Neonate for Midwives Kholoud - PowerPoint Presentation

Slide1

Neonate for Midwives

Kholoud

Salem AL-

Azab

BSM - MPH

Slide2

Chapter one

Recognizing the healthy baby at term through examination of the newborn screening

Slide3

Lecture (1)

1.1 The

first examination after birth The aim of the first examination performed within 24 hours of birth is to detect any observable congenital malformations and to assess initial adaptation to extra uterine life that could compromise health and wellbeing (Resuscitation Council 2011). The examination should be performed in the presence of the mother and partner (as appropriate).

Slide4

Cont.,

The ideal time is

a her the baby has had skin-to-skin contact and had its first feed, during which it maintained a body temperature within normal parameters. The midwife present at the birth to performs this examination and should ensure that the environment is warm and draught-free, with equipment ready for use.

Slide5

Cont.,

Diligent hand- washing is essential. The baby should be at rest on a flat surface. The skills of observation, palpation and auscultation should be utilized. See

Box 28.1 for screening principles that should be communicated when screening is undertaken.

Slide6

Box

28.1

The principles of screeningThe midwife should:inform the mother exactly why the examination is being conductedobtain informed consent from the mother to perform the examination on her babyensure the baby is wearing identification bracelets that correspond with the mother's identity and documentationperform a thorough examination of the babyprovide full details of the findings of the examinationoffer an action plan of care as requireddocument detailed findings and evidence of communication that arose between the midwife and mother/parents before, during and after the examination

Slide7

1.1.1 Assessment of the neonatal skin

According

to Baston and Durward (2010), the colour of the skin is generally considered a reflection of good health, but is most difficult to assess accurately in the first few hours of extrauterine life and the midwife needs to distinguish between different types and degrees of blue skin to know if the baby is well or whether to refer to the neonatal registrar.

Slide8

Cont.,

A blue skin as a result of central cyanosis

To assess blueness due to accumulation of carbon dioxide and deprivation of oxygen is a difficult task in white ethnic groups and even more so in babies from black ethnic groups who have a pigmented skin. The baby's oral mucus membranes and tongue are not pigmented and will provide the

midw

i

f

e

w

i

t

h

r

e

li

a

b

l

e

e

v

i

d

e

n

c

e

o

f

c

e

n

t

r

al

c

y

a

n

o

s

i

s

.

Slide9

Cont.,

A dull blue skin may indicate poor perfusion and can be assessed by measuring capillary refill time (CRT) by blanching the baby's chest skin with a finger and, on release, seeing how long it takes for the capillaries to refill. Any time over 2 seconds indicates poor peripheral perfusion. Pallor of the skin is a result of peripheral shutdown and is always a serious sign as this could also indicate acute blood loss,

a naemia, the processes involved in cooling or/and the presence of infection.

Slide10

Cont.,

Jaundice that develops from birth in the first 24 hours is considered pathological, is usually as a result of

haemolysis (excessive breakdown of red blood cells) and should also be reported immediately (England 2010b) (see Chapter 33).

Slide11

Con.,

A blue skin as a result of other factors

Most babies will have peripheral shutdown (acrocyanosis) in hands and feet as blood is diverted to major organs. Occasionally babies will present with a blue face as a result of petechiae, which are pinpoint hemorrhagic spots on the skin, usually as a result of a tightening cord around the neck which constricts the jugular veins during fetal descent in the second stage of labour.

Slide12

acrocyanosis

Slide13

petechiae

Slide14

Cont.,

The venous blood is trapped in the sinuses of the brain and will find an exit point into the skin, thus the facial tissues become bruised. The use of a pulse oximeter will indicate the amount of

haemoglobin saturated with oxygen in the baby's blood and should be about 95% or above in the first 24 hours of life.

Slide15

Cont.,

Common skin lesions found at birth

Skin lesions, as they are discovered either by the parents or midwife, need addressing immediately. There is no room for guesswork and the prudent midwife will ask for a second opinion should there be any doubt.

Slide16

Cont.,

Common skin lesions found at birth

Cuts, abrasions and bruisesThese are carefully assessed as they may serve as portals of entry for infection. Create a line drawing in documentation to illustrate size and complexity to avoid disputes regarding origin (iatrogenic lesions caused by treatment, e.g. use of forceps or ventouse; see Chapter 31, Figs 31.1, 31.2) or as a result of non-accidental injury. Extensive bruising may lead to clinical jaundice.

Slide17

abrasions

and bruises

Slide18

Cont., Common skin lesions found at birth

Vascular birth marks found at birth

Vascular proliferations (increase in growth) in the skin will resolve and involute in time:A. Salmon patch haemangioma or ‘stork marks’: occur in 50% of babies, are superficial capillaries that blanche on pressure, resolve spontaneously, commonly found on the nape of the neck, eyelids and glabella.B. Strawberry haemangioma: not always present at birth; occurs in 10% of babies by the age of one year; bright red in colour. Benign but can develop over orifices, e.g. anus, to cause obstruction and can leave scar tissue. Laser treatment is available but natural resolution offers a better cosmetic outcome.

Slide19

Slide20

Slide21

Cont.,

C.

Cavernous haemangioma: similar to the strawberry haemangioma but invades deeper into the vascular tissues; leaves a blue discoloration to the skin and grows with the child.Vasculature malformations that do not involute are permanent and always present at birth:

Slide22

Cavernous haemangioma

Slide23

Cont.,

A. Port

wine stain: red, purple markings present in 0.3 % of neonates (Gordon and Lomax 2011) can be an isolated mark or associated with syndromes. Some lesions (Sturge– Weber syndrome) follow the trigeminal nerve (fifth cranial nerve); have a midline cut off and can infiltrate into the meninges and cerebral cortex on the affected side resulting in seizures and eye abnormalities. This condition can devastate parents and the midwife needs to provide empathic informed support.Pigmented birthmarks

Slide24

Port wine stain

Slide25

Cont.,

A.

Mongolian blue spots are produced by clusters of melanocytes in the dermis, are benign and have no clinical significance. Present in 90% African, 81% Asian and 9.6% white caucasian babies, they have a slate-grey to blue-black discoloration usually found over the buttocks, back and legs and fade by 7 years of age. They resemble bruising so a line drawing is useful to distinguish from future non-accidental injury (Griffith 2009).

Slide26

Cont.,

B.

Pigmented naevi affect 3% of babies, present at birth as a dark brown patch on the lower back or buttocks with speckles around the edge of the lesion, usually as a solitary patch. Major concern is the development of malignancy over time and must be monitored closely for changes in size and shape.

Slide27

Cont.,

C.

Milia are small white follicular cysts commonly known as milk spots (Fig. 28.2). They normally appear on the cheeks forehead and nose and are thought to be retention of keratin and sebaceous secretions. They clear within 4 weeks of birth.

Slide28

Thank you 

Slide29

Lecture 2

1.1.2 Assessment of the neonatal

head

Slide30

Normal skull of the newborn

Slide31

According

to

Noonan et al (2011), the shape, size and symmetry of the head in relation to the face and rest of the body should

be assessed.

