Newborn Resuscitation and Apgar Scoring

• Infants not making respiratory effort and a heart rate of less than 100 bpm may need laryngotracheal suctioning.
• Always apply suction while removing the tube.
• Flicking feet, rubbing the back, and towel drying are acceptable methods of stimulating a newborn.
• Slapping, shaking, spanking, and holding a newborn upside down are dangerous and contraindicated.
• Warming, clearing the airway, and stimulating non-meconium-stained infants occur within 30 seconds of birth.

Apgar Score

• Introduced by Virginia Apgar in 1952.
• Evaluates newborns based on these five factors: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color
• Evaluate newborns immediately after birth.
• Used as a predictive index of neonatal mortality and neurologic outcome.
• It is best-established index of immediate postnatal health.
• Scoring is done 1 minute after delivery.
• It evaluates future interventions.
• Don't interrupt resuscitation for Apgar scoring.
• Scoring done again at 5 minutes of age.
• This gives information about the infant's ability to recover from the stress of birth.
• If the 5-minute score is less than 7, additional scores are obtained every 5 minutes
• Survival is unlikely if the score is 0 after 10 minutes.
• Heart rate is the most important sign because it indicates life or death.
• Failure of heart rate to respond to resuscitation is an ominous sign.
• Heart rate appears to be least affected by developmental maturity.
• Skin color has the weakest correlation with the other four components.
• Color does not reliably correlate with umbilical arterial pH, carbon dioxide pressure, and base excess.
• A score of 0 indicates:
  • No heart rate
  • No respiratory rate
  • Pale blue skin
  • No response to stimuli
  • Limp muscle tone
• A score of 1 indicates:
  • Heart rate less than 100 bpm
  • Weak, irregular breathing
  • Body pink, extremities blue
  • Grimace upon stimulation
  • Some muscle flexion
• A score of 2 indicates:
  • Heart rate over 100 bpm
  • Strong cry
  • Completely pink skin
  • Cry, cough, or sneeze upon stimulation
  • Well flexed muscles

Gestational Age and Size Assessment

• Ideally done before the neonate is 12 hours old.
• Allows the best reliability for infants less than 26 weeks of gestational age.
• Requires considering these three factors: gestational length, prenatal ultrasound evaluation, physical and neurological examinations
• Postnatal exams for determining gestational age include the Ballard score.
• The Ballard score is based on external physical findings and neurologic criteria.
• Vernix caseosa is a gray-white cheeselike substance.
• Vernix is abundant in preterm infants.
• Lanugo, the fine hair on premature infants mostly over the shoulders, back, forehead, and cheeks, suggests an even younger gestational age.
• Weight, length, and head circumference are plotted on a standard newborn grid.
• Weight less than the 10th percentile for gestational age is small for gestational age.
• Weight more than the 90th percentile is large for gestational age.
• Consider race and gender-specific charts.
• Abnormal gestational age and size are associated with many neonatal diseases.

Neonatal Physical Examination

• Physical exam is done generally from head-to-toe.
• The order of examination is modified to establish critical information such as listening to the heart and lungs before the infant gets agitated.

Vital Signs

• Neonatal blood pressure ranges correlate with the clinical situation
• Heart rate is assessed best with a stethoscope for the apical beat over the precordium.
• In the delivery room, feeling the umbilical cord can quickly estimate heart rate.
• Normal heart rate is 120-170 bpm.
• A term infant in deep sleep may decrease to 80 or 90 bpm.
• An infant undergoing a painful procedure have a heart rate greater than 200 bpm.
• A neonate greater than 35 weeks has greater heart rate variability.
• Values for Vital Signs in the Neonatal Patient

General Inspection

• The infant should be examined lying quietly and unclothed in a neutral thermal environment.
• Body position/symmetry and muscular activity provide information about possible birth trauma
• An infant who does not move their arms symmetrically might have a clavicle fracture.
• The infant’s skin is an indicator of intravascular volume, perfusion status, or both.
• Capillary refill time should be less than 3 seconds.
• Perfusion should be good and skin color pink.
• Blue hands and feet in the immediate postnatal period indicate decreased perfusion.
• True cyanosis shows blue or dusky mucous membranes and circumoral area.
• Mottling is irregular areas of dusky skin with pale skin, suggesting hypotension or anemia.
• A ruddy appearance is associated with a high hematocrit value or polycythemia.
• Yellow associated with mild to moderate jaundice common after the first day; jaundice on the first day always is an indication for evaluation.
• Yellow-green staining suggests meconium-stained amniotic fluid in utero.
• Mongolian spots over the sacrum/buttocks commonly occur in Black/Asian infants and are often confused with bruising

