Neonatal hypoglycaemia
Cause:
Maternal diabetes mellitus
Large or small for gestational age
Prematurity
fetal stress
Symptoms
Jitteriness
Lethargy
Poor feeding
Apnoea
Screening tests done in labour room
G6PD and TSH from cord blood.
Wednesday, 15 October 2014
Tuesday, 14 October 2014
Neonatal resuscitation
Aim: prevention of birth asphyxia and brain damage resulting in failure to initiate and sustain breathing
Anticipate
Adequate preparation
Timely recognition
Quick and correct action
Prerequisite
Trained in neonatal rescitation
Prepare appropriate equipments
close communication between obstetrician and paediatricinan to identify high risk women before labour if possible or high risk newborn during delivery
High risk delivery
Maternal
Antenatal:
Pre-eclampsia, Maternal diabetes, PPROM, Preterm, maternal substance abuse, lack of ANC, Multiple pregnancy, anemia in pregnancy
Rh isoimmunisation
Oligo and polyhydramios
cchronic maternal illness
Teenage pregnancy <18,
Elderly primi >35
Post term pregnancy
Intrapartum
Prolonged labour
Prolonged rupture of membrane delivery interval
Precipitous labour
Cord prolapse
Placental abruption or praevia
Instrumental delivery
Emergency C section
Fetal bradycardia-- hypoxia, acidosis, local anaesthetics, epidural, pethidine to mother, propanolol, MgSo4, fetal heart conduction defect
Meconium stained liquour
Narcotics to mother 4 hours before delivery
General anaesthesia
Chorioamnionitis
Fetal
IUGR
Prematurity
Postmaturity
Congenital anomalies
Multiple pregnancy
Delivery complications
Transverse lie or breech presentation
Chorioamnionitis
foul smelling or meconium stained liqour
antenatal asphyxia with abnormal fetal heart rate pattern, maternal administration of a narcotic within four hours of birth or delivery instrumentation eg forceps vacuum or caesarean
Asphyxia in a neonate can be due to to types of apnoea
Primary: Blue, heart rate increase, rescuscitate easily
Secondary: white floppy, heart rate decreased, BP decrease, require active rescuscitation like intermittent positive pressure ventilation.
APGAR score
Appearance - Blue or pale Pink centrally blue extremities completely pink
Pulse Absent <100bpm >100bpm
Grimace No response grimace on painful stimulus cry, cough, sneeze
Activity Limp some flexion active movement
Respiration absent slow irregular cry vigorous cry
Apgar score 1 minute signanls need for immediate resuscitation
5 minute apgar score indicates response to resuscitation rough prognostic indicator
If <7 at 5 min, repeat every 5 minutes up to 20 minutes to note progress
APGAR score at 20min is a good prognostic indicator for neurological outcome
Physiology of the newborn
There is basically a transition from fetal to Extrauterine life
Initial respiration inflates the lings and fluid in the lungs is absorbed
Clamping of umbilical arteries and veins removes low resistance placenta circulation and increase systemic BP
Lung expands and increases oxygenation so decreasing pulmonary vascular resistanc and increase pulmonary blood flow
Ductuus arteriosus and foramen ovale closes
Birth
Term gestation?
