2. Delivery is an unconditioned reflex act is
directed to expulsion of fetus from uterine
cavity. Term of gestation must be not less than
22 weeks, body weight of fetus – not less than
500 g.
Physiological delivery (labor) – delivery has
spontaneous beginning and labor activity
progress in low-risk group pregnant woman at
term of pregnancy 37-42 weeks.
3. immunological,
humoral,
oxytocine,
nervous plexus compressing etc.
An important role of neurohumoral and
hormonal systems of mother’s organism and
fetoplacental complex has been proofed at
present time.
placental.
4. Predominance of breake processes in brain
cortex and subcortical structures irritability
are present at the end of pregnancy and labor
beginning. Spinal reflexes increase, reflex and
muscular irritability are increased.
Estrogens level increase and progesterone
level decrease take place last two weeks of
pregnancy especially before labor.
5. An important role in labor activity beginning
have prostaglandins (Е2, F2а) are produced
in decidua and fetal membranes; their
production increase before labor.
Prostaglandins biosynthesis are activated by
steroid hormones, so estrogens level increase
lead to prostaglandins level increase in
uterus. Adrenal glands of fetus take place in
this process.
Prostaglandins induce labor by myometrium
cells membranes depolarization that leads to
calcium ions activation and contraction of
myometrium. Besides that, prostaglandins
stimulate oxytocin secretion and
progesterone destruction.
6. There are different mediator and hormonal
receptors in myometrium: α-adrenoreceptors,
serotonin, m-cholino-, gystamino-, estrogen-,
progesterone- prostaglandin- receptors. There
are Е2-receptors in cervix and F2α-receptors
in corpus of uterus.
Sensitivity of uterine receptors depends on
hormonal homeostasis, mainly on correlations
of sex steroid hormones – estrogens and
progesterone. Level of estrogens is in direct
dependence on functional state of fetus and
placenta. So, fetus renders determining
influence on active estrogens level in placenta
and mother’s blood. Normal labor activity
takes place on a background of optimal
maintenance of estrogens and formations of
enough active receptors in uterus.
7. 1. Cervix preparation for labor.
2. Instrumental in α-adrenoreceptors formation on the
surface of myocytes which react on oxytocynic
(oxytocyn, prostaglandins, serotonin) and bioactive
matters (catecholamines, acetylcholine, kinins).
3. Promote activity of phospholypase. Those lead to
lysosomal membranes destabilization and free and
activate prostaglandins Е2 and F2α from arachidonic
acid.
4. Synthesis of contractive proteins in myometrium
increase such as another matters are necessary for
energy of uterine contractions synthesis.
5. Permeability of cellular membranes increase for ions,
which increase myometrial cells sensitivity to irritation.
6. Increase of speed and intensity of biochemical
reactions.
7. Increase of blood stream and circulation of blood in
myometrium, oxygen use, intensity of ORP processes,
power providing of uterus.
8. Estrogens promote and structural changes of
cervix, myometrium preparation for uterine
pacemaker formation, synchronizations of
complex case bound smoothle bunches
(layers) contractions in uterus.
An important pre-condition of normal course
of labor is «maturation» of cervix.
Tissue of cervix undergoes to hydratation, to
making friable, destruction of connections in
collagen fibers.
9. -Hydratation (tissue of cervix absorbs water
actively);
-Making collagen net friable with collagen
concentration decrease;
-Destabilization of connections between
different fibers;
- Change of structure and concentration of
proteoglycans;
- Change of mechanical properties of cervix
(soft, elastic, pliable).
10. Time for cervix preparation to labor makes on
the average 8-14 days. High levels of estrogens
and prostaglandins Е2 that promote collagen
distention have influence to process of cervical
maturation. Processes of cervix and
myometrium preparation to labor have common
factors of adjustment and normally take place
synchronously.
Structural changes of cervix usually finish to
38-40th week of pregnancy.
