This document provides information on caring for distressed newborns in the pre-hospital setting. It discusses the normal transition from fetal to neonatal circulation and common complications such as respiratory distress, hypothermia, and congenital heart anomalies. It outlines the steps of newborn resuscitation which include establishing an airway, preventing heat loss, cutting the umbilical cord, assessing vital signs, providing oxygen or ventilation, and administering chest compressions or medications if needed. Specific situations like meconium aspiration, apnea, and prematurity are also addressed. The document emphasizes the importance of supporting the newborn's first breaths to prevent hypoxia and acidosis.

1. OB Review

2. Question
How many days are there between ovulation
and the start of the menstrual cycle?

3. Question
What is the term for the premature separation
of the placenta from the uterine wall?

4. Question
Where should the umbilical cord clamps be
placed?

5. Question
Name some risk factors for OB patients?

6. Paramedic Care:
Principles & Practice
Volume 5
Special Considerations/
Operations

7. Topics
General Pathophysiology, Assessment, and
Management
The Distressed Newborn
Specific Neonatal Situations

8. Introduction
Neonate
– Birth to 1 month
Newborn
– A baby in the first few hours of its life, also
known as newly born infant
BABY

9. C
A
D
B

10. Epidemiology
Approximately 6% of field deliveries require
life support
The incidence of complications increases as
the birth weight decreases
Approximately 80% of newborns weighing
1500 g (3 pounds, 5 ounces) at birth require
resuscitation

11. Risk Factors

12. Pathophysiology
To prepare it for
extrauterine life,
the respiratory
system must
suddenly initiate
and maintain
respirations

13. Conversion from Fetal to
Neonatal Circulation

14. Major Circulatory Changes
in Newborn Circulation

15. Pathophysiology
Ductus Arteriosus
– After closure, becomes ligamentum arteriosum
– If hypoxia or severe acidosis occurs it may reopen
Result in persistent fetal circulation

16. IMPORTANT ! ! !
Paramedic should support the
first few breaths
to prevent hypoxia and
acidosis

17. Pathophysiology
Infants are susceptible to hypoxemia
– Primary apnea
Simple stimulation and oxygen delivery will reverse
bradycardia
– Secondary apnea
Infant becomes unresponsive to stimulation and will not
spontaneously resume respiration
Ventilation, oxygenation, and compressions may be
necessary

18. Congenital Heart Anomilies
Classifications
– Increase pulmonary
blood flow
Patent ductus arteriosus
Septal defect
Atrial septal defect
Ventricular septal defect

19. Septal Defects
Atrial and Ventricular

20. Congenital Heart Anomilies
Transposition of great
vessels

21. Tetralogy of Fallot

22. Congenital Heart Anomilies
Classifications (cont.)
– Obstruction of Blood Flow
Coarctation of the aorta
Narrows the aorta
Mitral stenosis, pulmonary stenosis, or aortic stenosis
Valve problem causes obstruction
Hypoplastic left heart syndrome
Usually fatal within 1 month if not corrected
Left side of heart is under developed

23. Congenital Heart Anomilies

24. Other Congenital Anomalies
Diaphragmatic hernia
– BVM ventilations may distend the abdominal
contents into the thoracic cavity
Meningomyelocele
– Spinal cord or associated structures exposed
Omphalocele
– Abdominal contents in the umbilicus

26. Diaphragmatic Hernia
Management
– Positioning
Head elevation
– Do not use BVM
May inflate abdominal organs
– Intubate, if necessary

28. Omphalocele

29. Neural Tube Defects

32. Assessment
Assess the newborn immediately after birth
Normal respiratory rate is 40–60 per minute
– Ventilate as necessary
Normal heart rate is 150–180 at birth
– A pulse less than 100 indicates distress
– Evaluate skin color as well
Use the APGAR score

33. APGAR Scale
Know it….. Love it…….
– 7 to 10: active and vigorous newborn
– 4 to 6: moderately distressed newborn
– < 4 requires immediate resuscitation

34. APGAR Scale

35. Treatment
Begins prior to delivery
Vast majority of term newborns require no
resuscitation beyond suctioning of the airway,
mild stimulation, and maintenance of body
temperature

36. Establishing an Airway
Critical step in
caring for the
newborn
Suction the baby’s
mouth first, then the
nose, to avoid risk of
aspiration