Meconium stained liquour? Yes Routine care:
Breathing or crying? Provide warmth,
Good muscle tone? Dry: remove wet towel, replace with dry
Colour pink? Clear aiway- suck nose and mouth
Position
NO
Provide warmth
Neutral position
Clear airway if necessary
Dry stimulate reposition
Give oxygen if necessary
Evaluate breathing heart rate colour and tone
Apnoeic or HR <100bpm- assess heart rate with stethoscope
Give PPV ( mask ventilation, O2 5L/min
Intubate when mask ventilation inadequate to oxygenate or ventilate
HR <60bpm (count by palpate the umbilicus)
PPV plus chest compression
HR less than 60bpm
Consider epinephrine with or without volume
administered through umbilical vein
If heart rate does not increase and adequate lung inflation not achieved consider DOPE
D- displaced tube (esophagus or right bronchus)
O- Obstructed tube (meconium)
P- patient--- lung disorder eg pneumothorax, shock, birth asphyxia, upper airway obstruction
E- equipment failure- exhausted gas supply
1 minute- 60-65%
2min- 65-70%
3min- 70-75%
4min - 75-80
5min- 80-85%
10min- 85-95
Breathing (ventilation): PPV by bag and mask ventilation required: infant gasping or apnoeic
HR <100
ET intubation if:
Tracheal suctioning for meconium is required
BMV is ineffective or prolonged
Chest compressions are being performed
Chest compressionsa re initiated if the infants heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds
Administration of drugs such as epinephrine and or volume expansion
If the heart rate remains less than 60 beats per minute despite adequate ventilation and chest compressions administration of epinephrine is indicated
Rarely volume expansion or a narcotic antagonist eg naloxone may be useful
THe decision to progress from one step to the nect is determined by the time dependent response of the infant to the applied resuscitiative effort based upon his or her respiration and heart rate
A time allocation of 30 seconds is given to apply the resuscitative procedure evaluate and decide whether to proceed to the nect intervention
Monitoring of oxygen satyration by using pulse oximetry should be performed in infants who are gasoing apnoeic have laboured breathing persistent cyanosis or a heart rate less than 100 beats per minute. No further rescuscitative efforts are needed if he responds with spontaneous respirations and a heart rate of above 100 beats per miute
Equipment
Radiant warmer
Warm towel and blankets kept in the warmer
2 infant masks normal size and small size
A suction device- mucus extractor
Resuscitation bag and mask- self inflating bag
Oxygen source and tubing
suction source and tubing
drugs and fluid
syringes, needles, cannula and IV lines
Endotracheal tubes
Laryngoscopes
Stethoscope
Anticipate
Adequate preparation
Timely recognition
Quick and correct action
Prerequisite
Trained in neonatal rescitation
Prepare appropriate equipments
close communication between obstetrician and paediatricinan to identify high risk women before labour if possible or high risk newborn during delivery
High risk delivery
Maternal
Antenatal:
Pre-eclampsia, Maternal diabetes, PPROM, Preterm, maternal substance abuse, lack of ANC, Multiple pregnancy, anemia in pregnancy
Rh isoimmunisation
Oligo and polyhydramios
cchronic maternal illness
Teenage pregnancy <18,
Elderly primi >35
Post term pregnancy
Intrapartum
Prolonged labour
Prolonged rupture of membrane delivery interval
Precipitous labour
Cord prolapse
Placental abruption or praevia
Instrumental delivery
Emergency C section
Fetal bradycardia-- hypoxia, acidosis, local anaesthetics, epidural, pethidine to mother, propanolol, MgSo4, fetal heart conduction defect
Meconium stained liquour
Narcotics to mother 4 hours before delivery
General anaesthesia
Chorioamnionitis
Fetal
IUGR
Prematurity
Postmaturity
Congenital anomalies
Multiple pregnancy
Delivery complications
Transverse lie or breech presentation
Chorioamnionitis
foul smelling or meconium stained liqour
antenatal asphyxia with abnormal fetal heart rate pattern, maternal administration of a narcotic within four hours of birth or delivery instrumentation eg forceps vacuum or caesarean
Asphyxia in a neonate can be due to to types of apnoea
Primary: Blue, heart rate increase, rescuscitate easily
Secondary: white floppy, heart rate decreased, BP decrease, require active rescuscitation like intermittent positive pressure ventilation.
APGAR score
Appearance - Blue or pale Pink centrally blue extremities completely pink
Pulse Absent <100bpm >100bpm
Grimace No response grimace on painful stimulus cry, cough, sneeze
Activity Limp some flexion active movement
Respiration absent slow irregular cry vigorous cry
Apgar score 1 minute signanls need for immediate resuscitation
5 minute apgar score indicates response to resuscitation rough prognostic indicator
If <7 at 5 min, repeat every 5 minutes up to 20 minutes to note progress
APGAR score at 20min is a good prognostic indicator for neurological outcome
Physiology of the newborn
There is basically a transition from fetal to Extrauterine life
Initial respiration inflates the lings and fluid in the lungs is absorbed
Clamping of umbilical arteries and veins removes low resistance placenta circulation and increase systemic BP
Lung expands and increases oxygenation so decreasing pulmonary vascular resistanc and increase pulmonary blood flow
Ductuus arteriosus and foramen ovale closes
MANAGEMENT OF NEWBORN
Birth
Term gestation?
