PENGENALAN

KEGAWATAN
PADA
NEONATUS

Dr. Aris Primadi, Sp.A(K)

RSHS/ FK UNPAD BANDUNG

Danger signs
Asphyxia Abdominal distension
Lethargy Yellow palms/soles
Bleeding
Hypothermia
Excessive weight loss
Respiratory distress Vomiting
Cyanosis Diarrhea
Convulsion
 APGAR Scores

Sign Score = 0 Score = 1 Score = 2

---------------------------------------------------------------------------------------------------
APPEARANCE Blue all over, Acrocyanosis Pink all over or
(color) pale
PULSE Absent Below 100 Above 100
(heart rate)
GRIMACE No response Grimace or Good cry
(reflex irritability) weak cry
ACTIVITY Flaccid Some flexion of Well flexed, or active
(muscle tone) extremities movements of extremities
RESPIRATIONS Absent Weak, irregular, Good crying
or gasping
============================================
The APGAR score should be assigned at one minute and five minutes, finding the total
score (0-10) at each time by adding up points from the table above.
Continue to assign scores every five minutes thereafter as long as the APGAR score is less
than 7.

Bernapas atau menangis? Ya P e ra w a t a n rutin:

 Pastikan bayi tetap hangat
DIAGRAM ALUR
To n u s b a i k ?
 Keringkan bayi
Tidak
 Lanjutkan observasi pernapas an,
BANTUAN?
PADA SETIAP LANGKAH TANYAKAN: APAKAH ANDAMEMBUTUHKAN

l aju d e n y u t j a n t u n g , d a n t o n u s
RESUSITASI NEONATUS
30 detik

Langk ah awal: (nyalakan pencatat waktu)

 Pastikan bayi tetap hangat
 Atur posisi dan bersihkan jalan n a p a s
Keterangan:
 Keringkan d a n stimulasi
DI
P a d a bayi dengan berat
 Posisikan kembali
≤ 1 5 0 0 gram , bayi
l angs ung di bungk us plastik
O bs er v as i u s a h a napas , laju d e n y u t j ant ung (LDJ ), d a n t o n u s ot ot beni ng tanpa dikeringkan
terlebih d a h u l u k ecuali
wajahnya, kemudian
FASILITAS
Tidak bernapas/ Bernapas spontan
d i p a s a n g t opi .
megap-megap, dan atau
atau LDJ < 100x/ menit
Bayi tetap dapat
distimulasi wal aupun
PELAYANAN
D i s t r e s n a p a s ( Ta k i p n u , di bungk us plastik
S i anos i s sentral
30 detik

`
retraksi, at au merintih) persisten
KESEHATAN
Ve n t i l a s i
t e k a n a n positif Pertimbangkan
Cont inuous positive
(VTP)
airway pres s ure (CPA P )
P E E P 5-8 c m H 2O
suplementasi oksigen
RUJUKAN
Pemantauan SpO2 Pemantauan SpO2
Pemantauan SpO2

Gagal CPAP
Keterangan: 
A p a b i l a L D J > 1 0 0 k ali p e r
FASILITAS
Bila L D J tet a p
< 1 0 0 kali/ m e n i t P E E P 8 c m H 2O m eni t d a n target saturasi
FiO2 > 4 0 % ok s i gen tercapai:
D e n g a n distres n a p a s
P ert imbangk an intubasi
 Ta n p a a l a t  L a n j u t k a n k e
perawatan observasi
LENGKAP
Setiap 30 detik sekali nilai laju denyut jantung, usahanapas dan tonus

 D e n g a n alat  Lanjut k an k e
perawat an paska-resusitasi
Pengembangan dada adekuat?

Ya T id a k Wa k t u dari Ta r g e t S p O 2
Lahir Preduktal

Dada mengembang adekuat Bila d a d a tidak 1 menit 60-70%

n a m u n L D J < 60x/ m eni t mengembang adekuat
2 menit 65-85%
VT P (O2 100%) +
kompresi dada
(3 k o m p r es i tiap 1 n ap as )
Evaluasi:
 Posisi kepala bayi
3 menit 70-90% UKK Neonatologi
 Obstruksi jalan n ap as 4 menit 75-90%
Pert imbangk an Intubasi
 Kebocoran sungkup
 Te k a n a n p u n c a k 5 menit 80-90% IDAI 2014
Observasi LD J dan usaha inspirasi c u k u p atau
tidak 10 menit 85-90%
n a p a s tiap 3 0 detik

Keterangan:
Intubasi endot rak ea dapat
dipertimbangkan pada
L D J < 60/ menit ? l a n g k a h ini a p a b i l a V T P t i d a k
ef ek t i f a t a u t e l a h d i l a k u k a n
selama 2 menit
P ertimbangk an pem beri an obat dan cairan intravena
 Lethargy and poor sucking

 In a term baby who was feeding earlier

 indicates neonatal illness (as perceived by mother)

 In a preterm baby
 needs careful assessment
because it may be due to cold stress or immaturity

VOLPE, 2008
Level of Penampilan Respon Respon Motorik
Alertnes Bayi Kuantitas Kualitas
s Bangun