The

head

circumference

measurement

of

the

occipitofrontal

diameter

should

be

in

the

range

of

32–36

cm

for

a

term

b

a

b

y.

Slide32

Slide33

Lumsden

(2010) asserts that macrocephaly (greater than the 97th centile) or microcephaly (below the 2nd centile) can be draw on a head circumference grow

th

chart

in

the

Child

Health

Record

.

A

head

that

is

disproportionate

to

body

size

may

indicate

asymmetrical

i

n

t

r

a

u

t

e

r

i

n

e

g

ro

w

t

h

r

e

st

r

i

c

t

i

o

n

w

h

e

r

e

t

h

e

h

e

ad

h

as

b

ee

n

s

p

a

r

e

d

d

i

s

r

up

t

i

o

n

t

o

i

t

s

g

ro

w

t

h

(

s

e

e

C

h

a

p

t

e

r

30

)

.

Slide34

Slide35

Macrocephaly

Slide36

B

e

aware that a stand-alone head measurement may appear

pe

r

f

e

c

t

l

y

n

or

m

al

b

u

t

i

t

s

r

e

l

a

t

i

o

n

s

h

i

p

w

i

t

h

t

h

e

b

o

d

y

m

ay

r

e

n

d

e

r

i

t

l

a

r

g

e

.

A

l

a

r

g

e

h

e

ad

i

s

a

l

s

o a

ss

oc

i

a

t

e

d

w

i

t

h

h

y

d

roc

e

p

h

a

l

y

a

n

d

co

n

g

e

n

i

t

al

s

y

n

d

ro

m

e

s

.

A

s

m

a

l

l

h

e

ad

i

s

a

ss

oc

i

a

t

e

d

w

i

t

h poor

brain

d

e

v

e

l

o

p

m

e

n

t

.

Fetal

alcohol

spectrum

disorders

(FASD)

and

transplacental

infections

will

deleteriously

affect

fetal

brain

g

ro

w

t

h

.

Slide37

Hy

d

rocephaly

Slide38

FASD

Slide39

O

b

servation and palpation of thescalp will indicate the presence anddegree of caput succedaneum which will

resolve in

2–3

days.

Slide40

The

direction

and degree of molding can indicate the engaging diameter of the fetal skull involved in the process of labour.

Slide41

Slide42

The

bones,

sutures and fontanelles can then be examinedThe anterior fontanelle (bregma) closes at 18 months of age and if tense o

r b

u

l

g

i

n

g

c

an

i

n

d

i

c

a

t

e

co

n

g

e

n

i

t

al

h

y

d

roc

e

p

h

a

l

y

,

i

n

t

e

rcr

a

n

i

al

h

a

e

m

orr

h

a

g

e

o

r

meningitis

.

A

sunken

bregma

is associated with dehydration because as an extracellular fluid, cerebrospinal fluid is derived from venous blood.

Slide43

The posterior fontanelle (lambda) closes around 6 weeks. More than one lambda along the lamboidal

suture lines

ohen alongside a flat occiput can indicate trisomy 21, as can abnormal paferns of hair growth (low hair line, extra crowns) which are featured in a variety of syndromes (see Chapter 32).

Slide44

Thank you 

Slide45

Lecture 3

1.1.3 assessment of the face

The midwife should see both parents before expressing concern on an unusual-looking face, The face should be analyzed as a whole.Individual features in isolation do not necessarily indicate a syndrome but in combination with other features they make a syndrome more likely. The baby's facial expression could indicate an underlying condition, e.g. pain, irritability, distress and is worthy of note.

Slide46

The symmetry of the face should be observed as this could indicate birth trauma in the form of facial paralysis where one side of the face appears to droop, especially around the eye and mouth on one side, when the baby is

crying.

This is a result of damage to the seventh cranial nerve (facial), known as Bell's palsy, during the application of forceps or from head compression against the sacral promontory during birth. Any degree of recovery will depend upon the amount of damage to the myelin sheath that covers and feeds the nerve.

Slide47

Right-sided facial palsy. Note that the eye is open on the paralyzed side and the mouth is drawn over to the non-paralyzed

side.

Slide48

EAR:

The

ear position should be similar on both sides. The upper margin of the ear pinna should be on the level of the eyes. However, a finding of low set ears alone may be a normal variation. Malformed and/or low set ears are associated with chromosomal abnormalities or urogenital malformations and warrant referral. Roth et al (2008) argue that peri-auricular skin tags can indicate hearing impairment.

Slide49

peri-auricular skin

Slide50

The incidence of significant permanent congenital hearing impairment (PCHI) is 1 : 1000 births in developed

countries.

The NHS Newborn Hearing Screening Program offers hearing screening in the first week of life and aims to provide high-quality detection care and support for babies and their families. A pre- auricular sinus may be blind-ending or connected to the inner ear. The later condition will need referral to the Ear Nose and Throat (ENT) surgeon.

Slide51

A pre- auricular sinus

Slide52

NOSE:

The

nose shape will vary, but the two nares should be centrally placed and be patent. Most babies are obligatory nose-breathers and patency can be observed when the baby is breathing normally at rest. Nasal flaring may be indicative of respiratory distress. Choanal atresia is a condition in which one or both posterior nasal passages are blocked by either bone or soft tissue.

Slide53

In the bilateral condition the baby will be centrally cyanosed at rest but will become better perfused when crying. Urgent referral to an ENT surgeon will be

required.

Slide54

LIP AND

PALATE:

When a cleft lip is detected by antenatal screening, automatic referral is made to the local cleft lip and palate team (plastic surgeon, ENT surgeon, audiologist, orthodontic surgeon and speech therapist) before the baby is born. For those babies who have their condition detected after birth, the midwife should refer to the registrar who will make referral to the cleft lip and palate team.

Slide55

Cleft

lip can be either unilateral or bilateral and can extend into the hard and

soft palate. A cleft palate is not always obvious and requires thorough assessment in order to confirm its presence. A gloved finger should be inserted into the mouth, eliciting a suck reflex. By palpating the hard palate it should be possible to feel if a cleft is present. Detection of clefts in the soft palate should involve visual inspection using a pen torch and tongue depressor.

Slide56

Cleft lip and palate

Slide57

The

palate should be high arched, intact with a central

uvula.Cleft lip and/or palate may be familial or may be as a result of maternal medication (e.g. phenytoin) or chromosomal abnormality (e.g. Down syndrome). A small jaw (micrognathia) may be familial or part of a syndrome like Pierre Robin, which comprises a midline cleft palate and protruding tongue (glossoptosis).

Slide58

Slide59

The baby may also experience problems with feeding. Referral to the ENT and orthodontic surgeons will be made alongside the speech

therapist.

Epstein's pearls are a cluster of several white spots in the mouth at the junction of the soft and hard palate in the midline.They are the same as milia, are of no significance and disappear spontaneously.

Slide60

Epstein's pearls

Slide61

Natal teeth are lower incisors that have small crowns with no roots and pose the risk of tongue ulceration and, if they become loose, inhalation into the trachea.

Referral to the orthodontic team for elective removal is required. The tongue should also be examined for cysts and dimples

.

