Neonatal Assessment
How do we know that a baby is healthy right after birth? The pediatrics team performs an assessment called the “APGAR Score” at minutes 1, 5, and 10 after birth. There are major physiologic changes that happen during the transition of being in the uterus to now living in the outside world. This score helps predict the safety and the need for cardiopulmonary assistance after the baby is born. It was put into practice in 1963 and has remained the mainstay of assessment for newborns almost 60 years later.
The APGAR score has 5 different vital signs that are measure, each having a point value of 0 to 2 (scores range from 0-10). The 5 different vital signs are:
Appearance
Pulse
Grimace
Activity
Respiration
About 10% of newborns new some degree of assistance with their breathing (ie. Supplemental O2, positive pressure ventilation) and less than 1% require advance life support such as chest compressions and/or epinephrine. Most newborns with an APGAR score of 8 or more require little assistance other than tactile stimulation by drying them off with a towel and suctioning the mouth and nose. Scores of 10 are rare because the blueish hue of the baby’s skin (acrocyanosis) can persist well past the first 5 minutes of life. After the baby has been evaluated and it is determined that they do not require any cardiopulmonary assistance, the baby should be placed on a radiantly heated bed or skin-to-skin contact with the mother.
The neonatal assessment starts once the baby is detached from the mom’s placenta and is brought to the warming station. If breathing and crying does not occur, the first step is clearing the airway (mouth and nose) with suction and stimulating the baby by rubbing the chest or back. If apnea and/or gasping persists, you should attach a pulse ox and ECG leads while considering positive pressure ventilation to assist the baby’s breathing. If the heart rate drops below 100 bpm, you should evaluate adequate chest rise during ventilation as hypoxia can lead to bradycardia. FiO2 can be titrated to obtain the desired SpO2 for the baby based on time since delivery. If ventilation doesn’t seem adequate, you should intubate or place a laryngeal mask airway (LMA). If the heart drops below 60 bpm, you should begin chest compressions and administer 100% O2 after establishing an airway. If the heart rate persists below 60 bpm, you should administer 0.1 to 0.3 ml/kg of 1:10,000 epinephrine solution (100 mcg/ml —> 10-30 mcg/kg). This dose can be repeated every 3 to 5 minutes as needed. In certain situations like placental abruption or placenta previa, a baby may be suffering from hypovolemia secondary to maternal blood loss. Blood or isotonic crystalloid should be administered in 10 ml/kg boluses via an umbilical venous catheter. If hypoglycemia is suspected because of maternal diabetes or intrauterine growth restriction, a heel stick can be performed to obtain a blood glucose level.
