Obstetrics

The Newborn and

Neonatal Problems
Section 7

Atul K Shankar
34
Resuscitation and Examination of Newborn
ABGAR Score
- useful technique to make a rapid assessment of the condition of the newbo, particularly in
places where access to facilities is not always available
- done in every baby at minute 1 and 5 minutes
- scores of 0-2 are given for:
o Heart rate
o Respiration
o Muscle tone
o Reflex response
o Colour

SIGN 0 1 2
Heart Rate Absent Below 100bpm Over 100bpm
Respiration Absent Slow/gasping Good cry
Muscle tone Flaccid Some flexion Active motion of
extremities
Reflex No response Cry or active response Grimace and
withdraw
Colour Blue or pale Body is pink, Completely pink
extremities are blue
- It is useful for describing the status of the neonate at birth and his or her subsequent
adaptation to the extrauterine environment
- If the score is less than 7, scores should be assigned every 5 minutes for up to 20 minutes
- Score of 4-6 with slow gasping breathing = MODERATE ASPHYXIA
- Score of 0-3 with no respiratory efforts = SEVERE ASPHYXIA

Asphyxia Neonatorum
- In compromised clinical situations, time for successful establishment of respiration and/or
colour should be noted
- If more than 5 minutes are required, it should be labelled as severe asphyxiaand less than 5
minutes as moderate asphyxia
- Perinatal Asphyxia is reserved for an infant who manifests
o Umbilical cord artery pH of less than 7 with a base deficit of 10mEq/L
o Apgar score is less than 5 minutes
o Neonatal neurological manifestations are suggestive of hypoxic ischaemic
encephalopathy
o There is evidence of multiorgan dysfunction
 Neonatal Resuscitation
- Maintenance of Temperature
o Immediately after delivery, baby should be dried through with a pre-warmed towel
and covered with another dry pre-warmed towel and then placed in the radiant
warmer
o Wet baby loses heat rapidly and drying with pre-warmed towels reduces
evaporative heat loss
- Suctioning
o If baby is vigorous, no suctioning of oro-pharynx or the trachea is required
o In non-vigorous babies, if there is copious secretions, turn the head to the side so
that secretions collect in the cheek and can be sucked out
o Oropharyngeal suction should be done in all non-vigorous babies and if baby is
delivered with meconium-stained liquor, suction may have to be followed by
tracheal intubation
o Secretions may be removed from the airway by wiping the nose and mouth with a
towel or by suctioning with a mucus extractor or suction catheter
o If suctioning is done, mouth should be suctioned before the nose to avoid any
aspirations of the contents if the baby gasps
o Vigorous suctioning of posterior pharynx is harmful and produces reflex
bradycardia and may damage the oral mucosa resulting in later difficulty in sucking
- Ventilation
o Normal newborn breathes within seconds of delivery and establishes regular
respiration within a minute of delivery
o The baby needs positive pressure ventilation if the baby is apnoeic or gasping, or
the heart rate is less than 100 bpm
o Before applying positive pressure ventilation, airway should be cleared and the
head is placed in a sniffing position
o Most babies respond to bag and mask ventilation, though it may be difficult
sometimes in premature babies with non-compliant lungs
- Indications for intubation
o Antenatally diagnosed congenital diaphragmatic hernia
o Depressed newborn with history of meconium-stained liquor
o For administration of drugs through ET tube
o Prolonged period of bag and mask is required or ineffective ventilation with bag
and mask
- External Cardiac Massage
o If heart rate does not increase to more then 60 bpm after effective ventilation,
external cardiac massage is required along with positive pressure ventilation at the
rate of 90 compressions and 30 ventilations to a depth of 1/3 of chest diameter
o If there is no response after 30 seconds, drug therapy should be initiated.
o There are 2 techniques
 Thumb Technique – both thumbs are used to depress the sternum, while the
hands encircle the torso and the fingers support the spine
 Neonatal Sepsis
- Invasive infection, usually bacterial in nature occurring in the neonatal period
- This can be
o Early – within 3 days of birth
o Late – after 3 days of birth