Respiratory Function

• The normal newborn respiratory rate is 40-60 breaths per minute.
• Note irregular respirations.
• If the rate is more than 60 normalize in several hours, there may be transient tachypnea of the newborn.
• Newborns display an irregular breathing pattern.
• Periodic breathing is an irregular pattern of intermittent pauses longer than 5 seconds.
• Apnea is when breathing ceases for over 20 seconds.
• Apnea is associated with cyanosis, bradycardia, pallor, and hypotonia.
• Apnea is associated with nonspecific symptoms of diseases.

Signs of Respiratory Distress

• Silverman scoring system considers multiple factors to quantify an infant's distress.
• Nasal flaring occurs during inspiration when the muscles of the nasal passages result in reduction in airway resistance.
• Grunting is an expiratory noise to increase positive end-expiratory pressure.
• Retractions of the chest wall during inspiration may occur in chest regions.
• Retractions usually shows reduced lung compliance but are also associated with obstructive processes.
• Newborn musculature is relatively thin and weak, and the thoracic cage is very compliant.
• Abdominal/thoracic muscles move in parallel or show paradoxical respirations, indicating respiratory distress or a “see-saw” effect.
• Auscultation can prove sometimes to be difficult.
• Abdominal sounds may even transmit to the lungs.
• Asymmetrical sounds may indicate unilateral disease such as pneumothorax.

Chest and Cardiovascular System

• The chest circumference is equivalent to head circumference in a newborn
• Bulging or asymmetry of the chest wall usually indicates important pathologic conditions.
• The point of maximal cardiac impulse (PMI) is the position on the chest wall at which the cardiac impulse can be maximally seen.
• A mediastinal shift caused by a pneumothorax will move the PMI away from the affected side of the chest
• High heart rate variations may be normal depending on gestational age
• Heart murmurs are described as a soft to loud harsh sound
• Palpating pulses provides information such as weak pulses suggesting low cardiac and bounding pulses seen in infants with patent ductus arteriosus and left-to-right shunt
• Brachial and femoral pulses should be equal in intensity and felt
• A pulse oximeter can provide valuable information in the CV system.

Abdomen

• Successful abdominal examination requires a calm and quiet infant.
• The examiner should observe the contour of the abdomen and determine whether it is scaphoid, flat, or distended.
• When examining the abdomen, the examiner should auscultate and palpate over all four quadrants.
• The umbilical cord is yellowish white with three blood vessels.
• The presence of meconium in the amniotic fluid causes a greenish yellow staining of the umbilical cord.
• With an umbilical hernia the intestinal muscles protrude into this weakened tissue.

Head and Neck

• The head is usually the presenting part and often shows evidence of bruising and molding
• In term infants the molding should resolve within a few days.
• Fontanels and suture lines should be soft and should not bulge.
• Soft skull areas that can be compressed like a ping-pong ball are called craniotabes.
• Rarely, edema is attributed to a subgaleal hemorrhage.

Musculoskeletal system, spine and extremities

• The intrauterine environment often affects the extremities and musculoskeletal system
• Many limb and other deformations in the fetus result from intrinsic (fetal) or extrinsic (uterine) factors
• Extra digits may be familial or may be associated with a number of syndromes
• The symmetry and bony structure of the spine are easily examined in newborns.

Cry

• Cry should be assessed for amount of details.
• A piercing, high-pitched cry often has a neurologic injury, drug withdrawal, or increased intracranial pressure.
• Hoarse crying can be associated with laryngeal edema, as in recently extubated infants or hypothyroidism.
• Perhaps the most distinctive cry is associated with a deletion of the short arm of the fifth chromosome.

Neurologic Assessment

• The examiner should note whether the infant responds appropriately to his or her surroundings.

This resource covers key aspects of newborn resuscitation, including suctioning techniques, stimulation methods, Apgar scoring, and gestational age assessment. It addresses critical interventions for meconium-stained infants and factors influencing heart rate. These principles are crucial for effective newborn care.