11. - it is located on the pelvic axis (is centered);
- an external os is located on the level of a
spinal line;
- it is shortened to 1.5-2.0 cm;
- it is fully softened;
- an internal os is soft, fluently pass to lower
segment;
- cervical canal is 2-3 cm dilated (freely skips a
finger);
- lenght of vaginal part of cervix correspond to
lenght of cervical canal.
12. Fetus accepts optimal flexor position under
the action of preparatory contractions of
uterus till the end of pregnancy. Head of
fetus fixes densely (cuddles to a pelvic inlet)
ore disposes in a pelvic inlet by a small
segment. Sagittate suture sets in an oblique
or transversal diameter, small fontanel –
under the pubis. All that will promote more
easy passage of fetus in future.
Preparative contractions of uterus are
characterized by not only structural changes
of cervix, and by complete painlessness, big
intervals between separate uterine
contractions (so called «folce» birth pains),
might continue some hours and even some
days.
13. Level of serotonin which promote retractive
activity of myometrium increase during
preparative pre-labor period. Level of oxytocin
which stimulate frequency and amplitude of
birth pains and promotes tone of uterus
increase till the end of pregnancy at enough
estrogens saturation.
Prostaglandins and oxytocin are synergists,
they are able to strengthen the action of each
other.
14. 1. Uterine fundus goes down on a few cm due to
amount of amniotic waters decrease.
2. Presenting part of fetus is densely fixed in pelvic
inlet.
3. Cervix becomes soft, elastic, tensile.
4. Muco-serous discharges appear from birth canal.
5. «Labor dominant» - stagnant focus of excitation,
regulating preparation to labor and process of labor
forms in CNS. It shows up by an enhanceable
somnolence, internal concentration.
6. Tissues of birth canal (myometrium, cervix, vagina,
pelvic articulations) are satiated by estrogens
maximally (estriol).
15. 7. Excitability of uterus increases.
8. The precursor labor pains (spontaneous
contractions of uterus) appear.
9. Body weight of pregnant goes down on 800-
1000 gr. 5-7 days before labor.
10. Sympathoadrenal system activity increase.
11. Force of uterine contractions increase.
Solitary coordinated contractions that lead to
gradual shortening and dilatation of cervix
arrear. An internal cervical os fluently pass
to lower segment of uterus.
12. Separation of fetal membranes on lower
pole of amniotic sac from uterine wall takes
place. Those lead to intensive synthesis of
prostaglandins.
16.
17. After months of relative inactivity during pregnancy,
the uterus contracts more and more often in the weeks
before birth. Occasional uterine contractions have
taken place throughout pregnancy, but they have been
so sporadic and weak that they have had no effect on
the cervix.
Contractions during last weeks of pregnancy irregular
and imperceptible to the mother but they are more
frequent and coordinated than earlier ones.
These contractions were first described by an English
doctor named John Braxton. Hicks in 1872, and hence
they became known by his name.
If Braxton Hicks contractions increase and become
rhythmic late in the pregnancy, they are referred to as
"false labor."
18.
19. - After 37th week – spastic pains at the low
regions of stomach and sacrum with
mucosanguineous or watery discharges from
vagina appearance.
- Not less than 1 birth pain by duration 15-20
sec per 10 min.
- Change of shape and disposition of cervix;
dilatation of cervix.
- Gradual descending of head of fetus to pelvic
inlet.
20. A delivery act
is a process of
cooperation of
3 components:
labor forces,
birth canal
and fetus.
21. - Development of automatic regular contractive
activity of uterus (birth pains).
- Changes of structure of cervix, which
shortens, smoothles completely and as
disappear, is transformed in an uterine os.
- Distention of lower segment. A clear border is
a contraction ring is formed between body and
lower segment of uterus. It can be determined
at outward palpation as deep furrow. High of
contraction ring above pubis usually
correspond to degree of cervical dilatation.
22. - A ring of contiguity formation between
pelvic bones of mother and head of fetus,
due to what takes place division of amniotic
waters on two non-equal portions: greater
part – posterior waters, which are higher
than a ring of contiguity and less part -
anterior waters, being below a ring of
contiguity and fillings an amniotic sac.
