Neonatal-Evaluation-and-management ..ppt
- 2. One minute, and again at five minutes after birth, the infant is assessed using the APGAR scale. Within seconds after birth of the healthy newborn, the umbilical cord is clamped and cut, mucous is suctioned from the nose and throat, and a cap is placed on the head to help prevent heat loss and stabilize body temperature. Some doctors commonly prescribe an injection of Vitamin K. This would prevent any incidence of hemorrhagic disease ( heavy bleeding). Antiseptic ointment may be put in the eyes to prevent infections of the cornea that might result during vaginal delivery. This replaces the diluted silver nitrate formerly used.
- 3. Score 0 Score 1 Score 2 Heart rate absent <100 >100 Respiration absent weak or irregular strong Muscle tone none some flexion active movement Reflex irritability no response to stimulation grimace/feeble cry when stimulated sneeze/cough/pulls away when stimulated Skin color blue all over blue at extremities normal The Apgar score was devised in 1952 by Virginia Apgar as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after childbirth. The Apgar score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two and summing up the five values thus obtained. The resulting Apgar score ranges from zero to 10.
- 4. The purpose of the Apgar test is to determine quickly whether a newborn needs immediate medical care; it was not designed to make long-term predictions on a child's health. Some ten years after the initial publication, the acronym APGAR was coined in the US as a “mnemonic” learning aid: The APGAR test is generally done at one and five minutes after birth, and may be repeated later if the score is, and remains, low. Scores of 0-2 are generally regarded as critically low or “poor”, with 3 to 7 indicating “fair” condition and 8-10 generally normal or “good”. The one minute scores usually indicate how well the baby tolerated the delivery. The 5 minute scores indicate their adaptation to the new environment. A score of “0” at both 1 and 5 minute intervals might generally indicate a stillborn baby. Appearance (skin color) Pulse (heart rate) Grimace (reflex irritability) Activity (muscle tone) Respiration.
- 5. Heart rate - range 120 to 160 beats per minute Common variations: Heart rate range to 100 when sleeping to 180 when crying Heart rate may be irregular with crying Respiration - range 30 to 60 breaths per minute Common variations Bilateral bronchial breath sounds Moist breath sounds may be present shortly after birth Babies in distress may be placed in an incubator for relief and constant monitoring of vital signs.
- 6. We would expect to see well-flexed, full range of motion, spontaneous movement Signs of potential distress or deviations from expected findings Posture limp Asymmetry of movement Persistent tremor, twitching
- 7. Reflex irritability is scored on the basis of the infant’s response to stimuli, such as a mild pinch. No response to a pinch= a score of 0 points. A grimace or feeble cry = a score of 1 point. A lusty cry scores 2 points on the APGAR! To “pinch” baby and encourage crying is in conflict with the Leboyer method of childbirth. This method is used to minimize trauma to the infant during and after delivery. The room is dimly lit and quiet, the baby’s head is not pulled. The infant is massaged or given a warm water bath. This is all in direct contrast to the outdated method of smacking baby’s bottom to encourage deep breaths!
- 8. Expected findings: Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin is flaky, dry and pink in color; it is excessively flaky in babies that were overdue Edema (excess fluid causes swelling) around eyes, feet, and genitals Some vernix caseosa or lanugo may remain Common variations: Acrocyanosis – blue colored fingers, toes, hands, and/or feet are the result of sluggish peripheral circulation Mongolian spots – Patches of purple-black or blue- black color distributed over backside of infants of African-American or Asian descent. Resolves in time. Mottling - Generalized red and white discoloration of skin of chilled infants with fair complexion
- 9. Jaundice is a yellow discoloring of the skin, mucous membranes, and eyes, caused by too much bilirubin (a breakdown product of hemoglobin made by the liver) in the blood. High levels of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes. Using bili lights is a therapeutic procedure performed on newborns to reduce elevated levels of bilirubin, which tends to accumulate in the brain tissue, and can cause permanent brain damage. The bili lights, like sunlight, allow the body to manufacture Vitamin D. This vitamin is manufactured by the body when the skin is exposed to sunlight, and affects liver function. In very mild cases of jaundice, baby might simply be placed in the window on a sunny day. In newborns, jaundice often exists due to an immature liver.