Normal Bangun Normal Normal High Level

Stupor
Ringan Mengantuk Berkurang Berkurang High Level
(slight) (slight)
Sedang Tidur Berkurang Berkurang High Level
(sedang) (sedang)
Berat Tidur Tidak ada Berkurang High Level
(jelas)

Koma Tidur Tidak ada Berkurang (jelas)/ Low Level

tak ada
 Primitive gut formed

Gut rotation

Structure
Villi

Digestive enzymes

Small intestine mature

Swallow

Gastrointestinal motor activity

Organized motility
Function

Nutritive sucking and swallowing

Post-menstrual age (wk)
The ontogenic timetable showing structural and functional gastrointestinal development

Clin Perinatol 2000

Body temperature in newborn infant (oC)

37.5o
Normal range

36.5o
Cold stress
Cause for concern
36.0o
Moderate hypothermia
Danger, warm baby

32.0o
Severe hypothermia Outlook grave, skilled
care urgently needed
Respiratory problems

 RR > 60 / min*
 Retractions
 Grunting
 Central cyanosis
 Apnea

* Rate should be counted in a quiet state and not

immediately after feed
 Cyanosis

Peripheral
 Normal at birth
 Seen in extremities
due to cold

Central
 Always needs te referral
appropria
 Seen on lips and
mucosa
 Indicates cardiac or
pulmonary disease

Respiratory Distress Evaluation

Silverman Anderson retraction score

Score Upper chest Lower chest Xiphoid Nasal Grunt

restraction retraction retraction dilatation

0 Synch None None None None

1 Lag on Just visible Just visible Minimal Stethoscope
inspiration only
2 See-Saw Marked Marked Marked Naked ear

A score of > 6 is indicative of impending respiratory failure

Silverman WC, Anderson DH. Controlled clinical trial on effects of water mist on obstructive respiratory signs, death rate and
necropsy findings among premature infants. Pediatrics 1956; 17: 1-4.
 Respiratory Distress Evaluation

Classification of breathing difficulty (WHO – Depkes)

Respiratory Distress Evaluation

Downes’ score

Score Respiratory Cyanosis Air entry Grunt Retraction

rate
0 <60/min Nil Normal None Nil
1 60-80/min In room air Mild ? Ausc Mild

with
stet
hosc
ope
2 >80/min In >40% Marked ? Audible with Moderate
Score naked ear
< 3 Minimal respiratory distress
Score 4 – 5 Moderate respiratory distress
Score > 6 Severe respiratory distress

Wood DW, Downes’ JJ, Locks HI. A clinical score for the diagnosis of respiratory failure.
Amer J Dis Child 1972; 123: 227-9.
 Convulsion

17

ABDOMINAL
DISTENSION

Feeding Intolerance
Stop enteral feeds and reassess:
 Bilious (or greenish residuals)
 Vomiting
 Acute increase in abdominal girth >2 cm
 Frankly bloody or very watery stool
 Increased residuals
 Other signs of illness
Yellow staining of soles

19

Clinical assessment of severity of jaundice

• Cephalocaudal progression
– face 5 mg/dL (approximately)
– upper chest 10 mg/dL (approximately)
– abdomen and upper thighs 15 mg/dL (approximately)
– soles of feet 20 mg/dL (approximately)

• Visual inspection may be misleading

20
 Kernicterus - Neuropathology

Yellow staining and neuronal

necrosis
• Basal ganglia:
– globus pallidus
– subthalamic nucleus
• Cranial nerve nuclei:
• vestibulocochlear
• oculomotor
• facial
• Cerebellar nuclei
21

BLEEDING

Disseminated Intravascular
Coagulation

22
 Bleeding infant

Screening tests
Activated partial thromboplastin time (aPTT)
Thrombin clotting time (TCT)
Prothrombin Time (PT)
Fibrinogen (Fbg)
Platelet Count
Bleeding Time
(BT)

All aPTT PT prolonged aPTT, PT, Thrombocytopenia BT abnormal,

tests prolonged TCT, Fbg Platelet count
normal abnormal
normal

CAPILLARY REFILL TIME

(CRT)
 Indicates tissue perfusion
Normal CRT < 3
seconds Prolonged CRT > 3
seconds *
* Hypotension, hypothermia,
acidosis
Excessive
weight loss pattern

 > 10 percent of birth weight in term

 > 15 percent in preterm
 > 5 percent acute weight loss

Failure to pass
meconium &
urine

Failure to pass meconium

Majority pass within 24 hrs
 Delayed passage
 May have passed in –utero
 Suspect obstruction

Failure to pass urine

Majority pass within 48 hrs
 Delayed passage
 Exclude obstructive uropathy or renal
agenesis
 Vomiting*

 Ingestion of meconium stained amniotic

fluid
 Systemic illness
 Raised ICP – IVH, asphyxia

• Persistent, projectile or bile stained

 intestinal obstruction

Diarrhea

 Infective diarrhea*
(often non breast fed baby)
 Metabolic disorders
 Maternal drug addiction

* Infective diarrhea needs

treatment with systemic antibiotics