- Gradual dilatation of an internal os until
complete dilatation - 10 cm.
- Passage of fetus on a birth canal and his
(her) delivery.
- Placenta separation and afterbirth
(placenta+cord+membranes) expulsion.
23. I stage – dilatation of cervix – starts from the
beginning of regular birth activity and finishes
by complete dilatation of cervix (10 cm).
II stage - expulsion of fetus – starts from
complete dilatation of cervix, when labor
pushing appears, and finishes by (expulsion,
extraction) of fetus.
III stage - stage of placenta separation and
afterbirth expulsion, starts from birth of fetus
and finishes by complete expulsion of
afterbirth.
Mean time of physiological labor - 7-12
hours.
24. Labor (expulsive) forces - are complex
physiological process, are regulated by by
nervous and humoral ways.
Uterus is innervated by sympathetic and
parasympathetic nerves. The main
sympathetic mediators are noradrenalin and
adrenalin. A physiological effect of
catecholamines takes place by their action
through two types of adrenoreceptors - а and
β. At excitation of α-adrenoreceptors
contraction of uterus happens, at excitation of
β-adrenoreceptors – braking of contractive
uterine function.
25. At physiological course of labor contraction of uterine
muscles take place under the action of acetylcholine.
In future there is destruction of acetylcholine by a
cholinesterase, that leads to gradual wave of
contraction falling. Next contraction of uterus arises
up at appearance of new portion of acetylcholine.
Wave of contraction of birth pain begins in one of
uterine tube corners («pacemaker») and spreads with
decreasing force downward, to lower segment and
cervix uteri. Speed of uterine contraction spread is 2-5
cm/sec. After 15-20 sec. contractions engulf all
uterus. Pacemaker usually is located in place opposite
to placenta location. Besides that, it can migrate,
displace to body, lower segment of uterus, that lead to
pathology of contractive activity of uterus and
abnormal birth pains. Pacemaker is not anatomical but
physiological conception.
26. REVIEW OF NORMAL UTERINE ACTION:
Regular interval.
Interval gradually shortens.
Intensity gradually increases.
Discomfort in the back and abdomen.
Associated with cervical dilatation.
Discomfort not relieved by sedation.
27.
28. Uterine contractions starts in fundus of uterus
(in the region of one of tube corners) and
spread from top to down (from uterine fundus
to lower segment) with decreasing strength.
Superior parts of uterus contracts more strong
than lower regions that lead to traction of
cervical muscle fibers up. Amplitude of
contraction of fundus 3 times more than lower
segment. That phenomenon is named «triple
descending gradient». Duration of contraction
diminishes according to retire from the fundus
of uterus to lower segment.
29. REVIEW OF NORMAL UTERINE
CONTRACTIONS POLARITY OF UTERUS:
when upper segment contracts, lower
segment relaxes.
PACEMAKERS: two pacemakers situated
at each corners of uterus generating
the contraction in coordinated manner.
PATTERN OF CONTRACTIONS: uterine
contraction starts at corners,
propagates towards lower uterine
segment with decrease in the duration
and intensity of contraction as it
moves away from pacemaker.
30. - Under the action of mediators of autonomous
nervous system (noradrenalin, adrenalin,
acetylcholine), prostaglandins Е2, F2α, oxytocin and
others bioactive matters, which act in α-
adrenoreceptors, contraction of all longitudinally
located smoothle fibers takes place (processes of
retraction and contraction).
- Active relaxation of smoothle fibers have circular
direction takes place at the same time, which
determines distraction of lower segment and cervix
of uterus.
- Uterine contraction (systole of birth pain) continues
to diastole (relaxation). A diastole is usually longer
than systole of birth pain.
31.
32.
33. Frequency of birth pains is determined by
number of uterine contractions per 10 min.
Frequency of birth pains in case of normal labor
is 3 to 5 per 10 min.