Clinical Features

- Diminished spontaneous activity

- Less vigorous sucking
- Apnoea
- Bradycardia
- Temperature instability
- Respiratory distress
- Vomiting, Diarrhoea
- Abdominal distension
- Jitters and Seizures
- Jaundice

Diagnosis

- Sepsis Screen
o Gastric Aspirate for polymorphs
o Micro ESR
o Absolute Neutrophil Count
o C reactive protein
o Band Cell Protein
- Blood Culture
o Must be obtained using 2 culture media, and at least 0.5mL of blood must be
collected in each bottle
o If less blood is available, 0.5mL of blood may be used in bile broth media
o It is the gold standard for the diagnosis of septicaemia
- Cerebrospinal Fluid Examination
o Done in all babies with suspected or proven sepsis, preferably before starting
antibiotics
o Abnormal CSF
 More than 30 WBC/mm3
 More than 60% of the WBC being polymorphs
 CSF glucose: blood glucose ratio < 50%
 Protein concentration > 150mg/dL
 Positive gram stain in CSF culture

Treatment

- Ampicillin + Gentamicin/Cefotaxime
o Narrowed to organism specific drugs as soon as possible
 Neonatal Jaundice
Physiological Jaundice

- Bilirubin values of >2mg/dL during the first week

Pathological Jaundice

- Clinical jaundice in the first 24 hours of life with total serum bilirubin increasing by
>5mg/dL/day
- Total serum bilirubin > 12.9/dL in full term infants and >15mg/dL in preterm infants
- Conjugated serum bilirubin > 1.5mg/dL
- Clinical Jaundice is persisting for >1 week in full term or > 2 weeks in preterms

Causes:

- Physiological Causes
- Prematurity
- Rh Incompatibility and ABO incompatilbilty
- Glucose-6-Phosphate Dehydrogenase deficiency
- Intrauterine infections
- Asphyxia
- Use of oxytocics during labour
- Congenital

Severity

- Face – 5-7mg/dL
- Chest – 10mg/dL
- Lower abdomen/thigh – 12 mg/dL
- Soles/palms - >15mg/dL

Complications

- Bilirubin Encephalopathy
o Stages
 Stage 1 – poor moro reflex, decreased tone, lethargy, poor feeding,
vomiting, high pitched cry
 Stage 2 – opisthotonos, seizures, fever, rigidity, oculogyric crisis, paralysis of
upward gaze
 Stage 3 – spasticity is decreased
 Stage 4 – late sequalae (spasticity, athetosis, deafness, mental retardation,
paralysis, dental dysplasia)

Investigations

- Blood grouping
- Screening for G6PD deficiency
- Haemogram – elevated reticulocyte count, fall in PCV, haemoglobin, peripheral smear
- Conjugated bilirubin fraction is estimated

Management – Phototherapy, Exchange transfusion, Immunoglobulins, Oral phenobarbitone, Agars,

Metalloporphyrins
 Erythroblastosis Fetalis
- Haemolytic disease caused by incompatibility of blood groups between the mother and the
foetus
- Characteristic clinical features
o Oedema
o Jaundice
o Anaemia
- These infants require special antenatal, intranatal and neonatal care
- Whenever a diagnosis of Rh-isoimmunisation is made, the patient should be referred to a
high-risk obstetric unit

Cephalohaematoma
- Represents a subperiosteal collection of blood overlying a cranial bone and is limited by
suture line
- It usually resolved within 1-2 months
- Significant hyperbilirubinaemia can result from a big cephalohaematoma
- Common associated complications include
o Skull fractures
o Intracranial bleeds

Caput Succedaneum
- Area of oedema over the presenting part, which is present at birth
- Resolves spontaneously within the next few days

Subgaleal Haemorrhage
- Collection of blood in the soft tissue space between the galea aponeurotica and the
periosteum of the skull
- Usually results from forceps delivery or vacuum extraction
- This is a serious life-threatening complication and is sometimes associated with systemic
signs and symptoms of blood loss
- Mortality rate is as high as 25%

Intracranial Bleed
- Intracranial haemorrhage is a life-threatening complication
- It may be subdural, intraparenchymal or intraventricular
- these are often associated with significant mortality and morbidity