Slide62

A tight frenulum that is attached too far forward to the floor of the mouth restricts mobility of the tongue to different degrees and will give the appearance of tongue-tie (

ankyloglossia

).Treatment for severe tongue-tie is frenulotomy (surgical division of the frenulum), especially when breastfeeding is being adversely affected.

Slide63

Ankyloglossia

Slide64

EYE:

The

eyes should be symmetrically positioned on the face in relation to the other facial features such as eyelids, eyebrows and the slant of the palpebral fissures.The outer and inner canthal distance can be divided equally.Extremely wide (hypertelorism) or narrowly spaced eyes are abnormal and may indicate a syndrome, as may epicanthic folds.

Slide65

Canthal

distance

Slide66

Epicanthic folds

Slide67

The sclera is normally white in

colour

; a yellow discoloration occurs with jaundice. Conjunctival hemorrhages may occur as a result of the birth, are insignificant and will take a few days to resolve.The iris of a baby is navy blue with radiating from the center. It should be perfectly circular with a round pupil in the center.

Slide68

White

specks on the iris called

Bushfield spots are associated with Down syndrome. Opacity of the lens could indicate congenital cataract.Clouding of the cornea could be a sign of congenital glaucoma.Small eyes occur as a result of transplacental infection, e.g. rubella, cytomegalovirus. Any profuse or purulent discharge from the eyes should be swabbed and sent for culture and sensitivity.

Slide69

Eye

drops/ointments to treat gonococcal

infection, staphylococci and chlamydial conjunctivitis should be started while awaiting the results.Absence of one or both eyes may have an environmental or chromosomal cause and such a finding requires referral to the ophthalmologist.

Slide70

Thank you 

Slide71

Lecture 4

1.1.4 The

chest and abdomenBedford and Lomax (2011) assert that: the heart rate will vary in range from 100 to 160 beats per minute (bpm).The respiratory rate will be 30–40 breaths per minute (bpm), but not exceed 60 bpm and will vary in rhythm with small periods of apnoea (absence of breathing for 20 seconds or more).There should be no sternal or costal recession.

Slide72

Cont.,

The nipples should be lateral to the mid-clavicular line and should be normal in shape and form

. The presence of abnormal or supernumerary (extra) nipples should be recorded as a line drawing on a body map with referral to the registrar.Observation of respiratory movement should reveal that chest and abdominal movements are synchronous as the diaphragm is the major muscle of respiration.

Slide73

The nipples should be lateral to the mid-clavicular line

Slide74

Asymmetrical

chest movement may be caused by either unilateral pneumothorax or phrenic nerve damage on the side that isn't moving

. Also consider the presence of a diaphragmatic hernia noted when the chest looks relatively big in comparison to a (sunken) abdomen.

Slide75

The abdomen should look and feel

soft

and rounded. The cord should be checked for bleeding. The cord vessels should have two arteries and one vein. A single umbilical artery increases the chances of congenital abnormalities but further investigations are not justified on this finding alone.

Slide76

Exomphalos is where the bowel, covered by a transparent sac composed of amnion and peritoneum, protrudes through the umbilical cord and is associated with Beckwith–

Wiedemann

syndrome (exomphalos, large for gestational age, abnormal glucose metabolism, characteristic skin creases to the ears). By comparison, gastroschisis is caused by a defect in the abdominal wall, which allows bowel to protrude through it.

Slide77

Exomphalos

Slide78

skin creases to the ears

Slide79

Gastroschisis

Slide80

No sack covers the loops of bowel, so before birth the bowel has been in contact with the irritant properties of amniotic fluid, but there are no associations with other congenital abnormalities. Both conditions may be found on antenatal screening and at birth the protruding bowel is covered with film wrap to prevent fluid and heat loss in readiness for surgical repair.

Slide81

1.1.5 The anus

Inspection for the presence and appearance of the anus is vital.

The presence of meconium does not always exclude imperforate anus (anal atresia). In a perforate anus, the rectum and anal sphincter connect so that substantial amounts of meconium can be passed at any one time.

Slide82

If there is an underlying defect referred to as a high imperforate obstruction, there could be a rectal–vaginal fistula or a rectal–urethral fistula that may allow passage of small amounts of

meconuim

.

Slide83

England

(2010a) contends that anal abnormalities can indicate that other gastrointestinal malformations may be present, so caution with feeding is recommended.

The passage of a nasogastric tube and withdrawal of hydrochloric acid can exclude oesophageal atresia but does not necessarily rule out tracheoesophageal fistula.

Slide84

1.1.6 The genitalia

Male

genitaliaThe penis should be about 3 cm in length, straight, with no chordee (a bend in the shah). According to Fox et al (2010), an apparently short penis is more common, usually buried in supra-pubic fat, but remains a finding that can cause real consternation to parents.

Slide85

True micro-penis is rare and associated with hypopituitarism and referral to the

paediatric

.Observing the baby pass urine may help to detect a hypospadius where the urethral meatus opens on the ventral (under) side of the penis and an epispadius where the urethral meatus opens on the dorsal (upper) side.

Slide86

Slide87

Parents should be advised not to have their baby circumcised for religious or cultural reasons, as the foreskin will be used to surgically repair the defect

.

According to Gordon (2011), the scrotum should be examined to ensure symmetry on both sides as asymmetry may indicate a persistent connection between the abdominal cavity and scrotum, so that fluid (hydrocele) or loops of bowel (inguinal hernia) can escape and occupy the scrotal sac on the affected side.

Slide88

A dark discoloration of the scrotum, with or without swelling, is abnormal and may indicate testicular torsion.

The

testicle twists on itself, limits its own blood supply and the testicle dies from ischaemia. Torsion can occur at any age and requires immediate surgical review.

Slide89

The testicles should descend into the scrotal sac by term. Each testicle is 1–1.5 cm in size, palpable along the route from the posterior abdomen to the scrotal sac, often found in the groin. Undescended testicles (

cryptorchidism

) occurs in 2–4% of term babies. If not descended by one year, orchiopexy is performed to surgically place the testicle in the scrotal sac to prevent infertility and malignancy in later life.

Slide90

Female

genitalia

The examination will confirm that the general anatomy appears appropriate, with the labia majora covering the labia minora.Disorders of sex development (ambiguous genitalia)

Slide91

Honesty is the only way to effectively manage this situation, however, and the midwife's choice of words should be tactful but truthful, with an immediate response to the parents' queries. Recent practice of placing the newborn onto the mother's abdomen has enabled the parents to examine their baby and make their own discoveries,

often

before the midwife has had chance to see for her/himself.

Slide92

According

to

Wassner and Spack (2012), there are many different causes of ambiguous genitalia: the most common is congenital adrenal hyperplasia, with an incidence of 1 : 15 000 babies.

Slide93

An XX female baby has an enlarged clitoris that appears like a penis and labia that may look more like a scrotum

.

This is an autosomal recessive condition where lack of an enzyme called 21 hydroxylase interferes with the cholesterol pathway in the production of progesterone.