During first 4-5 hours of labor main structural
changes of cervix take place. After smoothing
and 3-4 cm dilatation of cervix active phase of
labor starts. Speed of dilatation of cervix
increase 1,5-2 times.
Speed of fetus passage increase unevenly too. It
is 1 cm/hour during 1 stage of labor. After
complete dilatation (II stage of labor) of cervix it
increases to 4 cm/hour.
34. I - latent – phase starts from
appearance of regular birth pains
and finishes by 4 cm dilatation of
cervix. Its duration is about 4-5
hours. Birth pains are painless or a
little painful. Woman is quiet.
Speed of dilatation of cervix is 0,35
cm/hour.
35. After 4 cm dilatation and proceeds to
complete dilatation of cervix II – active
– phase of labor starts. It is
characterized by active labor activity
and rapid dilatation of uterine os.
Mean time of this phase is 3-4 hours.
Speed of dilatation of cervix is 1,5-2
cm/hour in primapara and 2-2,5
cm/hour in multypara. After amniotic
waters outflow in active phase labor
activity increase.
38. 1 - A ring of
contiguity ;
2 – anterior
waters;
3 – posterior
waters.
39. Since moment of complete dilatation of cervix II
stage of labor (fetus expulsion) starts; it ends
by fetus (child) birth. In the second stage of
labor head of fetus pass broad and narrow parts
of pelvic cavity and descends on a pelvic floor.
Duration of II stage of labor is 30-60 min in
primapara, 15-20 min in multypara.
In the end of II stage, when presented part
irritates receptors of inferior part of vagina and
of pelvic floor, labor pushing (contractions of
skeleton muscles and diaphragm) appear
additionally to labor (birth) pains.
40. Forward movements of fetus take place on an
axis of birth canal, presenting part do some
adaptive movements (biomechanism of labor).
In case of well-coordinated labor activity,
physiological course of labor fetus does not
suffer during labor pains. Frequency of fetal
palpitations does not change strongly, it’s
maximal change in I stage is ±12 st./min.
41. To estimate degree of risk of maternal and
perinatal pathology development.
To determine a plan of the labor conduct and
to receive an informed agreement of woman.
To control mother’s and fetus’ condition
during labor (with partogram use).
Anaesthetization – in indications.
To estimate condition of fetus after birth,
primary conduct of newborn, early breast-
feeding.
42. Estimation of fetus’ condition: frequency of heartbeats
of fetus per 1 min. – every 15 min. during active phase
and every 5 min. during II stage of labor.
2) Estimation of mother’s condition: body temperature
– every 4 hours, parameters of pulse and arterial
blood pressure – every 2 hours; dyuresis – every 4
hours.
3) Estimation of labor activity effectiveness:
- frequency, duration and intensity of birth pains –
every 1 hour in latent phase and every 30 min. in active
phase;
- bimanual (internal) obstetrical examination – every 4
hours; position of fetal presenting part – during every
external and internal obstetrical examination.
4) If rupture of amniotic sac has happened – control of
color, consistency and amount of amniotic waters.
43. Woman may choose the most comfortable
position in II stage of labor. Estimation of
general state of woman, her hemodynamic
indexes (AP, pulse – every 10 min.), fetus’
condition (control of heartbeats – every 5
min.), passage of fetal head throw birth canal.
Amnyotomy should be done in indications.
Delivery of head of fetus needs for gentle
obstetrical manual aid (protection of
perineum) use.
44. 10 UA of oxytocin should be injected intramuscularly
during first minute after childbirth for hemorrhage
prophylaxis.
Controlled traction by cord might be done only at
positive signs of placenta separation presence. At
absence of signs of placenta separation and external
bleeding during 30 min. after child birth manual
separation of placenta and removal of afterbirth must
be done.
Massage of uterine fundus throw anterior abdominal
wall and catheterization of urinary bladder should be
used at once after afterbirth expulsion.
After afterbirth expulsion it must be examined to be
shure all placenta and membranes has been removed
completely and uterus has contracted.
