CHAPTER 17: Neonatology

APGAR SCORES

The Apgar score was designed to provide a quick, reproducible way to evaluate a newborn’s condition following delivery. Scores of 0, 1, or 2 are assigned in each of five categories (respiration, color, tone, heart rate, and reflex irritability) at 1 and 5 minutes after birth. The maximum score is 10. If the 5-minute score is less than 7, additional scores are assigned every 5 minutes until the newborn has a score of 7 or more, up to 20 minutes of age.

• The Apgar score itself does not determine the need for resuscitation as such decisions should often begin prior to Apgar score assignment

• The 1-minute score has not been shown to have predictive value, but a 5-minute score of 0–3 is associated with increased mortality in both preterm and full-term infants

• The change between scores at 1 and 5 minutes may reflect the effectiveness of the resuscitation efforts (Table 17-1)

NEONATAL RECUSCITATION

Approximately 10% of infants will require some form of resuscitation at birth. Therefore, every delivery should have at least one person trained in neonatal resuscitation present. The Neonatal Resuscitation Program updates the algorithm used for clinical decision-making at delivery periodically, the most recent recommends the actions below.

CLINICAL DECISION-MAKING

• Following delivery, the infant is warmed and dried and the airway cleared

• Is the infant term gestation, breathing/crying, and have good tone?

  • ✓ If yes to the above and if there are no other issues of concern, the infant may remain with the mother

  • ✓ Additional evaluation as necessary

• Heart rate below 100bpm or presence of gasping or apnea?

  • ✓ Administer positive pressure ventilation (PPV)

  • ✓ Place pulse oximeter

  • ✓ Administer supplemental oxygen as appropriate (see targeted oxygen saturations below under “Important Considerations”)

• If heart rate does not increase

  • ✓ Assess adequacy of assisted ventilation

• If heart rate remains <60 bpm

  • ✓ Continue PPV

  • ✓ Continue to assess adequacy of ventilation

  • ✓ Begin chest compressions (coordinate with PPV)

  • ✓ Consider endotracheal intubation

  • ✓ Consider causes of poor response to resuscitation, including hypovolemia and pneumothorax

  • ✓ Consider IV epinephrine

• If heart rate above 100 bpm but labored breathing or cyanosis?

  • ✓ Clear airway

  • ✓ Administer supplemental oxygen as appropriate

  • ✓ Consider continuous positive airway pressure (CPAP)

IMPORTANT CONSIDERATIONS

• Targeted Oxygen Saturations: If assisted ventilation is required, a pre-ductal pulse oximeter should be placed on right hand and ...