(primitive) reflexes, deep tendon reflexes, spontaneousmotor activity, and cranial nerves (involving retinal examination, extraocular muscle movement, masseter power asin sucking, facial motility, hearing, and tongue function).The Moro reflex, present at birth and gone in 3 to 6 months,is one of the primary newborn reflexes. It is elicited by sudden, slight dropping of the supported head from a slightlyraised supine position, which should elicit opening of thehands and extension and abduction of the arms, followed by upper extremity flexion and a cry. The palmar grasp ispresent by 28 weeks’ gestation and gone by 4 months of age.Deep tendon reflexes may be brisk in a normal newborn; 5to 10 beats of ankle clonus are normal. The Babinski signis extensor (upgoing). The sensory examination can be evaluated by withdrawal of an extremity, grimace, and cryin response to painful stimuli. The rooting reflex (turningof the head toward light tactile stimulation of the perioralarea) is present by 32 weeks’ gestation.
Special Conditions Requiring Resuscitation in the Delivery Room
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Acrocyanosis (blue color of the hands and feet with pinkcolor of the rest of the body) is common in the delivery roomand is usually normal. Central cyanosis of the trunk, mucosal membranes, and tongue can occur at any time after birth andis always a manifestation of a serious underlying condition.Cyanosis is noted with 4 to 5 g/dL of deoxygenated hemoglobin. Central cyanosis can be caused by problems in manydifferent organ systems, although cardiopulmonary diseasesare the most common (Table 58-10). Respiratory distress syndrome, sepsis, and cyanotic heart disease are the threemost common causes of cyanosis in infants admitted to aneonatal intensive care unit. A systematic evaluation of theseand other causes of cyanosis is required for every cyanoticinfant after prompt administration of oxygen, with or withoutassisted ventilation.
Various congenital anomalies can interfere with vital organ function after birth (see Table 58-9). Some malformations, such as choanal atresia and other lesions obstructing the airway, may complicate ventilation. Intrathoracic lesions, such as cysts or diaphragmatic hernia, interfere with respiration. Other malformations that obstruct the gastrointestinal system at the level of the esophagus, duodenum, ileum, or colon may lead to aspiration pneumonia, intestinal perforation, or gangrene. Gastroschisis and omphalocele are associated with exposed bowel on the abdominal wall. Omphalocele is often associated with other malformations, whereas intestinal necrosis is more common in gastroschisis.
Shock in the delivery room is manifested by pallor, poor capillary refill time, lack of palpable pulses, hypotonia, cyanosis, and eventually cardiopulmonary arrest. Blood loss before or during labor and delivery is a common cause of shock in the delivery room. Blood loss may be caused by fetal-maternal hemorrhage, placenta previa, vasa previa, twin-to-twin transfusion syndrome, or displacement of blood from the fetus to the placenta as during asphyxia (asphyxia pallida). Hemorrhage into a viscus, such as the liver or spleen, may be noted in macrosomic infants, and hemorrhage into the cerebral ventricles may produce shock and apnea in preterm infants. Anemia, hypoalbuminemia, hypovolemia, and shock at birth are common manifestations of Rh immune hydrops.