45.
46.
47.
48.
49. The puerperium is the
period of time
encompassing the first
few weeks following birth.
The duration of this
period is understandably
inexact, and it is
considered by most to be
between 6 and 8 weeks.
50. Vagina and Vaginal Outlet
Early in the puerperium, the vagina and its outlet
form a capacious, smooth-walled passage that
gradually diminishes in size but rarely returns to
nulliparous dimensions.
Rugae begin to reappear by the third week but are
not as prominent as before.
The hymen is represented by several small tags of
tissue.
Vaginal epithelium begins to proliferate by 4 to 6
weeks, usually coincidental with resumed ovarian
estrogen production.
51. Lacerations or stretching of the perineum
during delivery may result in relaxation of the
vaginal outlet.
Some damage to the pelvic floor may be
inevitable, and parturition predisposes to
uterine prolapse as well as urinary and anal
incontinence.
52. Uterine Vessels
The massively increased uterine blood flow
necessary to maintain pregnancy is made
possible by significant hypertrophy and
remodeling of all pelvic vessels.
After delivery, their caliber diminishes to
approximately the size of the prepregnant state.
Within the puerperal uterus, larger blood vessels
become obliterated by hyaline changes,
gradually resorbed and replaced by smaller
ones.
Minor vestiges of the larger vessels, however, may
persist for years.
53. Cervix and Lower Uterine Segment
During labor, the outer cervical margin, which corresponds to
the external os, is usually lacerated, especially laterally.
The cervical opening contracts slowly and for a few days
immediately after labor readily admits two fingers.
By the end of the first week, this opening narrows, the cervix
thickens, and the endocervical canal reforms.
The external os does not completely resume its pregravid
appearance. It remains somewhat wider, and typically,
bilateral depressions at the site of lacerations become
permanent. These changes are characteristic of a parous
cervix.
54. The markedly thinned-out lower uterine segment
contracts and retracts, but not as forcefully as
the uterine corpus.
During the next few weeks, the lower segment is
converted from a clearly distinct substructure
large enough to accommodate the fetal head, to
a barely discernible uterine isthmus located
between the corpus and internal os.
Cervical epithelium also undergoes considerable
remodeling, and this actually may be salutary.
55. Uterine Involution
Immediately after placental expulsion, the fundus
of the contracted uterus lies slightly below the
umbilicus. It consists mostly of myometrium
covered by serosa and lined by basal decidua.
The anterior and posterior walls, in close
apposition, each measure 4 to 5 cm thick.
Immediately postpartum, the uterus weighs
approximately 1000 g.
Because the blood vessels are
compressed by the contracted
myometrium, the uterus on
section appears ischemic
compared with the reddish-
purple hyperemic pregnant
organ.
56. Two days after delivery, the uterus
begins to involute, and at 1 week,
it weighs about 500 g.
By 2 weeks, it weighs about 300 g
and has descended into the true
pelvis.
Around 4 weeks after delivery, it
regains its previous nonpregnant
size of 100 g or less.
At the end of the first day
postpartum fundus level is 16-18
cm above simphysis, and normally
it descends not less than 2 cm a
day.
The total number of muscle cells
probably does not decrease
appreciably.
Involution of the connective tissue
framework occurs equally rapidly.
57. Because separation of the placenta
and membranes involves the spongy
layer, the decidua basalis is not
sloughed.
The decidua that remains has striking
variations in thickness, has an
irregular jagged appearance, and is
infiltrated with blood, especially at the
placental site.
It takes up to 5 weeks for the uterine
cavity to regress to its nonpregnant
state of a potential space.
58. Afterpains
In primiparas, the uterus tends
to remain tonically contracted
following delivery.
However, in multiparas, it often
contracts vigorously at intervals
and gives rise to afterpains,
which are similar to but milder
than the pain of labor
contractions.
They are more pronounced as
parity increases and worsen
when the infant suckles, likely
because of oxytocin release.