37. Establishing an Airway
For lots of secretions, use a DeLee Suction Trap
If meconium is present:
– Do not stimulate or suction….use meconium aspirator
– Will require intubation and suctioning

38. Establishing an Airway
Drying and suctioning
produce enough
stimulation to initiate
respirations in most
newborns
– Stimulate the newborn
as required by flicking its
feet or rubbing its back

39. Prevention of Heat Loss
Heat loss can be life
threatening to newborns
Most heat loss results
from evaporation
Core temperature can
quickly drop 1° Celsius
from its original temp

40. GOAL: KEEP BABY WARM

41. Dry the newborn immediately
Maintain room temperature at 74–76 degrees
Close all windows and doors
Swaddle the infant
– In colder areas, use water bottles or rubber gloves
filled with warm water
Prevention of Heat Loss

42. Kangaroo Care

43. Newborn Swaddling 101

44. Cutting the
Umbilical Cord
Perform after you
have stabilized the
patient’s airway and
minimized heat loss
Keep newborn at
level of mother to
avoid transfusion of
blood

45. Cutting the
Umbilical Cord
Place the first
clamp
approximately 10
cm (4 inches) from
the newborn
Place the second
clamp about 5 cm
(2 inches) farther
Cut and inspect for
bleeding
periodically

46. The Distressed Newborn

47. The Distressed Newborn
Presence of fetal meconium at birth indicates
that fetal distress has occurred
– Particulate meconium
– Meconium staining
Aspiration of meconium can cause significant
respiratory problems

48. Meconium Aspiration

49. The Distressed Newborn
Most common problems experienced by
newborns of life involve the airway
– Ventilation and oxygenation
Fetal heart rate is the most important
indicator of neonatal distress
– Hypoxia leads to bradycardia
– If heart rate < 60, begin compressions

50. The A’s and B’s
Apnea
– leads to
Bradycardia
Sometimes babies need to be reminded
to breathe.

51. Resuscitation
The vast majority of newborns do not require
resuscitation beyond stimulation,
maintenance of the airway, and maintenance
of body temperature
EMS units should carry a neonatal
resuscitation kit

52. Inverted Pyramid
for Resuscitation

53. Resuscitation
Step 1: Drying, Warming, Positioning,
Suctioning, Tactile Stimulation

54. Newborn Assessment
Parameters
Respiratory Effort
– Rate and depth should increase immediately
with tactile stimulation
– Ventilate if necessary
Heart Rate
– If heart rate > 100 and respirations present,
continue with assessment
– If heart rate < 100 initiate
positive pressure ventilations

55. Newborn Assessment
Parameters
Color
– If central cyanosis present, administer
supplemental oxygen
APGAR
– Unless it is necessary to resuscitate, obtain
APGAR at 1 and 5 minutes

56. Resuscitation
Step 2: Supplemental
Oxygen
– Blow oxygen across the
newborn’s face
– Will not cause toxicity
– Do not withhold oxygen

57. Resuscitation
Step 3: Ventilation
– Ventilate if:
HR < 100 bpm
Apnea
Persistent central cyanosis
– Ventilate at 40-60
breaths per minute
– Pop-off valve on BVM
may need to be disabled

58. Resuscitation
Intubate for the following conditions:
– The bag-valve-mask unit does not work
– Tracheal suctioning is required (such as in cases
of thick meconium)
– Prolonged ventilation will be required
– A diaphragmatic hernia is suspected
– Inadequate respiratory effort is found

59. Resuscitation
Step 3: Chest Compressions
– Initiate compressions if:
The heart rate is less than 60 beats per minute
– Compress lower half of the sternum
Rate of at least 100 compressions per minute
30:2 compression/ventilation ratio
– Reassess every 30 seconds

60. Chest Compressions

61. Intubation Considerations
Always use an uncuffed endotracheal tube
– 3.0 for normal newborn
– 2.5 for premie
Intubation bypasses glottic function and
eliminates PEEP
– Administer PEEP of 2–4 cm/H2O when ventilating
Gastric Distension
– Place oro or nasogastric tube
– Oxygenate first