Slide94

In the absence of serum cortisol and aldosterone, the anterior pituitary hormone

adrencorticotrophin

(ACTH) stimulates the pathway but only testosterone is produced, which results in masculinized genitalia and life-threatening imbalances in sodium and cortisol levels.Referral to an endocrinologist and a paediatric surgeon

Slide95

The genitalia of male XY babies look within normal limits but these babies may present later with failure to thrive, vomiting and dehydration related to abnormal aldosterone and steroid physiology

.

Slide96

The midwife should warn the parents of the likelihood that their baby may be transferred to the neonatal intensive care unit (NICU) for extra monitoring.

Slide97

1.1.7 Limbs

, hands and

feetThe term baby will lie in a flexed position with the head in the midline or turned slightly to one side. The hands are flexed, with the thumb lying beneath the fingers in a fist. In addition to noting length and movement of the limbs and joints, it is essential that the digits are counted and separated to ensure that webbing (syndactyly) is not present on hands and feet.

Slide98

The

hands should be opened fully as any extra digits (polydactyly) may be concealed in the clenched fist

. X-ray assessment will determine whether the defect needs referral to either the plastic surgeon (skin only) or orthopaedic surgeon (bone and skin). A single palmar (Simian) crease is associated with Down syndrome, however 10% of the normal population have a single palmar crease on one hand and 5% have one on both hands.

Slide99

Slide100

Davis (2011) uses the word structural

clubfoot

to refer to the most common foot deformity (1 : 1000 births in the UK), known as congenital talipes equinovarus. The word talipes means ankle and foot. In this condition the foot is plantar-flexed (turned downwards like a horse's foot and inwards towards the midline of the baby). The ratio of boys to girls is 3 : 1 and in 50 % of cases, both feet are affected. The cause is unknown but is associated with Down syndrome and spina bifida.

Slide101

Slide102

Referral to an orthopaedic

surgeon is required. First line treatment is the

Porseti method of gentle manipulation and serial casting in plaster of Paris at weekly intervals, which allows the foot to be gradually corrected over a period of 6 weeks.

Slide103

Slide104

1.1.8 The spine

The best way to examine the spine is by holding the baby per chest/abdomen on one hand, and running the fingers of the other hand down the spinal processes

. Any curvature of the spine can be noted. Spina bifida occulta (characterized by a missing vertebral process) may lie beneath a fat pad, swelling, dimple, tuft of hair or birthmark.

Slide105

For spina

bifida

cystica (mylomeningocele and meningocele), A sacral dimple should be carefully examined to make sure it is skin-lined with no sinus to the CSF pathway.If CSF is leaking it represents a portal for infection, so referral to both the plastic surgeon and neurosurgical teams will be made. In the interim, X-ray of the lumbosacral spine and an ultrasound scan of the lower spinal cord, kidneys and bladder will be arranged.

Slide106

Slide107

Thank you 

Slide108

Lecture 5

1.1.9 Neck

Slide109

1.1.10

Communication

and documentationAs soon as the examination is completed, the baby should be handed back to the mother and skin-to-skin contact re-established. This first examination a

fter birth

is

extremely

important

and

needs

to

be

done

thoroughly

.

Slide110

The

words

used to obtain consent from the mother set the scene on how she will perceive the importance of the examin

ati

o

n

.

For

example,

if

the

m

i

d

w

i

f

e

says

‘I

need

to

take

a

quick

look

over

your

baby

to

see

if

everything

is

alright’,

this

could

imply

that

the

e

x

a

m

i

n

a

t

i

o

n

is

being

done

quickly

because

it

is

not

really

necessary

but

is

routine

and

has

to

be

done.

Slide111

If the midwife says ‘Will you please allow me to examine your baby in detail, so that if I find anything that I think will affect your baby’s health, I can tell you about it and then, with your permission, ask for a second opinion?’, this question offers a detailed explanation of the midwife's intention in gaining consent.

What

the midwife says should be documented alongside details of examination findings, parental reaction, referral details and support provided.

Slide112

1.2 The daily examination screen

This

examination is usually performed daily while the baby remains in hospital and continues on a more intermittent basis once the baby is in community until discharge to the care of the health visitor. A healthy term baby weighs approximately 3.5 kg, has a clear skin, good muscle tone, cries, feeds well, keeps warm and sleeps.

Slide113

The midwife will continue the health screening process by always asking the mother how her baby is.

Carefully

listening to her answer is a crucial part of the examination and her response will often dictate in what order the midwife performs the examination, starting with any areas of concern. Recording what the mother has said (and how she said it) is helpful for other health care practitioners who will see the baby at a future time.

Slide114

1.2.1 Breathing

The

midwife should observe the baby's respiratory rate that involves the diaphragm, chest and abdomen rising and falling synchronously. It

should be

e

x

p

l

a

i

n

e

d

to

the

parents

that

babies

have

a

periodic

breathing

pa

tt

ern

that

is

erratic,

w

i

t

h

respirations

being

shallow

and

irregular,

interspersed

w

i

t

h

brief

10–15

second

periods

of

apnoea

.

Slide115

Given

that babies are either obligatory (required) or preferential nose-breathers, it is important to check that their nostrils are clear of dried secretions. Tickling the edge of the nostrils with cotton wool can induce sneezing, which aids some clearance. An irritable baby with excessive snuffles and sneezing could indicate opiate withdrawal.

Slide116

In

an assessment of health, the midwife must consider that respiratory difficulties can occur because of neurological, metabolic, circulatory or thermoregulatory dysfunction as well as infection, airway obstruction or abnormalities of the respiratory tract itself.

Slide117

1.2.2 Thermoregulation – the importance of keeping warm

One of the midwife's priorities is to make sure the baby is maintaining a body temperature within normal

parameters.According to Brown and Landers (2011), a neutral thermal environment is one that is neither too hot nor too cold and enables the baby to use the minimal amount of energy to stay warm.

Slide118

Babies are individuals, with each one having their own metabolic rate, so the clinical acceptable temperature range of

36.5–37.5°C

is wide. In the first week of life core temperature can be unstable as the heat- regulating center in the hypothalamus and medulla oblongata is attempting to adapt from a hot water intrauterine environment to an cooler extra uterine air environment with concurrent threats of heat loss via radiation, conduction, evaporation and convection.

Slide119

Cooling babies are unable to shiver and instead

attempt

to maintain body heat by a means of non-shivering thermogenesis whereby they utilize brown fat and simultaneously increase their metabolic rate by increasing glucose and oxygen consumption to make more energy, carbon dioxide and heat

Slide120

For this process of aerobic glycolysis to function effectively, the baby needs available oxygen and glucose.

As

oxygen is consumed, energy can be made in the absence of, or with minimal amounts of oxygen, which is referred to as anaerobic glycolysis, however the amounts of glucose to maintain this form of energy production is more than 20 times greater to make the same amount of energy as in aerobic glycolysis.

Slide121

Hence the baby becomes hypoxic and may begin to show signs of respiratory distress.

England

(2010a) argues that a transient expiratory grunt may be one of the first respiratory signs of cooling. Nasal flaring, tachypnea, sternal or subcostal recession, are all signs of respiratory distress that may follow. Hence the importance of listening to how the mother or father describes the baby.