Usually, afterpains decrease in
intensity and become mild by
the third day.
59. Lochia
Early in the puerperium, sloughing
of decidual tissue results in a vaginal
discharge of variable quantity.
The discharge is termed lochia.
Lochia persists for up to 4 to 8 weeks after
delivery.
60. For the first few days after delivery, there is blood
sufficient to color it red—lochia rubra. It is made up of
mainly blood, bits of fetal membranes, decidua,
meconium and cervical discharge.
After 3 or 4 days, lochia becomes progressively pale in
color—lochia serosa. The lochia serosa contains less
red blood cells but more white blood cells, wound
discharge from the placental and other sites, and
mucus from the cervix.
After about the 10th day, because of an admixture of
leukocytes and reduced fluid content, lochia assumes
a white or yellowish-white color—lochia alba. It mainly
consists of decidual cells, mucus, white blood cells,
and epithelial cells.
61. Endometrial Regeneration
Within 2 or 3 days after delivery, the remaining
decidua becomes differentiated into two layers.
The superficial layer becomes necrotic and is
sloughed in the lochia. The basal layer adjacent
to the myometrium remains intact and is the
source of new endometrium.
The endometrium arises from proliferation of the
endometrial glandular remnants and the stroma
of the interglandular connective tissue.
Endometrial regeneration is rapid, except at the
placental site. Within a week or so, the free
surface becomes covered by epithelium, and fully
restored endometrium obtained from the 16th
day.
Histological endometritis is part of the normal
reparative process, it does not reflect infection.
62. Uterine Subinvolution
This term describes an arrest or
a retardation of involution. It is
accompanied by prolongation of
lochial discharge and irregular or
excessive uterine bleeding, which
sometimes may be profuse.
On bimanual examination, the uterus is larger and
softer than would be expected.
Both retention of placental fragments and pelvic
infection may cause subinvolution.
Ergonovine or methylergonovine (Methergine), 0.2 mg
every 3 to 4 hours for 24 to 48 hours, is recommended
by some for subinvolution, but its efficacy is
questionable.
On the other hand, bacterial metritis responds to oral
antimicrobial therapy. Thus, azithromycin or
doxycycline therapy is appropriate empirical therapy.
63. Placental Site Involution
Complete extrusion of the placental site takes up to 6
weeks.
When this process is defective, late-onset puerperal
hemorrhage may ensue.
Immediately after delivery, the placental site is
approximately the size of the palm, but it rapidly
decreases thereafter. Within hours of delivery, the
placental site normally consists of many thrombosed
vessels that ultimately undergo organization. By the end
of the second week it is 3 to 4 cm in diameter.
The involution is not simply absorption in situ.
Exfoliation consists of both extension and "downgrowth"
of endometrium from the margins of the placental site,
as well as development of endometrial tissue from the
glands and stroma left deep in the decidua basalis after
placental separation. The placental site exfoliation
results from sloughing of infarcted and necrotic
superficial tissues followed by a remodeling process.
64.
65. Urinary Tract
Bladder trauma is associated most closely with
the length of labor and thus to some degree is a
normal accompaniment of vaginal delivery.
Postpartum, the bladder has an increased
capacity and a relative insensitivity to intravesical
pressure. Thus, overdistension, incomplete
emptying, and excessive residual urine are
common.
The dilated ureters and renal pelves return to
their prepregnant state over the course of 2 to 8
weeks after delivery.
Urinary tract infection is of concern because
residual urine and bacteriuria in a traumatized
bladder, coupled with a dilated collecting system,
are conducive to infection.
66. Peritoneum and Abdominal Wall
The broad and round ligaments require considerable time to
recover from the stretching and loosening that occur
during pregnancy.
As a result of ruptured elastic fibers in the skin and
prolonged distension caused by the pregnant uterus, the
abdominal wall remains soft and flaccid.
Several weeks are required for these structures to return to
normal.
Recovery is aided by exercise.
Except for striae, the abdominal wall usually resumes its
prepregnancy appearance.
