Medical brain notes 42

  Intrapartum Fetal Heart Rate Monitoring   Fetal heart rate (FHR) monitoring  is a modality in-tended to determine if a fetus is well-oxygenated. The ma-jority of neonates (approximately 85%) born in the United States are assessed with  electronic fetal monitoring(EFM),  making it the most common obstetric procedure.  Intermittent auscultation  of the FHR after a contractionalso is used to assess intrapartum fetal well-being. Beginning  in the 1980s, EFM became more common; rates of its use have doubled over the past 35 years. EFM may be performed externally or internally. Most external monitors use a Doppler device with computerized logic to interpret and count the Doppler signals. Internal FHR monitoring is accomplished with a fetal electrode, which is a spiral wire placed directly on the fetal scalp or other presenting part. Fetal heart rates by EFM are described in terms of base-line rate, variability, presence of accelerations, periodic or e...

  Ancillary Tests   Because the rate of false-positive diagnosis of EFM is high, attempts have been made to find ancillary tests that help confirm a nonreassuring FHR tracing. FETAL STIMULATION   In the case of an EFM tracing with decreased or absent variability without spontaneous accelerations, an effort should be made to elicit one. Four techniques are avail-able to stimulate the fetus: 1) fetal scalp sampling,   Allis clamp scalp stimulation, 3) vibro-acoustic stim-ulation, and 4) digital scalp stimulation.  Each of thesetechniques involves accessing the fetal scalp through the di-lated cervix.  In vibroacoustic stimulation, the fetal scalp isstimulated with a vibratory device, and in digital scalp stimulation, the physician uses his or her finger to gently stroke the scalp.   Each of these tests is a reliable method to exclude aci-dosis if accelerations are noted after stimulation. Because vibroacoustic stimulation and scalp stimulation are less i...

  Diagnosis and Management of a Persistently Nonreassuring FHR Pattern   A reassuring FHR pattern (Category I) may include a nor-mal baseline rate, moderate FHR variability, persistence of accelerations, and absence of decelerations. Patterns believed to be predictive of current or impending fetal as-phyxia (Category III) include recurrent late decelerations, recurrent severe variable decelerations, or sustained brady-cardia with absent FHR variability. A nonreassuring pattern (Category II) is one that falls between these two extremes.   In the presence of a nonreassuring FHR pattern, the etiology should be determined, if possible, and an attempt should be made to correct the pattern by addressing the primary problem. If the pattern persists, initial measures include changing the lateral position to the left lateral po-sition, administering oxygen, correcting maternal hypo-tension, and discontinuing oxytocin, if appropriate. Where the pattern does not respond to change in...

  INITIAL CARE OF THE WELL NEWBORN   Delivery Room Assessment   In accordance with the American Heart Association (AHA) and the American Academy of Pediatrics (AAP), at least one person skilled in neonatal assessment and resuscitation should be available at every delivery to care for the newborn.   Every delivering physician should be familiar with the ini-tial assessment, resuscitation, and care of a newborn infant.   Immediately following delivery, the newborn infant should first be assessed to decide whether resuscitation is necessary. Four characteristics define a newborn who requires no additional resuscitation:   ·                A full-term infant   ·                Clear amniotic fluid with no evidence of meconium and infection   ·            ...

  TRANSITIONAL CARE Following the initial assessment and routine care of a healthy neonate, continued close observation is necessary for the subsequent stabilization-transition period (the first 6 to 12 hours after birth) to identify any problems that may arise.  The following findings should raise concern and result incloser observation: temperature instability; change in activity, including refusal of feeding; unusual skin coloration; abnormal cardiac or respiratory activity; abdominal distention; bilious vom-iting; excessive lethargy or sleeping; delayed or abnormal stools; and delayed voiding.   Following delivery, all newborns should receive pro-phylactic application of antibiotic ointment (containing erythromycin [0.5%] or tetracycline [1%]) to both eyes to prevent the development of  gonococcal ophthalmia  neonatorum.  This is recommended regardless of the modeof delivery. This prophylactic measure can be delayed up to 1 hour to allow for breastfeedi...

  INITIAL CARE OF THE ILL NEWBORN   Although most deliveries are uncomplicated, requiring only basic neonatal care,  resuscitation  may be necessary in up to 10% of all deliveries; 1% of these require major resuscitative efforts. The need for these efforts increases in circumstances such as premature birth, low–birth-weight infants, prolonged labor, and non-reassuring measures of fetal well-being. Not all deliveries occur in a setting with intensive pediatric care immediately available. In the absence of such staff and facilities, maternal transport to a facility with a greater capacity to provide appropriate care should be attempted before delivery. Alternatively, the transport of a neonatal team from a tertiary care center to the primary care site is an option.   Neonatal Resuscitation   The normal newborn breathes within seconds of delivery and usually has established regular respirations within 1 minute of delivery. If the neonate is having difficulty b...

  NEWBORN SCREENING   Newborn screening programs, which should be available to all newborns, include tests designed to detect infants with specific conditions who may benefit from early diag-nosis and treatment. These conditions include disorders of metabolism, endocrinopathies, hemoglobinopathies, hear-ing loss, and cystic fibrosis. The tests may also identify par-ents who are carriers of inherited conditions.   To obtain a sample for testing, heel stick-derived blood is collected and placed onto filter paper. If the initial sample is collected before 12 to 24 hours after delivery, a second sample should be collected at 1 to 2 weeks of age to decrease the probability that phenylketonuria and other disorders with metabolite accumulation are missed as a result of early testing. Premature infants, neonates receiv-ing parenteral feeding, or those treated for illness should have a newborn screening test performed at or near 7 days of age, regardless of feeding status.   ...