Meconium stained liquour? Yes Routine care:
Breathing or crying? Provide warmth,
Good muscle tone? Dry: remove wet towel, replace with dry
Colour pink? Clear aiway- suck nose and mouth
Position
NO
Provide warmth
Neutral position
Clear airway if necessary
Dry stimulate reposition
Give oxygen if necessary
Evaluate breathing heart rate colour and tone
Apnoeic or HR <100bpm- assess heart rate with stethoscope
Give PPV ( mask ventilation, O2 5L/min
Intubate when mask ventilation inadequate to oxygenate or ventilate
HR <60bpm (count by palpate the umbilicus)
PPV plus chest compression
HR less than 60bpm
Consider epinephrine with or without volume
administered through umbilical vein
If heart rate does not increase and adequate lung inflation not achieved consider DOPE
D- displaced tube (esophagus or right bronchus)
O- Obstructed tube (meconium)
P- patient--- lung disorder eg pneumothorax, shock, birth asphyxia, upper airway obstruction
E- equipment failure- exhausted gas supply
1 minute- 60-65%
2min- 65-70%
3min- 70-75%
4min - 75-80
5min- 80-85%
10min- 85-95
Breathing (ventilation): PPV by bag and mask ventilation required: infant gasping or apnoeic
HR <100
ET intubation if:
Tracheal suctioning for meconium is required
BMV is ineffective or prolonged
Chest compressions are being performed
Chest compressionsa re initiated if the infants heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds
Administration of drugs such as epinephrine and or volume expansion
If the heart rate remains less than 60 beats per minute despite adequate ventilation and chest compressions administration of epinephrine is indicated
Rarely volume expansion or a narcotic antagonist eg naloxone may be useful
THe decision to progress from one step to the nect is determined by the time dependent response of the infant to the applied resuscitiative effort based upon his or her respiration and heart rate
A time allocation of 30 seconds is given to apply the resuscitative procedure evaluate and decide whether to proceed to the nect intervention
Monitoring of oxygen satyration by using pulse oximetry should be performed in infants who are gasoing apnoeic have laboured breathing persistent cyanosis or a heart rate less than 100 beats per minute. No further rescuscitative efforts are needed if he responds with spontaneous respirations and a heart rate of above 100 beats per miute
Equipment
Radiant warmer
Warm towel and blankets kept in the warmer
2 infant masks normal size and small size
A suction device- mucus extractor
Resuscitation bag and mask- self inflating bag
Oxygen source and tubing
suction source and tubing
drugs and fluid
syringes, needles, cannula and IV lines
Endotracheal tubes
Laryngoscopes
Stethoscope
- Place child in radiant warmer- prevent cold stress
- In neutral position- nose to the ceiling, towel under the neck to support. Maintains airway open.
- Clear airway by suction of FIRST MOUTH the nose.
- Wipe baby dry
- Stimulate the baby by gentle tap on the foot flick in heel or rubbing back briefly
- Repositioned and heart rate is evaluated along with respiration and colour.
- Oxygen if necessary-
- A- head in neutral position and bulb suction in mouth and nose.
- B- tactile stimulation. BMVPosition mask so no air can escape, give 5 inflation breaths to inflate the lungs . Squeeze bag, count 1 2 3, observe for chest wall rising. If it doesnt adjust baby position and repeat 5 inflation breaths
- Then ET tube connected to 100% O2
- C- circulation-- heart rate by listening to apical pulse wih steth, pulse in umbilius or brachial pulse
- Compressions if- cyanotic, increased work of breathing, nasal flaring, tachypnoea, grunting
- D- drugs- depends. Can be Epinephrine, sodium bicarbonate or dextrose. Even O neg blood
- E- environmental temperature by switching on radiant warmer and using warm blankets/ bunny rugs for premature baby
Apnoea- BMV and proper postioning. Ventilate for 30 seconds at a rate of 40-50 times/min
Bradycardia- less than 60bpm or Less than 6 beats in 6 seconds but chest is rising.--
chest compression with 100% oxygen CPAP
Firm support for baby back
Compression on lower 1/3rd sternum.