Slide122

The

first step is to observe the baby overall and feel the head and chest to gather a general sense of how warm the baby

is.Follow this by the use of a thermometer via the axilla, tympanic membrane (ear), or in the groin.

Slide123

A clothed term baby should maintain its body temperature satisfactorily provided the environmental temperature is draught- free, sustained between 18 °C and 21 °C, nutrition is adequate and movements are not restricted by tight

swaddling.

Inadequate clothing or/and being inadvertently left exposed is a common cause of heat loss. If the baby is cooling, skin-to-skin contact with the mother should be initiated immediately.

Slide124

The

baby's temperature and general condition should be reviewed after 30

minutes.Blackburn (2007) argues that pyrexia (37.7 °C and above) in a term baby may indicate infection; however, hyperthermia can occur if the baby is exposed to an inappropriate heat source (placed in a sunny window) or dressed inappropriately for the ambient temperature.

Slide125

Feet-to-foot placing of the baby in the cot in the supine position has contributed to the reduction in overheating and associated sudden infant death syndrome (Foundation for Sudden Infant Death 2013).

Over-heating

increases metabolic rate and can draw upon supplies of glucose and oxygen to maintain the required energy level. Respiratory distress may follow unless the baby is allowed to cool slowly.

Slide126

Slide127

1.2.3 Skin care

Although sterile at birth, the skin, when exposed to air is quickly colonized by microorganisms, which produce a pH of 4.9, creating an acid mantle that protects the skin from infection

. Vernix caseosa should be allowed to absorb into the skin because it is a highly sophisticated mixture of proteins and fatty acids that produce an antibacterial and antifungal skin barrier.

Slide128

Gordon and Lomax (2011) assert that the midwife should not be tempted to apply anything to a post-term skin that is dry and cracked, because within a few days of peeling, perfect skin will be revealed beneath.

Skin-to-skin

contact just after birth and during subsequent feeding (to include formula-fed babies too) is an excellent way to colonize the baby's skin with friendly bacteria. Great care must be provided to maintain the integrity of the lipids (fats) that seal each skin cell.

Slide129

Chemicals used in manufactured baby skin products can irrevocably damage epidermal lipids and lead to trans-epidermal water loss.

It

is recommended by Trofer (2010) that for the first month of life it is safer to bath all babies in plain water once or twice a week only. Cotton wool balls should be used for baby cleansing (top and tail).

Slide130

According to Gordon and Lomax (2011), the midwife should inspect the skin for rashes, septic spots,

excoriaor

abrasions. Seborrhoeic dermatitis (cradle cap) is commonly seen on the scalp of the newborn, but can occur in the axillae, groins and nappy area. It presents with scaly lesions that are greasy to the touch and thought to be as a response to irritants.

Slide131

Skin rashes such as erythema

toxicum

that occur within 72 hours of birth as a red blotchy rash, usually over the face and trunk, may be a sign of over-heating. Removing some of the baby's clothing/bedding will usually resolve it.

Slide132

Parents should be advised to file their baby's nails and not use scissors or bite them off to keep them short

.

The umbilical stump is rapidly colonized, necroses and separates by a process of dry gangrene, which usually takes between 7 and 15 days.

Slide133

The cord represents a portal of entry for infection (especially Escherichia coli as a result of contamination from stools) and must be observed for any signs of redness in the surrounding abdominal skin, referred to as an umbilical flare.

If

the flare begins to spread and extend up the abdomen, this must be reported immediately as antibiotic therapy will be required.

Slide134

1.2.4 Cardiovascular system and blood physiology

The Resuscitation Council (2011) recommends that the umbilical cord is not clamped for at least the first minute

after birth, to allow oxygenated blood to be transferred from the placenta to the baby. As a result, the total circulating blood volume at birth may exceed 80–90 ml/kg and ward off neonatal iron-deficiency anemia.

Slide135

The

hemoglobin

level may also be in excess of 18–22 g/l. The red cell count (5–7 ×1012/l) may contribute to the development of physiological jaundice.The white cell count is high initially (18.0 ×109/l) but decreases rapidly.

Slide136

According to

Lwaleed

and Kazmi (2009), the blood clotting system is immature because there is no trans placental passage of coagulation proteins from the mother, so all levels of blood clotting reflect fetal synthesis which is completed before the 30th gestational week.

Slide137

Vitamin K is poorly transferred across the placenta, and due to the low amount in breast milk the incidence of classic hemorrhagic disease of the newborn (HDN) occurring within the first week of life

is an enhanced

in babies who are exclusively breastfed, until the bowel becomes colonized by E. coli and the Vitamin K-dependent clotting factors II (prothrombin), VII, IX and X can be synthesized in the presence of bile salts.

Slide138

Vitamin K (intramuscular or oral suspension) is available to all babies in the UK as a prophylactic precaution against

HDN.

Early onset HDN (within first 24 hours) is exclusively caused by trans placental passage of anticoagulant medicines that inhibit Vitamin K activity. In this situation the baby will be prescribed a therapeutic dose of Vitamin K via intramuscular injection (Lwaleed and Kazmi 2009).

Slide139

1.2.5 Renal system

About 20% of babies will pass urine in the birthing room and this should be noted.

Ninety per cent will void by 24 hours of age and 99% by 48 hours. The rate of urine formation varies from 0.05 to 5.0 ml/kg/hour at all gestational ages with a range of 25– 300 ml/kg/day. The commonest cause of initial delay or decreased urine production is inadequate perfusion of the kidney and the kidneys are immature and the glomerular filtration rate is low, but mature within the first month of life.

Slide140

Tubular

reabsorption capabilities are also limited, which renders the baby unable neither to concentrate or dilute urine adequately, nor to compensate for high or low levels of sodium, potassium and chloride in the blood.

Slide141

Urate

crystals may cause red brick staining in the nappy, which is usually a sign of under-

hydration.It is the midwife's responsibility to assess whether the urine output falls within acceptable parameters by asking the mother about the character of the baby's wet nappies given that delay in urine production/passage may be due to physiological stress, intrinsic renal abnormalities or obstruction of the urinary tract.

Slide142

The midwife should check the records for antenatal scan findings that may identify abnormality such as the presence of

oligohydramnios

, which may indicate problems with passing urine as a fetus. Many syndromes involve kidney function, especially those babies with low set ears, abnormal genitalia, anal atresia and lower spine anomalies.

Slide143

Fox

et al (2010) argue that the baby should be assessed for signs of dehydration, infection and a palpable abdominal bladder with referral to the registrar for further investigations as necessary

.

Slide144

1.2.6 Gastrointestinal system

The gastrointestinal (GI) tract of the neonate is structurally complete, although functionally immature in comparison with that of the adult (Blackburn 2007).

The mucous membrane of the mouth is pink and moist. The teeth are buried in the gums and ptyalin secretion is low.Sucking and swallowing reflexes are coordinated.

Slide145

The

tongue may be coated with milk plaques, which should be distinguished from the fungus Candida

albicans, which will need treatment. The stomach has a small capacity (15–30 ml), which increases rapidly in the first weeks of life. The cardiac sphincter is weak, predisposing to regurgitation of milk.