- 10. Head circumference - 33 to 35 cm Expected findings: Head should be 2 to 3 cms larger than chest Chest circumference - 30.5 to 33 cm Common variations: Molding of head may result in a lower head circumference measurement: Fontanelles should be soft, firm, and flat. Bulging fontanelles may indicate distress or deviation from normal Head and chest circumference may be equal for the first 24 to 48 hours of life. On average, the newborn infant weighs 7 pounds and is 20 inches long. Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.) Length range - 48 to 53 cms (19 - 21 inches) Once the APGAR scores and general measurements are determined, additional reflexes will be tested. In fact, they will continue to be tested throughout the first year of life in order to evaluate neurological function and development. Absent or abnormal reflexes in an infant, persistence of a reflex past the age where the reflex is normally lost, or redevelopment of an infantile reflex in an older child or adult may suggest problems with the nerve system.
- 11. The Moro response is a normal reflex for an infant when he or she is startled, feels like they are falling, or their head drops back. A loud noise should also elicit this reflex. The infant will have a "startled" look and the arms will fling out sideways with the palms up and the thumbs flexed OR are quickly drawn upward. Absence of the Moro reflex in newborn infants is abnormal and may indicate an injury or disease. Remember the correct definition of reflex: an automatic and involuntary reaction as the result of the nervous systems’ response to a stimulus.
- 12. When your baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called "fencing." Baby's may sleep in this position for years, but when awake, this reflex usually disappears by the age of 4 months.
- 13. Palmer Grasp reflex…put something against baby’s palm and they grip fingers and hold it Plantar Grasp reflex…put something on sole of baby’s foot; they clench their toes in an effort to hold it
- 14. The stepping or walking reflex is present at birth. If the infant is held erect and the feet come in contact with a surface, the infant will make step-like movements. Some parents incorrectly interpret this movement as a desire to stand and walk. It is important that this motion is not allowed to be weight- bearing, as leg muscles are not developed. It is interesting that this reflex occurs even if the baby is held upside down and the feet come in contact with a surface.
- 15. When your baby is placed on his/her stomach, they will automatically assume a "crawling" position. This usually disappears by 4 months. When the position reappears, it is closer to 6 – 10 months. At that point the baby will actually be learning to crawl rather than just exhibiting a reflex movement.
- 16. A mild pinch or slapping on the bottom of the foot elicits the flexion reflex. This causes the body to automatically draw back from the painful stimulus. It is a reflex for protection or survival.
- 17. The sucking reflex may have been present long before birth, as shown above in this fetus. This reflex will allow the infant to ingest food from the nipple of a bottle or breast. As shown in the picture above, this reflex occurs when any nipple-sized object is placed on the baby’s lips.
- 18. Rooting reflex When you stroke the corner of your baby's mouth and move your finger slowly toward his ear you will see his tongue, mouth, and sometimes even his head follow the direction of your hand. They also open their mouth. This reflex helps babies to locate the nipple for feeding. This usually disappears by 3-4 months. 1. 2.
- 19. When you stroke the bottom of your baby's foot, the big toe flexes toward the top of the foot, the other toes fan out, and the leg extends outward. This usually disappears by 9 months to 2 years, when the toes curl under and the leg is pulled back. Also known as the Extensor Plantar Reflex or Toe Sign
- 20. The infants’ eyes will open and close in response to a touch on the face, a bright light, a loud sound, a strong odor, or a bitter taste. This reflex serves to help protect the eyes, and is present during the entire lifetime.
- 21. The infants’ pupils open automatically in response to weak light and contract in response to bright light. This reflex not only allows for better vision, but protects the eyes. It is present throughout the lifetime.
- 22. A stork bite is a vascular lesion quite common in newborns consisting of one or more pale red patches of skin. Most often stork bites appear on the forehead, eyelids, tip of the nose, upper lip or back of the neck. They are usually gone within 18 months of birth. Some may be attributed to birth injuries such as stretch marks. Also called “salmon patches”, they occur in about one third of all newborn infants. They are flat, pink areas with irregular borders, and may become darker with crying or room temperature changes. They fade with pressure, but the reddish appearance returns when the pressure is removed. Stork bites clear up spontaneously over a period of months and are usually gone completely by 18 months with the exception of those at the nape of the neck. Those may persist for years, but are generally covered by hair.
