146–147, Therapeutic hypothermia, 116–135. Ventilation, mechanical. See
172t See also Hypoxic-ischemic Mechanical ventilation
poor parent-baby attachment, encephalopathy (HIE) Ventilatory rate, 79
155–156, 172t indications for, 123–126 Vision screening, 152–153
retinopathy of prematurity initiating, 134–135 Volume depletion, 30t
(ROP), 152–153, neuroprotective interventions Volume overload, 30t
169–170t with, 128–129
seizures, 128, 163, 171t posttest, 132 W
short bowel syndrome, 162, recommended routines, 130 Warming of blood, 25
170–171t self-test, 129, 131 Waveforms, 4, 8–10
Spironolactone, 166t skill unit, 133 abnormally shaped, 9
Stomach decompression, CPAP, as supportive treatment, damped, 8–9
61–62 127–128 Weaning
Substance use disorder, maternal, Thrombocytopenia, 31t from CPAP, 62–63
190–192 Thrombosis, 29t from incubator, 142
Suctioning of endotracheal tube, TI. See Inspiratory time (TI) from mechanical ventilation,
95–97 T-piece resuscitator, 61, 106 107
Sudden unexpected infant death Transducer blood pressure monitors, Weight, 144–146, 165t, 170t,
(SUID), 154 4–5, 13–17 172t
SUID. See Sudden unexpected infant calibrating, 16–17 Withdrawal of life-sustaining
death (SUID) equipment preparation, 14–15 measures, 197–198

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11-Index_BKIV_PCEP_245-250.indd 250 5/29/21 8:06 AM
 Time-efficient, cost-effective perinatal education and training

PCEP PCEP

PCEP Book 4: Specialized Newborn Care, 4th Edition

4

BOOK
Perinatal Continuing Education Program, 4th Edition Perinatal Continuing Education Program
4TH EDITION
EDITOR IN CHIEF, NEONATOLOGY

Specialized
Robert A. Sinkin, MD, MPH, FAAP

EDITOR IN CHIEF, OBSTETRICS EARN UP TO PCEP Workbook Contents

Christian A. Chisholm, MD, FACOG 56.5 CME MATERNAL AND FETAL EVALUATION AND IMMEDIATE
CREDITS O
R
For more than 35 years, the Perinatal
NEWBORN CARE (BOOK 1)
CONTACT • Is the Mother Sick? Is the Fetus Sick?
Continuing Education Program (PCEP) HOURS! • Fetal Age, Growth, and Maturity

Newborn Care
• Fetal Well-being
has enhanced the knowledge and skills • Is the Baby Sick? Recognizing and Preventing Problems in
of physicians, nurses, nurse midwives the Newborn
• Resuscitating the Newborn
and practitioners, respiratory therapists, • Gestational Age and Size and Associated Risk Factors
and other providers of care for pregnant women and newborns. • Thermal Environment
• Hypoglycemia
The fourth edition PCEP workbooks have been completely updated
MATERNAL AND FETAL CARE (BOOK 2)
with cutting-edge procedures and techniques developed by leading • Hypertension in Pregnancy

Earn
experts in perinatal care. These information-rich volumes provide • Obstetric Hemorrhage
concise information, step-by-step perinatal skill instruction, and • Infectious Diseases in Pregnancy

CME credits
• Other Medical Risk Factors in Pregnancy
practice-focused exercises. They offer time-saving, low-cost solutions • Obstetric Risk Factors: Prior or Current Pregnancy

or contact
for self-paced learning or as adjuncts to instructor-led skills teaching. • Psychosocial Risk Factors in Pregnancy
• Gestational Diabetes

hours!
PCEP IS A COMPREHENSIVE EDUCATION TOOL FOR • Prelabor Rupture of Membranes and Intra-amniotic
• Improving perinatal care techniques, practices, policies, and Infection
• Preterm Labor
procedures. • Inducing and Augmenting Labor
• Teaching both practical skills and core knowledge. • Abnormal Labor Progress and Difficult Deliveries
• Encouraging cooperation and communication among diverse • Imminent Delivery and Preparation for Maternal/Fetal
Transport
health care teams.
• Simplifying education planning and budgeting. NEONATAL CARE (BOOK 3)
• Oxygen
• Saving time—self-paced study approach streamlines the • Respiratory Distress
learning process. • Umbilical Catheters
• Saving money—providing top-notch education at low • Low Blood Pressure (Hypotension)
• Intravenous Therapy
per-participant costs. • Feeding
• Hyperbilirubinemia
• Infections
• Identifying and Caring for Sick and At-Risk Babies
CONVENIENT, HASSLE-FREE CME CREDITS AND
• Preparation for Neonatal Transport
CONTACT HOURS
• Neonatal Abstinence Syndrome (Neonatal Opioid
AMA PRA Category 1 Credit(s)™, AAPA Category 1 CME credits, and Withdrawal Syndrome)
ANCC contact hours are available from the University of Virginia. Visit
www.cmevillage.com for more information. SPECIALIZED NEWBORN CARE (BOOK 4)
• Direct Blood Pressure Measurement
The University of Virginia School of Medicine and School of Nursing is • Exchange, Reduction, and Direct Transfusions
jointly accredited by the Accreditation Council for Continuing Medical • Continuous Positive Airway Pressure
Education (ACCME), the Accreditation Council for Pharmacy Education • Assisted Ventilation With Mechanical Ventilators
(ACPE), and the American Nurses Credentialing Center (ANCC) to • Surfactant Therapy
provide continuing education for the health care team. • Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic
Encephalopathy
• Continuing Care for At-Risk Babies
FOR OTHER PEDIATRIC RESOURCES, VISIT THE AMERICAN ACADEMY • Biomedical Ethics and Perinatology
OF PEDIATRICS AT SHOP.AAP.ORG.

AAP