Slide146

Gastric acidity, equal to that of the adult within a few hours

after

birth, diminishes rapidly within the first few days and by the 10th day the baby is virtually achlorhydric (without acid), which increases the risk of infection from the mouth. Gastric emptying time is normally 2–3 hours.

Slide147

Enzymes are present, although there is a deficiency of amylase and lipase, which diminishes the baby's ability to digest compound carbohydrates and fat, therefore no sandwiches are allowed! When milk enters the stomach, a

gastrocolic

reflex results in the opening of the ileocaecal valve. The contents of the ileum pass into the large intestine and rapid peristalsis means that feeding is often accompanied by reflex emptying of the bowel.

Slide148

Bowel sounds can be heard on auscultation within one hour of birth. Sterile meconium present in the large intestine from 16 weeks' gestation, is passed within the first 24 hours of life and should be totally excreted within 48–72 hours.

As

a result of air entering the gastrointestinal (GI) tract, E. coli colonizes the bowel and the stools become brownish- yellow in colour and odorous. Once feeding is established the faeces become yellow.

Slide149

The consistency and frequency of stools reflect the type of feeding

.

Digested breast milk produces loose, bright yellow and inoffensive acid stools. The baby may pass 8–10 stools a day. The stools of the formula-fed baby are paler in colour, semi-formed, less acidic and have a more offensive odour.

Slide150

A

melaena

stool contains digested blood from high in the GI tract, has a tar-like appearance and may be caused by blood swallowed at birth, bleeding maternal nipples or damage to the baby's GI tract itself. Low GI bleeding may result in frank blood, which is blood that can be seen in the stools with the naked eye and may be related to HDN (Lwaleed and Kazmi 2009).

Slide151

Glycogen stores are rapidly depleted so early feeding is required to maintain normal blood glucose levels (2.6–4.4

mmol

/l). Weight loss is normal in the first few days but more than 10% body weight loss is abnormal and requires investigation. Most babies regain their birth weight in 7–10 days, there after gaining weight at a rate of 150–200 g per week.

Slide152

1.2.7 Immunity

According to Paterson (2010), neonates demonstrate a marked susceptibility to infections, particularly those gaining entry through the mucosa of the respiratory

and gastrointestinal systems. Localization of infection is poor, with minor infections having the potential to become generalized very easily. The baby has some immunoglobulins at birth but the sheltered intrauterine existence limits the need for learned immune responses to specific antigens.

Slide153

There

are three main

immunoglobulins: IgG, IgA and IgM.Immunoglobulin G is small enough to cross the placental barrier. It affords immunity to specific viral infections and at birth the baby's level of IgG is equal to or slightly higher than those of the mother.

Slide154

This provides passive immunity during the first few months of life and by 2 months the baby is able to produce a good response to protein vaccines hence the timing for the commencement of routine childhood immunization

programmes

(Paterson 2010).Immunoglobulin M (IgM) and A (IgA) can be manufactured by the fetus and raised blood levels of IgM at birth are suggestive of intrauterine infection.

Slide155

This relatively low level of

IgM

is thought to render the baby more susceptible to gastroenteritis. Levels of IgA are also low and increase slowly.Colostrum and breast milk provide the baby with passive immunity in the form of Lactobacillus bifidus, lactoferrin, lysozyme and secretory IgA.

Slide156

1.2.8 Reproductive system: genitalia and

breasts

In both sexes, withdrawal of maternal oestrogens results in transient breast engorgement, sometimes accompanied by a milky secretion around the 5th day. Girls may develop pseudo-menstruation, a blood-stained discharge in the nappy, for the same reason. Both findings are insignificant but can be concerning for parents and an appropriate explanation should dispel any anxieties.

Slide157

1.2.9 Skeletomuscular system

The

muscles are complete, subsequent growth occurring by hypertrophy rather than by hyperplasia. Palpation around the sternomastoid muscle can identify a developing haematoma that feels hard to the touch and is referred to as a tumour.The long bones are incompletely ossified to facilitate growth at the epiphyses.

Slide158

(congenital torticollis).

The head may be held to one side and is the result of traction and tearing of the muscle.

Physiotherapy referral will be made once diagnosed.

Slide159

congenital torticollis

Slide160

Thank you 

Slide161

Lecture 6

1.3 The neonatal and infant physical examination (NIPE

)Performed within the first 72 hours of birth, this examination specifically screens for congenital heart disease (CHD), congenital cataract, devel

opme

n

t

al

dysplasia

of

the

hip

(DDH)

and

undescended

testes,

usually

in

that

order.

Slide162

This

is not a top-to-toe examination but more of an opportunistic approach when the baby is quiet enough to support auscultation of

the chest

and

awake

sufficiently

to

open

its

eyes.

Slide163

1.3.1 Examination of the heart

Sinha

et al (2012) argue that the best time for the heart examination to

be

conducted

is

w

h

e

n

the

baby's

major

physiological

adaptations

are

complete,

so

48

hours

post

birth

is

ideal

.

Half

of

the

k

n

o

w

n

cases

of

congenital

heart

disease

are

detected

by

antenatal

ultrasound

scan

so

the

postnatal

physical

e

x

a

m

i

n

a

t

i

o

n

is

the

only

other

means

of

early

detection.

Less

than

50%

of

heart

defects

are

actually

detected

because

many

heart

conditions

are

asymptomatic

and

trivial.

Slide164

Blake

(2008) recommends that reading the case notes for details of the present pregnancy, perinatal events and

neonatal

e

x

a

m

i

n

a

t

i

o

n

s

already

performed,

is

a

necessary

prerequisite

.

reports

that

maternal

congenital

heart

disease

o

ff

ers

15%

p

r

e

v

a

l

e

n

c

e

to

the

w

o

m

a

n

'

s

children

compared

to

1%

in

the

general

population.

When

one

child

is

a

ff

ected

the

sibling

recurrence

risk

is

3%,

especially

for

a

high

p

r

e

v

a

l

e

n

c

e

condition.

Slide165

Maternal medications such as anticonvulsants (phenytoin) and amphetamines are highly suspected teratogens.

Excessive

maternal alcohol intake may cause fetal alcohol syndrome in which VSD, PDA and the tetralogy of Fallot are commonly seen. Maternal diabetes increases the prevalence of transposition of the great arteries (TGA), VSD, PDA and cardiomyopathy. Sinha et al (2012) report that heart defects are common in chromosomal disorders, to include trisomy 13,18, 21.

Slide166

The cardiovascular examination

Gill and O'Brien (2007)

recommend that the heart itself should technically be left until last with auscultation as the final step, however auscultation is ineffectual if the baby starts to cry, so many examiners listen to the heart earlier in the examination. The mother's view is invaluable and is treated as significant unless proven otherwise. Using words to describe her baby as happy, cranky, responsive, sleepy, floppy can provide useful information on the baby's neurological and homeostatic state, especially how her baby responds physically to taking a feed.

Slide167

Inspection

England

(2010c) believes that inspection is the most important skill because it yields more information about the baby's cardiovascular be

hav

i

o

u

r

and

therefore

should

not

be

rushed

.