67. When muscles remain atonic, however, the
abdominal wall also remains lax.
Marked separation of the rectus muscles –
diastasis recti – may result.
68. Blood and Fluid Changes
Marked leukocytosis and thrombocytosis may
occur during and after labor.
The white blood cell count sometimes reaches
30,000*109/L, with the increase predominantly
due to granulocytes.
There is a relative lymphopenia and an absolute
eosinopenia.
Normally, during the first few postpartum days,
hemoglobin concentration and hematocrit
fluctuate moderately.
If they fall much below the levels present just
prior to labor, a considerable amount of blood
has been lost.
69. Although not extensively studied, in most
women, blood volume has nearly returned to
its nonpregnant level by 1 week after
delivery.
Cardiac output usually remains elevated for
24 to 48 hours postpartum and declines to
nonpregnant values by 10 days.
Heart rate changes follow this pattern.
Systemic vascular resistance follows inversely.
It remains in the lower range characteristic of
pregnancy for 2 days postpartum and then
begins to steadily increase to normal
nonpregnant values.
70. Pregnancy-induced changes in blood
coagulation factors persist for variable
periods during the puerperium.
Elevation of plasma fibrinogen is maintained
at least through the first week, and hence, so
is the sedimentation rate.
Normal pregnancy is associated with an
appreciable increase in extracellular water,
and postpartum diuresis is a physiological
reversal of this process. This regularly occurs
between the second and fifth days and
corresponds with loss of residual pregnancy
hypervolemia.
71. Breasts and Lactation
Anatomically, each mature mammary
gland or breast is composed of 15 to
25 lobes. They are arranged radially
and are separated from one another
by varying amounts of fat.
Each lobe consists of several lobules,
which in turn are composed of large
numbers of alveoli.
Each alveolus is provided with a small
duct that joins others to form a
single larger duct for each lobe.
These lactiferous ducts open
separately on the nipple, where they
may be distinguished as minute but
distinct orifices.
The alveolar secretory epithelium
synthesizes the various milk
constituents.
72.
73. Colostrum
After delivery, the breasts begin to
secrete colostrum, which is a deep
lemon-yellow liquid. It usually can be
expressed from the nipples by the second postpartum
day.
Compared with mature milk, colostrum contains more
minerals and amino acids. It also has more protein,
much of which is globulin, but less sugar and fat.
Secretion persists for approximately 5 days, with
gradual conversion to mature milk during the ensuing 4
weeks.
Colostrum contains antibodies, and its content of
immunoglobulin A (IgA) offers the newborn protection
against enteric pathogens.
Other host resistance factors found in colostrum and
milk include complement, macrophages, lymphocytes,
lactoferrin, lactoperoxidase, and lysozymes.
74. Milk
Human milk is a suspension of fat and protein in a
carbohydrate-mineral solution.
A nursing mother easily produces 600 mL of milk
daily, and maternal gestational weight gain has
little impact on its quantity or quality.
Milk is isotonic with plasma, and lactose accounts
for half of the osmotic pressure.
Essential amino acids are derived from blood, and
nonessential amino acids are derived in part from
blood or synthesized in the mammary gland.
Most milk proteins are unique and include
lactalbumin, lactoglobulin, and casein.
Fatty acids are synthesized in the alveoli from
glucose and are secreted by an apocrine-like
process.
All vitamins except K are found in human milk, but
in variable amounts. Vitamin D content is—22
IU/mL.
75. Whey is milk serum and
has been shown to
contain large amounts
of interleukin-6. It is
associated closely with
local IgA production by
the breast.
Prolactin appears to be
actively secreted into breast milk.
Epidermal growth factor (EGF) has been identified
in human milk, and because it is not destroyed
by gastric proteolytic enzymes, it may be
absorbed to promote growth and maturation of
newborn intestinal mucosa.
76. Endocrinology of Lactation
The precise humoral and neural
mechanisms involved in lactation are
complex.