Use fingertips of middle and index fingers or use distal portion of both thumbs
Compress sternum approx 1/3 AP diameter of chest to count cadence of "one and two and three and breath and "
Reassess baby after 30 seconds
Baby pink, HR>100- adequately resuscitated
Baby cyanosed on ventilation and chest compression, HR 60-100- ET and ventilation with chest compression
If cyanosed on ventilation and chest compression and HR <60 continue ventilation and chest compression along with epinephrine 1:10 000 for inotropic support, 0.01-0.03mg/kg if heart rate is less than 60
Ventilation breaths vs Inflation breaths
Much shorter
Mimic baby's pattern of breathing
35-40 per minute
Reassess after 30 seconds
Complications
Chest compressions
broken rib
laceration of liver
pneumothorax
Intubation
Pneumothorax
contusion of the airway
When to discontinue resuscitation
If neonate has demonstrate no signs of life after 10 minutes of resuscitation becomes outcome is associated with high early mortality and unacceptabl high morbidity among the rare survivors
Anaesthesia in OBG
Advantages of Regional Anaesthesia
Lower maternal mortality
Patient awareness
Post operative analgesia
Reduced incidence of DVT
Less neonatal depression
Reduced blood loss
Quicker return of GI function
Improved maternal bonding
Mother can participate in birth
Contraindications
Maternal refusal
Coagulopathy
Infection at injection site
uncorrected hypovolaemia
Raised ICP
Maternal haemorrhage and instability
0.5% Bupivacaie 2.2-2.5ml with Fentanyl 10-20mcg- post op analgesia plus reduce need for local anaesthesia
Co-load with 500ml of fluids or colloids to reduce hypotension after induction.
Treat hypo with phenylephrine
Advantages epidural over spinal anaesthesia
Ability to titrate the level of the block
Reduces the risk of profound and sudden hypotension
Unlimited duration of action if the catheter is used postoperatively for analgesia
Good for pre-eclamptic
Disadvantage of epidural
Inadvertent IV or subarachnoid injection
Increased time to surgical anaesthesia
Increased risk of post dural puncture headache if the dura breached and
Failed block/ inadequate block
Not all sensations will be blocked, especially during delivery of the baby. Can feel touch and movement but not pain
First test for light touch and then cold.
Sympathetic block is 2 segments higher than sensory block
Block from T4 (peritoneum) to T12
Advantages of combined spinal epidural
Rapid onset
All advantages of epidural
Regional Anaesthesia
Baseline maternal tachycardia indicates relative hypovolaemia and impending hypotenison
Give prophylactiv phenylephrine 100mcg per minute
Treat bradycardia with atropine
Dyspnoea and ineffective cough if extends to thoracic segments000 oxygenation with fae mask
Must check upper limb power to exclude possibility of an impending total spinal.
Itch- neuraxial opioid
Shivering- 20-25mg Pethidine or 25-50mcg Clonidine IV
Complications
Total spinal block
IV injection of LA
Headache
Obstetric palsy-- obturator nerve, femoral nerve and common peroneal nerve
Spinal or epidural abscess- permanent paralysis
Safest time for surgery
Early to mid 2nd trimester
- lower risk of preterm
- uterus still small
24-34 weeks- corticosteroids
15 degrees left lateral tilt to prevent aortocaval compression
Induction of labour reduces variability
Vasoactive and chronotropic modifying agets cross the placenta and can produce changes in fetal heart rate in accordance with their vasoactive effect
Progesterone supplementation is recommeded when the corpus luteum is removed prior to 7-9 weeks of gestation
Progesterone 50-100mg vaginal suppositivery every 8-12 hours or a daily IM injection of 1mL (50mg) progesterone in oil
Problems with general anaesthesia
Lower maternal mortality
Patient awareness
Post operative analgesia
Reduced incidence of DVT
Less neonatal depression
Reduced blood loss
Quicker return of GI function
Improved maternal bonding
Mother can participate in birth
Contraindications
Maternal refusal
Coagulopathy
Infection at injection site
uncorrected hypovolaemia
Raised ICP
Maternal haemorrhage and instability
0.5% Bupivacaie 2.2-2.5ml with Fentanyl 10-20mcg- post op analgesia plus reduce need for local anaesthesia
Co-load with 500ml of fluids or colloids to reduce hypotension after induction.