- 23. Some of the experts believe bonding must happen immediately after birth, but most believe it is truly an individual experience. It should be considered a process rather than a specific moment, involving cuddling, holding, talking to, etc. When experts talk about bonding, they're referring to the intense attachment the parent develops with the baby, in particular the mother, due to the biological connection. Some research indicates that Infants who have a deep bonding with their mothers tend to become very independent at a young age and display a higher sense of confidence, positive attitude, and self-esteem. They appear self- reliant and enjoy good relationships with peers, even when under stress or unstable home conditions. These children seem to be more successful in school, especially in mathematics. They have good school attendance and high achievement scores in comparison to children that did not bond as deeply with the mother.
- 24. Father-Newborn Bonding Most of the bonding research has focused on mother-infant bonding, but in recent years father-infant bonding has received increased attention. A special term is used to describe the father-infant relationship at birth-- "engrossment." Engrossment involves the holding and comforting of the baby and the display of a greater level of sensitivity in the father. Studies on father bonding show that fathers who are given the opportunity and are encouraged to take an active part in caring for their newborns can become just as nurturing as mothers. A father's nurturing responses may be less automatic and slower to unfold than a mother's, but fathers are capable of a strong bonding attachment to their infants during the newborn period. Fathers have their own unique way of relating to babies, and babies seem to thrive on this difference. There is also some scientific evidence to support bonding. Cortisol is a hormone that is regulated by the pituitary-adrenal system. It influences stress reactions, the immune system, sugar levels in the blood, motor skills, and memory. During the average day a typical child’s cortisol level peaks in mid- morning and decreases in the evening. In children who have no parental attachment, the cortisol levels continue to increase all morning and only decrease slightly by evening.
- 25. If there is no bonding with a child, the result seems to have a profound and long-lasting negative effect, often referred to as Reactive Attachment Disorder. The essential feature of RAD (Reactive Attachment Disorder) is the "markedly disturbed and developmentally inappropriate social relationships that begin before age 5 years and are associated with grossly pathological care". By definition, the grossly pathological care may take the form of persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection; the persistent disregard of the child’s basic physical needs; or repeated changes of primary caretaker that prevent formation of stable attachments. Children can exhibit poor peer relations, rage, poor eye contact, limited to no remorse for destructive or assaultive behaviors, chronic lying, agitating, and stealing; and preoccupation with morbid topics, destruction or cruelty to animals. Long term hospitalization of newborns may prevent bonding, as well as neglect or abandonment. “Holding therapy” during episodes of rage is one form of treatment being used for RAD.
- 26. The postpartum period begins after the delivery of the baby and ends when the mother's body has returned as closely as possible to its pre-pregnant state…a period of six weeks to two years. It involves the mother’s adjustment to physical, emotional, and hormonal changes, as well as learning how to care for a newborn and function in this new family unit. She will need to rebuild her strength, getting plenty of rest, good nutrition, exercise, and help during the first few weeks. Postpartum depression (PPD) is quite common after a baby's birth. It can range from mild "baby blues" which affect between 50 and 80 percent of all mothers, to psychosis. In general, over 10 percent of mothers experience some level of postpartum adjustment problems. When these problems begin to interfere with a mother's ability to take care of her baby and her daily tasks, it is time to seek professional help. Depression is a very real mental condition, not imagined or voluntary.
- 27. The mammary gland of the breast, upon receiving a hormonal signal after the birth of the baby, begins making secretions. This process is called lactation. The very first secretion from the breast is called COLOSTRUM. It is sticky, and a milky- yellow color. It is nature’s perfect baby food: 1. Provides baby with perfect nutrition 2. It is easily digestible 3. Contains immunities from the mother After several days, the colostrum is replaced with milk. Although breastfeeding contributes to bonding the mother and child, it may be limit how much the father is able to participate in his baby’s care.