Oxford Handbook of Midwifery (136 page)

This is related to the effort of breathing and the need to suck in the soft tissues around the neck and the ribs (known as recession)

because the baby is unable to fully expand its lungs on inspiration due to the lack of surfactant. The soft tissues fill the vacuum left by the unexpanded lungs and as everything is connected from the trachea to the diaphragm the chin is tugged downwards.

Diagnosis

• Perinatal asphyxia due to hypoxia
  
• Acidosis
  
• Hypothermia (a temperature <35°C decreases surfactant production and efficiency even further).
  

higher risk of intrapartum asphyxia due to the size of the baby. Babies of diabetic mothers tend to be larger than normal due to the maternal fluctuating blood sugar levels, which allows higher than normal levels of sugar to be transferred to the fetus via the placenta.
¹

Treatments

Include:

Surfactant replacement

Most preterm babies of 28 weeks’ gestation or less will be given surfactant at birth in measured doses directly down the endotracheal tube into the lower trachea.

CHAPTER 23
Care of the newborn

642

Curosurf
^®

This is an animal-based surfactant made from pigs’ lungs and is one of only two licensed for use in the UK for the treatment of surfactant-deficient RDS, the other being Survanta
^®
from calf’s lungs.

Curosurf
^®
is expensive, a single-dose vial 1.5mL costs £281. The 3mL vial costs £547.

•
The dose is 100–200mg/kg (1.25–2.5mL/kg).

• The baby must be lying supine and flat.
  
• The vials need to be warmed immediately prior to use, as they will have been stored in the fridge.
  
• Apply the surfactant directly down the endotracheal tube.
  
• Give the baby 1min of ventilation using a Neopuff
  ^®
  ventilation system (b see Neonatal resuscitation, p. 454) to disperse the surfactant as far as possible into the lungs, then reconnect to the ventilator.
  
• Give further doses in the same manner.
  
• If the baby has a closed suction device attached, give the surfactant through a catheter passed via the suction port. The baby can remain connected to the ventilator during this procedure.
  
• Following administration, pulmonary compliance can improve rapidly, requiring prompt adjustment of the ventilator settings and inspired oxygen concentrations to avoid hyperoxia.
  
• Avoid suction for at least 4h after administration.
  ²
  ,
  3
  

  Prophylaxis
  

  If the baby is deemed suitable for prophylaxis, the surfactant is given immediately and a chest X-ray is obtained as soon as possible.
  

  The aim is to give the surfactant within the first 30min after birth if the baby is <26 weeks’ gestation.
  

  The criteria for prophylaxis are:
  

• Gestational age 28 weeks or less
  
• Ventilated
  
• Receiving supplementary oxygen >30%
  
• Clinical judgement that the baby is unlikely to wean rapidly from the ventilator
  
• Chest X-ray compatible with RDS. The criteria for rescue treatment are:
  
• Ventilated
  
• X-ray diagnosis of RDS
  
• Inspired oxygen >40%
  

  •
  P
  aO
  ₂
  <7 kPa.
  ²
  ,
  3
  

  Nursing care
  

• Incubator care
  provides warmth, humidification, observation, oxygen therapy, protection from infection, and easy access.
  
• Vital signs
  : monitor hourly.
  
• Temperatures
  of incubator and inhaled gases: monitor hourly, along with the baby’s temperature.
  
• Blood pressure and blood gases:
  monitor via an arterial line 4–6h, backed up by continuous saturation monitoring.
  
• Blood sugar
  :
  check whenever blood samples are taken.
  
• Fluid intake/output
  : record hourly and evaluate every 24h.
  

  RESPIRATORY DISTRESS SYNDROME IN THE NEWBORN
  

  643
  

such as ‘rooming in’ and facilities for food and drinks. Involve all family members in support of the parents.
¹

Recovery from RDS
¹

ventilation for some weeks, due to other complications of prematurity.

1. Cameron J (2001). Management of respiratory disorders. In: Boxwell G (ed.)
   Neonatal Intensive Care Nursing
   , 2nd edn. London: Routledge, pp. 101–3.
   
2. Ainsworth SB (2004). Exogenous surfactant and neonatal lung disease: An update on the current situation.
   Journal of Neonatal Nursing
   10
   (1), 6–11.
   
3. OSARIS Collaborative Group (1992). Early versus delayed administration of synthetic surfactant— the judgment of OSARIS.
   Lancet
   340
   , 1363–9.
   

   CHAPTER 23
   Care of the newborn
   

   644‌‌
   

   Respiratory problems in the newborn
   

   Respiratory problems manifest as respiratory distress are the commonest cause of admission of newborns to the neonatal unit in the perinatal period.
   ¹
   

   Respiratory distress is a general term used to describe respiratory symptoms and is not synonymous with respiratory distress syndrome
   ²
   (b see Respiratory distress syndrome in the newborn, p. 640). Respiratory distress arises from:
   

   • Inadequate
     in utero
     maturation of the lungs and the mechanisms controlling respiration.
     
   • Disease processes present before or after birth which compromise respiratory function.
     ¹
     

     The clinical signs of respiratory distress are:
     

   • Tachypnoea: respiration rate greater than 60 breaths/min.
     
   • Expiratory grunt: the baby expires against a closed glottis, which helps to maintain a higher lung residual lung volume preventing alveolar collapse at the end of expiration thus improving oxygenation.
     
   • Central cyanosis.
     
   • Chest recession which can be intercostals, lower costal, sternal or sub- clavicular.
     
   • Nasal flaring and chin tug: these along with chest recession represent the baby’s use of accessory respiratory muscles.
     
   • These may be superseded by apnoea or acute collapse.
     ²
     Additional signs may include:
     
   • Cardiac murmurs
     

     •
     Abnormal peripheral pulses
     

   • Signs of cardiac failure may also be present if there is an underlying
     

     congenital heart defect.
     ¹
     

     Diagnosis
     

     If two or more of the symptoms persist for 4h or more then respiratory distress is the likely cause and a diagnosis will be made following:
     

   • A full clinical history
     
   • Physical examination including:
     
     • Observation
       
     • Vital signs
       
     • Auscultation of the lungs for air entry, symmetry and breath sounds
       
   • Palpation of dextrocardia and hepatomegaly
     
   • Appropriate investigations (b see p. 645) including a chest X-ray
     
   • Perinatal history including:
     
     • Gestational age
       
     • The presence of poly/oligohydramnios
       
     • Anomalies on ultrasound
       
     • Risk factors for sepsis
       
     • The passage of meconium
       
     • Respiratory depression at birth
       
     • Duration of membrane rupture.
       ²
       

RESPIRATORY PROBLEMS IN THE NEWBORN

645

Investigations