Treat hypo with phenylephrine
Advantages epidural over spinal anaesthesia
Ability to titrate the level of the block
Reduces the risk of profound and sudden hypotension
Unlimited duration of action if the catheter is used postoperatively for analgesia
Good for pre-eclamptic
Disadvantage of epidural
Inadvertent IV or subarachnoid injection
Increased time to surgical anaesthesia
Increased risk of post dural puncture headache if the dura breached and
Failed block/ inadequate block
Not all sensations will be blocked, especially during delivery of the baby. Can feel touch and movement but not pain
First test for light touch and then cold.
Sympathetic block is 2 segments higher than sensory block
Block from T4 (peritoneum) to T12
Advantages of combined spinal epidural
Rapid onset
All advantages of epidural
Regional Anaesthesia
Baseline maternal tachycardia indicates relative hypovolaemia and impending hypotenison
Give prophylactiv phenylephrine 100mcg per minute
Treat bradycardia with atropine
Dyspnoea and ineffective cough if extends to thoracic segments000 oxygenation with fae mask
Must check upper limb power to exclude possibility of an impending total spinal.
Itch- neuraxial opioid
Shivering- 20-25mg Pethidine or 25-50mcg Clonidine IV
Complications
Total spinal block
IV injection of LA
Headache
Obstetric palsy-- obturator nerve, femoral nerve and common peroneal nerve
Spinal or epidural abscess- permanent paralysis
Safest time for surgery
Early to mid 2nd trimester
- lower risk of preterm
- uterus still small
24-34 weeks- corticosteroids
15 degrees left lateral tilt to prevent aortocaval compression
Induction of labour reduces variability
Vasoactive and chronotropic modifying agets cross the placenta and can produce changes in fetal heart rate in accordance with their vasoactive effect
Progesterone supplementation is recommeded when the corpus luteum is removed prior to 7-9 weeks of gestation
Progesterone 50-100mg vaginal suppositivery every 8-12 hours or a daily IM injection of 1mL (50mg) progesterone in oil
Problems with general anaesthesia
- Failed intubation- significant upper airway edema and vascular engorgement in pregnancy
- Aspiration of gastric contents- difficult intubation, lower esophageal sphincter tone, labour pain and opiates delay gastric emptying. Prophylaxis: abstain from solid food for at least 6 hours prior to surgery, 8 hours for fried or fatty foods, clear liquids 2hours. Antacid, histamine receptor blocker and metoclopramide. Sodium citrate keeps pH >3.0 for 30 minutes. Cricoid pressure application at the time of rapid sequence induction of endotracheal intubation prevents aspiration of gastric contents until the airway has ben protected with a cuffed endotracheal tube
- Hypoxia- vasodilation due to decreased sympathetic tone during endotracheal itubation and direct cardiodepressant effect of inhalational anaesthetic agents-- hypotension--- decreased uterine blood flow. Controlled hypotension is dangerous for the fetus and should be avoided.
- Anaesthetic drug:
- Propofol
- THiopental- decrease dose
- Halothane, Isoflurane and enflurane- tocolytic effect, decreases uterine tone and inhibit labour during the procedure
- Inhaled NOx- no effect on uterine tone, maternal haemodynamic status nor fetal heart rate variability
- mechanical ventilation effect
- High progesterone in pregancy- respiratory alkalosis with an average pH of 7.44
- PaCO2 of 32mmHg
- HCO3 of 20mmHg
- SInce fetal and maternal PaCO2 correlate, maternal respiratory acidosis may lead to myocardial depression, hypotension and clinically significant vasoconstriction which csn compromise fetal oxygenation
Monday, 30 June 2014
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