arked homeostatic changes happen during the transition from fe-tal to neonatal life. The most rapid anatomic and physiologicchanges of this period occur in the cardiopulmonary system, sothe newborn’s major problems are usually related to this system. Theseproblems include asphyxia, respiratory distress, cold stress, jaundice, he-molytic disease,and anemia.Ideally,problems are anticipated and identifiedprenatally, and appropriate intervention measures are begun at or immedi-ately after birth.
CARE OF THE NEWBORN AT RISK DUE TO ASPHYXIA
Neonatal asphyxia results in circulatory, respiratory, and biochemicalchanges. Circulatory patterns that accompany asphyxia indicate the new-born’s inability to make the transition to extrauterine circulation—in effect,a return to fetal circulatory patterns. Failure of lung expansion and estab-lishment of respiration rapidly produces serious biochemical changes, in-cluding hypoxia (decreased oxygen concentration available to tissues),acidosis (increased acidity of blood reflected by low pH), and hypercarbia(excess levels of carbon dioxide in the blood).These biochemical changes cause abnormal changes in pulmonary cir-culation. Arterioles constrict, resulting in vascular resistance and dimin-ished pulmonary blood flow to the organs and the lungs, and a largeright-to-left shunt through the ductus arteriosus. The foramen ovale re-opens as right atrial pressure exceeds left atrial pressure, and blood flowsfrom right to left. (See Chapter 26 for a review of normal newborn car-diopulmonary adaptation.
)However, the most serious biochemical abnormality caused by hypoxia isa change from aerobic to anaerobic metabolism. This change results in thebuildupof lactateanddevelopmentof metabolicacidosis.Simultaneousrespi-ratoryacidosismayalsooccurduetoarapidincreaseincarbondioxide(P
)during asphyxia. In response to hypoxia and anaerobic metabolism, glycogenstores are mobilized to provide a continuous glucose source for the brain,andthe amounts of free fatty acids (FFAs) and glycerol in the blood increase.The newborn has several protective mechanisms against hypoxic insults.These include a relatively immature brain and a resting metabolic rate lowerthanthatof adults,anabilitytomobilizesubstanceswithinthebodyforanaer-obic metabolism and to use energy more efficiently, and an intact circulatory system able to redistribute lactate and hydrogen ions in tissues still being per-fused.Unfortunately,thebody’sstoresof glycogenmaybeuseduprapidlydur-ing an asphyxial attack. Severe, prolonged hypoxia overcomes the body’sprotective mechanisms,resulting in brain damage or death of the newborn.The newborn suffering apnea requires immediate resuscitative efforts.The need for resuscitation can be anticipated if specific risk factors are presentduring the pregnancy or labor and birth.
RISK FACTORS PREDISPOSING TO ASPHYXIA
The need for resuscitation may be anticipated if the mother demonstratesthe antepartal and intrapartum risk factors described in Table 10–1 inChapter 10 and Table 18–1 in Chapter 18.
Neonatal risk factors for re-suscitation are as follows (Thureen, Deacon, Hernandez et al., 2005):
Nonreassuring fetal heart rate pattern
Fetal scalp/capillary blood sample-acidosis
Cold stress, 831Erythroblastosis fetalis, 836Hemolytic disease of the newborn,838Hydrops fetalis, 836Hyperbilirubinemia, 835Hypoglycemia, 832Jaundice, 835Kernicterus, 835Meconium aspiration syndrome(MAS), 829Phototherapy, 837Physiologic anemia, 844Polycythemia, 845Respiratory distress syndrome (RDS),819Sepsis neonatorum, 846
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