The

e

x

a

m

i

n

e

r

should

look

at

the

sleeping/resting

baby's

general

appearance

and

co

m

p

a

r

e

g

e

st

a

t

i

o

n

al

a

g

e

w

i

t

h

w

e

i

g

h

t

a

n

d

s

i

z

e

,

as

s

m

a

ll

n

e

s

s

co

u

l

d

i

n

d

i

c

a

t

e

g

ro

w

t

h

d

i

s

r

up

t

i

o

n

at

t

h

e

t

i

m

e

w

h

e

n

m

a

j

o

r

or

g

a

n

s

w

e

r

e

e

v

o

l

v

i

n

g

Slide168

The examiner should question whether the baby has any

dysmorphic

features indicative of chromosomal abnormalities that are associated with heart defects. Once the baby's chest is undressed, breathing can be assessed. The rate should be counted for over a minute as breathing tends to be irregular. Central cyanosis needs urgent management. Pallor may precede respiratory distress, but again is difficult

to assess

Slide169

And

as Bedford (2011) argues, an oxygen saturation of haemoglobin <95% is abnormal and merits cardiologist assessment.It is wise to always check saturation levels pre and post ductal so if the baby has a PDA, proximal (hand) saturations may be within normal limits and post-ductal levels (foot) will be much lower.

Slide170

England

(2010a) believes that respiratory distress may be a sign of cardiac compensation so it is important to inspect for asymmetrical chest wall

movements,:Tachypnoea > 60 breaths per minute, nasal flaring, sternal or costal recession, the use of respiratory accessory muscles, head bobbing and the presence of an expiratory grunt.

Slide171

Capillary refill greater than 2 seconds is abnormal but oxygen therapy should always be considered cautiously as it may close a PDA, which could be is acting as a life-saving conduit in certain heart conditions (

Horrox

2002; Bedford 2011).

Slide172

 

Palpation

Palpation of the peripheral pulses for rhythm, strength, volume and character then follows. The easiest pulse to feel is the brachial

at the

antecubital

fossa

.

The

rate

should

be

counted

over

a

period

of

10

seconds.

Palpation

of

the

femoral pulses

is

a

di

ffi

cult

task

.

Many

e

x

a

m

i

n

e

r

s

apply

too

much

pressure

to

the

artery

and

in

e

ff

ect

they

eradicate

the

pulse

wave.

Slide173

Strong

arm pulses and weak leg pulses suggests

coarctation of the aorta (COA). If the right brachial artery pulse is stronger than the left brachial artery pulse, this could suggest a COA where the constriction is proximal to the left subclavian artery. Equal but bounding brachial pulses are found in PDA with a wide but diminishing pulse pressure in the lower limbs. A weak thready pulse is found in congestive heart failure (CHF) and in circulatory shock.

Slide174

In

a regular sinus rhythm, the rhythm and rate of the heartbeat are normal for the age of the baby. In sinus tachycardia, with beats above 160 per minute, first consider pyrexia. Gill and O'Brien (2007) contend

that

the

pulse

rate

will

accelerate

a

pp

ro

x

i

m

a

t

e

l

y

10

beats

per

minute

for

every

1°C

rise

in

temperature.

Hypoxia,

circulatory

shock,

CHF

and

thyrotoxicosis

are

other

possible

causes.

Slide175

Sinus

bradycardia is defined as beats below 80 per minute. Hypothermia, hypoxia, increased intercranial pressure and hypothyroidism may be causative factors.The m

idw

i

f

e

c

an

p

l

a

c

e

t

h

e

i

r

o

p

e

n

h

a

n

d

o

n

t

o

t

h

e

p

r

e

cor

d

i

u

m

,

w

h

i

c

h

i

s

t

h

e

a

r

e

a

o

v

e

r

t

h

e

sternum

and

ribs

to

the

le

ft side

of

the

chest.

Slide176

A

palpable precordium murmur is referred to as a thrill, which can sometimes be seen with the naked ey

e, is

c

h

a

r

a

c

t

e

r

i

st

i

c

o

f

h

e

a

r

t

disease

w

i

t

h

a

high

volume

overload

such

as

a

left-to-right

shunt

through

the

ductus

arteriosus

and

is

always

of

diagnostic

value.

Slide177

Right ventricular enlargement is best sought with one's fingertips placed between the 2nd, 3rd and 4th ribs along the

left

sternal edge. The apex beat is found in the 4th intercostal space along the mid-clavicular or nipple line. A diffuse, forceful and displaced apex beat, usually caused by hypertrophied heart muscle is relatively rare and described as a heave

Slide178

Palpation

of the upper abdomen that reveals an enlarged liver (greater than 1 cm below the costal margin) may indicate heart failure

as the liver acts as a reservoir of blood because the heart cannot cope with the required workload. An enlarged spleen, palpable in the left upper quadrant of the abdomen, complements this clinical picture.

Slide179

 

Auscultation

By the time inspection and palpation have been performed much of the information the baby can supply has been obtained and auscultation is the last step. It is recommended that a paediatric stethoscope should be used and its diaphragm (the flat side) utilized at all auscultation sites to hear the high-pitched sounds of a systolic murmur.

Slide180

The

sternum, clavicles and ribs, to include the costal and intercostal spaces, are important landmarks as well as the heart structures. There are two upper landmarks each side of the upper sternum. The

right

sternal

,

2nd

intercostal

space

is

the

aortic

area.

This

is

referred

to

as

the

upper

right

sternal

border

(URSB).

Slide181

The

left sternal 2nd intercostal space is the pulmonary area and

is

k

n

o

w

n

as

t

h

e

upp

e

r

l

e

ft

st

e

r

n

al

b

or

d

e

r

(

U

L

S

B

)

.

The baby should then be turned onto its right side and the heart should be examined for murmurs along the route of the aorta on the

left

side of the spine from the scapular area to below the ribs

.

The examiner is listening for turbulence of blood in the newly developed collateral circulation caused by COA.

Slide182

Each

cardiac cycle has two heart sounds that can be heard through a stethoscope when applied to the chest wall. The

first

h

e

a

r

t

s

o

u

n

d

(

S

1)

i

s

k

n

o

w

n

as

‘

l

u

b

’

a

n

d

i

s

d

e

s

cr

i

b

e

d

as

long

and

booming

and

occurs

w

h

e

n

the

a

t

r

i

v

e

n

t

r

i

c

u

l

ar

(AV)

valves,

the

tricuspid

and

bicuspid

(mitral)

valves

are

closing

at

the

beginning

of

v

e

n

t

r

i

c

u

l

ar

contraction

(systole).

Slide183

The

second heart sound is ‘dub’; it is short and sharp, and reflects closure of the semi lunar valves of the aorta and pulm

onary

a

r

t

e

r

y

,

at

t

h

e

b

e

g

i

nn

i

n

g

o

f

v

e

n

t

r

i

c

u

l

ar

r

e

l

a

x

a

t

i

o

n

(diastole

).

A heart murmur is an additional noise heard during the cardiac cycle.

Absence of

a murmur

does not exclude congenital heart disease.

Slide184

The

location, timing in the cycle, grade, duration or rhythm, quality and radiation of the murmur should be assessed.