62. Resuscitation
Step 4: Medications and Fluids
– Vascular access can most readily be managed by
using the umbilical vein
2 arteries
1 vein
Vein is larger and thinner-walled
– Other routes
Endotracheal
Peripheral veins
Intraosseous
– Fluid therapy should consist of 10 mL/kg bolus

63. The Umbilical Cord

65. Neonatal Resuscitation
Drugs

66. Maternal Narcotic Use
May complicate delivery
Shown to produce low birth weight infants
Such infants may demonstrate withdrawal
symptoms:
– Tremors, startles, decreased alertness, and
respiratory distress
Naloxone is the drug of choice
– Within 4 hours of delivery
– Avoid use in opiate addicted mother as acute
withdrawal may occur

67. Neonatal Transport
Distressed newborns
should be transported
on their side
Transport to NICU from
stabilizing facility may
be required
– If isolette unavailable,
keep MICU warm and
keep newborn warm
© Ray Kemp/911 Imaging

68. Specific Neonatal Situations

69. Specific Neonatal Situations
Meconium-Stained
Amniotic Fluid
Apnea
Diaphragmatic
Hernia
Bradycardia
Prematurity
Respiratory Distress
Hypovolemia
Seizures
Fever
Hypthermia
Hypoglycemia
Vomiting
Diarrhea

70. Meconium-Stained
Amniotic Fluid
Occurs in approximately 10–15% of deliveries
Fetal distress and hypoxia can cause the
passage of meconium into the amniotic fluid
– Thick meconium is aspirated into the lungs in
utero or with first breath
– May produce respiratory distress
Partial obstruction of some airways may lead
to pneumothorax

71. Meconium-Stained
Amniotic Fluid
Intubation and
suctioning may be
necessary
– Suction prior to
stimulating newborn
Suction at 100
cm/H2O or less
– Repeat as
necessary
Ventilate following
suction

72. Apnea
Usually due to hypoxia or hypothermia; other
causes include:
– Narcotics or CNS depressants
– Weakness of respiratory muscles
– Septicemia
– Metabolic disorders
– CNS disorders
Manage with tactile stimulation and
ventilations, if necessary
– Intubate if prolonged episode
– Consider Narcan if suspected opiate involvement

73. Bradycardia
Most commonly caused by hypoxia
– Follow the procedures in the inverted pyramid
Suctioning, positioning, administration of oxygen or
ventilation, tracheal intubation, and maintain warmth
Resist the temptation to treat bradycardia in a
newborn with pharmacological measures
alone
– Epinephrine is drug of choice if unresponsive to
measures above
– NO ATROPINE

74. Prematurity
An infant born prior to 37 weeks or weight
ranging from 0.6 to 2.2 kg (1 pound, 5
ounces, to 4 pounds, 13 ounces)
Greater risk of:
– Respiratory suppression, head or brain injury
caused by hypoxemia, changes in blood pressure,
intraventricular hemorrhage, and fluctuations in
serum osmolarity
– Hypothermia

75. Prematurity
Prematurity should not be a factor in
short-term treatment
Maintain airway and body temperature
during transport

76. Respiratory Distress/Cyanosis
Occurs most frequently in premature infants
– Immature central respiratory control center
– Easily affected by environmental or metabolic
changes
Assessment Findings
– Tachypnea
– Paradoxical breathing
– Intercostal retractions
– Nasal flaring
– Expiratory grunt

77. Respiratory Distress/Cyanosis
Management
– Follow the inverted pyramid of treatment
Pay attention to airway and ventilation
Chest compressions, if indicated
– Medications
Sodium bicarbonate
Dextrose
– Maintain body warmth

78. Hypovolemia
Leading cause of shock in newborns
Signs of hypovolemia
– Pale color
– Cool skin
– Diminished peripheral pulses
– Delayed capillary refill, despite normal ambient
temperature
– Mental status changes
– Diminished urination (oliguria)

79. Hypovolemia
Management
– Administer a fluid bolus and assess the infant’s
response
10 mL/kg of an isotonic crystalloid solution
Infant may often need 40–60 mL/kg of fluid
– Do not use solutions containing dextrose

80. How much fluid was that?

81. 10 mL/kg

82. Seizures
Usually indicate a serious underlying
abnormality
Types of Neonatal Seizures
– Subtle
– Tonic
– Focal clonic
– Multifocal
– Myoclonic