Slide185

Finally

Thorough

documentation should reflect inspection, palpation and auscultation findings.A cardiac murmur if present should include details of location, timing in the cycle,

grade,

character

and

be

illustrated

.

Slide186

If

the baby looks and feels healthy but the midwife can hear extra heart

sou

n

d

s

t

h

at

w

a

rr

a

n

t

a

s

e

co

n

d

o

p

i

n

i

o

n

,

r

e

f

e

rr

al

should

be

made

to

the

registrar,

w

i

t

h

the

parent's

informed

consent

.

As

a

result

of

the

registrar's opinion,

the

parents

should

be

informed

that

at

this

moment

in

time

their

baby's

heart

appears

healthy

or,

a

l

t

e

r

n

a

t

i

v

e

l

y

,

needs

further

i

n

v

e

st

i

g

a

t

i

o

n

Slide187

Chapter

t

wo

Resuscitation of the healthy baby at

birth

T

he

importance

of

drying,

airway

management

and

establishment

of

breathing

Slide188

lecture 8

2.1

Drying the baby

Slide189

Thoroughly drying of the baby is always the

first step to management of resuscitation at birth.

Taking the time to dry the baby's head, to include the face alongside the arm and leg creases, is sometimes not performed as thoroughly as it should be. Heat loss and cooling of the baby is inevitable but failure to spend time doing this task meticulously can result in the baby using oxygen and glucose to maintain or raise its metabolic rate.

Slide190

Also, in order to place a baby in skin-to-skin contact with its mother, the baby needs to be thoroughly dry; furthermore, the mother needs to be dry so that the baby can benefit from conductive heat gains

.

During this time of drying, which can take up to a minute, the midwife should assess the baby for its colour and muscle tone. The Apgar score is used as a communication tool to inform other team members should it be necessary. A score at 1, 5 and 10 minutes is entered into the record (Nursing and Midwifery Council [NMC] 2009).

Slide191

Slide192

Most babies will be blue at birth, which indicates that there is accumulation of carbon dioxide (CO2) in the blood and tissues.

It is important to remember that CO2 is a stimulant to the respiratory

center in the medulla oblongata, so blue skin is a normal physiological sign and most babies will not require resuscitating. However, too much CO2 will depress respiration and this may account for why the baby may be showing little or no respiratory effort.

Slide193

White or

modeled

grey skin is an indication of peripheral shut down as the baby is responding to low oxygen levels and is conserving the available oxygen for the heart and brain by diverting blood away from the skin and other non-essential organs (Leone and Finer 2012).This is the baby that needs to be thoroughly dried as their reserves of oxygen cannot be wasted on attempting to keep warm. So, the rule of thumb must be the poorer the colour, the more thorough the drying process should be.

Slide194

The midwife should not let their own anxiety or that of others hurry them in this drying process.

All

wet towels should be discarded and the baby covered in warmed dry ones. Identification name bands should also be placed on the baby in the hospital setting, should there be need to separate the baby from the mother at any time.

Slide195

The assessment of muscle tone indicates to what degree the nerves are stimulating the skeletal muscles. When a baby is well toned for its gestational age, this signals that the baby is generally in good condition even though they may not be breathing.

A baby that is both white and floppy reflects the possibility of long-term hypoxia as a result of the

labour process or some other co- existing factor, for example, infection.

Slide196

Slide197

The midwife should simultaneously assess whether the baby is breathing by assessing the presence or absence of chest movement and any other signs, such as gasping

.

If the baby is crying, the baby has an open airway. This assessment is followed by auscultation of the chest to assess the heart rate.

Slide198

Dawson et al (2010) argue that the midwife needs to establish whether there is a heart rate and, if so, if it is above or below 60 beats per minute (

bpm

). In the first minute, the average heart rate of a healthy term baby is below 100 bpm, however by the second minute it has usually risen to around 140 bpm and by 5 minutes to 160 bpm.Dawson et al (2010) consider that the heart rate is the most important indicator of health in newborn babies and this is why it is so important to make a regular assessment, hence the 1 and 5 minutes time- frame of the Apgar score (Apgar 1952).

Slide199

During this time of assessment, the umbilical cord can remain uncut so that extra red blood cells can be transported to the baby and enhance the baby's oxygen-carrying capacity.

Even

if the heart rate is really slow, opening the airway must be the first task to achieve.

Slide200

Without an open airway, the baby has no way of being oxygenated, as this is the only means of assisting the heart to function.

Hence

the midwife should note the Airway, Breathing and Circulation of resuscitation when C must follow B and B must follow A.

Slide201

2.2 Airway management and breathing

Slide202

2.3 Difficulties in establishing an open airway

If there is no chest movement

after five inflation breaths, this indicates that the airway is not open, so the alveoli will remain filled with lung fluid. This is a good time to consider calling for medical assistance because failure of the following interventions may result in the need for tracheal intubation (RCUK 2011). In the home, paramedic support will take longer to arrive so early anticipation of problems is considered good practice.

Slide203

If the baby has a poor

colour

and muscle tone, this may indicate that the position of their head has not been maintained in the neutral position and there is a definite need for a second person's help both to hold the head and apply jaw thrust. The jaw of a floppy baby can fall backwards and as the tongue is attached to the jaw, the tongue falls back into the airway, blocking the airway. A second person, with their fingers on each side of the jaw, can push the jaw forwards and hold it in that position.

Slide204

Slide205

This is an easily performed

maneuver

because the baby does not offer any muscle tone resistance. Five inflation breaths should then be given. If there is still no chest movement, suction to the oropharynx under direct vision using the light of a laryngoscope may be considered should there be an obstruction.

Slide206

Video

Slide207

Occasionally if there is maternal bleeding at the birth, some blood may have entered the baby's mouth, initially as fluid but then over time may have

clotted

. After this intervention five inflation breaths are given. If not successful, an oropharyngeal (Guedel) airway can be inserted to open the airway mechanically, especially in babies who may have congenital abnormalities such as choanal atresia and/or micrognathia

Slide208

The correct sizing of the airway is vital

.

When held along the line of the lower jaw with the flange at the level of the middle of the lips, the end of the airway should reach the angle of the jaw. The airway is slipped over the tongue in the same attitude that it will finally lie. The midwife should make sure that the tongue is not pushed back into the back of the mouth

Slide209

Once in situ the mask can be placed over the airway (both the mouth and nose) and a further five inflation breaths should be given. If the chest fails to rise

after

these interventions, intubation of the trachea will be required and an experienced neonatal registrar will be needed to assist.

Slide210

2.4 parental support through effective communication

Resuscitation

of the baby occurs in the presence of the parents, so a clear, simple explanation in a calm tone should be given to inform and support them during the process. Parental stress and anxiety will affect how the couple are able to receive information and respond to it. Non-verbal communication is more influential in informing the parents of the midwife's state of mind.

Slide211

Documentation should always reflect obtained consent and specific aspects of the resuscitation, including any interactions between the parents and

multi/professional

team that have occurred (NMC 2008, 2009, 2012). It is important to recognize that records should always be sequentially detailed enough, should they be required to support the midwife's actions at a later date and read out in court or at the NMC.