83. Seizures
Causes of neonatal seizures
– Sepsis, fever, hypoglycemia, hypoxic-ischemic
encephalopathy, metabolic disturbances,
meningitis, developmental abnormalities, or drug
withdrawal
Management
– Airway management and oxygen saturation
– Anti-convulsant
Benzodiazepine such as lorazepam (0.05 mg/kg)
– Dextrose

84. Fever
A rectal temperature of 38.0° C (100.4° F) or
higher is considered fever
– May be caused by life-threatening conditions such
as pneumonia, sepsis, or meningitis
Fever is the only sign of meningitis in the neonate
Assessment Findings
– Mental status changes (irritability/somnolence)
– Decreased feeding
– Skin warm to the touch
– Rashes or petechiae

85. Petechiae

86. Fever
Management
– Ensure a patent airway and adequate ventilation
– Administration of an antipyretic agent to a neonate
is of questionable benefit

87. DO NOT USE COLD PACKS ON
NEWBORNS TO TREAT FEVER

88. Hypothermia
Common and life-
threatening condition
The increased
metabolic demands can
produce a variety of
related conditions
– Metabolic acidosis,
pulmonary hypertension,
and hypoxemia

89. Hypothermia
Assessment findings
– Pale color
– Skin cool to the touch, particularly in the
extremities
– Acrocyanosis
– Respiratory distress
– Possible apnea
– Bradycardia
– Central cyanosis
– Initial irritability
– Lethargy in later stages

90. Hypothermia
Management
– Ensure adequate ventilations and oxygenation
– Compressions, as necessary
– Warm fluids through an IV fluid heater
– Administration of Dextrose

91. Hypoglycemia
More common in:
– Premature or small-for-gestational-age (SGA)
infants
– The smaller twin
– Newborns of a diabetic mother
Infants with hypoglycemia may be
asymptomatic
– A blood glucose screening test of less than 45
mg/dL indicates hypoglycemia

92. Hypoglycemia
Assessment Findings
– Twitching or seizures
– Limpness
– Lethargy
– Eye-rolling
– High-pitched cry
– Apnea
– Irregular respirations
– Possible cyanosis

93. Hypoglycemia
Management
– Management of the airway and ventilations
– Compressions, if necessary
– Administer dextrose (D10W or D25W)
– Maintain warmth

94. Vomiting
Uncommon during the first weeks of life
– May be confused with regurgitation
– Result of an abnormality
Assessment Findings
– Distended stomach, signs of infection, increased
intracranial pressure, or drug withdrawal
Management
– Focus on ensuring a patent airway
– Watch for bradycardia due to vagal stimulation

95. Diarrhea
Can cause severe dehydration and electrolyte
imbalances
– Consider 5-6 stools a day normal
Causes
– Bacterial or viral infection
– Gastroenteritis
– Lactose intolerance
– Phototherapy
– Neonatal abstinence syndrome (NAS)
– Thyrotoxicosis
– Cystic fibrosis

96. Diarrhea
Assessment Findings
– Loose stools, decreased urinary output, and other
signs of dehydration such as prolonged capillary
refill time, cool extremities, and listlessness or
lethargy
Management
– Maintenance of airway and ventilations, adequate
oxygenation, and chest compressions
– Consider fluid administration

97. Common Birth Injuries
2 to 7 of every 1,000 live births
2–3 percent of infant deaths
Risk Factors

98. Common Birth Injuries
Management
– Protection of the airway, provision of adequate
ventilation and oxygen, and, if needed, chest
compressions
– Newborns with birth injuries usually require
treatment at specialized facilities

99. Cardiac Resuscitation, Post-
resuscitation, and Stabilization
The incidence of neonatal cardiac arrest is
related primarily to hypoxia
Risk factors include:
– Bradycardia
– Intrauterine asphyxia
– Prematurity
– Maternal drug use
– Congenital diseases
– Intrapartum hypoxemia

100. Assessment Findings
– Peripheral cyanosis, inadequate respiratory effort,
and ineffective or absent heart rate
Management
– Follow the inverted pyramid for resuscitation
– Administer drugs or fluids according to medical
direction
– Maintain body temperature
Cardiac Resuscitation, Post-
resuscitation, and Stabilization

112. That’s It