Progesterone, estrogen, and placental
lactogen, as well as prolactin, cortisol,
and insulin, appear to act in concert to
stimulate the growth and development of
the milk-secreting apparatus.
With delivery, there is an abrupt and
profound decrease in the levels of
progesterone and estrogen. This decrease
removes the inhibitory influence of
progesterone on lactalbumin production
by the rough endoplasmic reticulum.
Increased lactalbumin stimulates lactose
synthase to increase milk lactose.
Progesterone withdrawal also allows
prolactin to act unopposed in its
stimulation of -lactalbumin production.
77. The intensity and duration of subsequent lactation
are controlled, in large part, by the repetitive
stimulus of nursing.
Prolactin is essential for lactation, and women with
extensive pituitary necrosis—Sheehan
syndrome—do not lactate.
Although plasma prolactin levels fall after delivery
to levels lower than during pregnancy, each act
of suckling triggers a rise in levels.
Presumably a stimulus from the breast curtails the
release of dopamine (prolactin-inhibiting factor)
from the hypothalamus, and this in turn
transiently induces increased prolactin secretion.
78. The neurohypophysis secretes oxytocin in
pulsatile fashion. This stimulates milk
expression from a lactating breast by causing
contraction of myoepithelial cells in the
alveoli and small milk ducts.
Milk ejection, or letting down, is a reflex
initiated especially by suckling, which
stimulates the neurohypophysis to liberate
oxytocin. The reflex may even be provoked
by an infant cry and can be inhibited by
maternal fright or stress.
79.
80. Immunological Consequences of Breast
Feeding
Antibodies in human colostrum and milk are poorly
absorbed by infants. This does not lessen their
importance because the predominant
immunoglobulin is secretory IgA. This macromolecule
is secreted across mucous membranes and has
important antimicrobial functions.
Milk contains secretory IgA antibodies against
Escherichia coli, and breast-fed infants are less prone
to enteric infections than bottle-fed infants.
Human milk also provides protection against rotavirus
infections, which cause up to half of cases of infant
gastroenteritis in this country.
Breast feeding also likely reduces the risk of atopic
dermatitis and wheezing illnesses in early childhood.
81. Much attention has been directed to the role of
maternal breast-milk lymphocytes in the
immunological processes of the newborn.
Milk contains both T and B lymphocytes, but the T
lymphocytes appear to differ from those found in
blood.
Specifically, milk T lymphocytes are almost
exclusively composed of cells that exhibit specific
membrane antigens, including the LFA-1 high-
memory T-cell phenotype.
These memory T cells appear to be another avenue
for the neonate to benefit from the maternal
immunological experience.
Lymphocytes in colostrum undergo blastoid
transformation in vitro following exposure to
specific antigens.
82.
83. Nursing
Human milk is ideal food for neonates. It provides age-
specific nutrients as well as immunological factors and
antibacterial substances.
Milk also contains factors that act as biological signals for
promoting cellular growth and differentiation.
Breast feeding is associated with decreased postpartum
weight retention.
85. Ten Steps to Successful Breastfeeding (WHO/UNICEF)
1. Every facility providing maternity services and care for newborn infants
should:
2. Have a written breastfeeding policy that is routinely communicated to
all health care staff.
3. Train all health care staff in skills necessary to implement this policy.
4. Inform all pregnant women about the benefits and management of
breastfeeding.
5. Help mothers initiate breastfeeding within half an hour of birth.
6. Show mothers how to breastfeed, and how to maintain lactation even
if they should be separated from their infants.
7. Give newborn infants no food or drink other than breast milk, unless
medically indicated.
8. Practise rooming-in - that is, allow mothers and infants to remain
together - 24 hours a day.
9. Encourage breastfeeding on demand.
10.Give no artificial teats or pacifiers (also called dummies or soothers) to
breastfeeding infants.
11.Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital or clinic.
86. Breast Engorgement
Women who do not breast feed may experience
engorgement, milk leakage, and breast pain, which
peaks at 3 to 5 days after delivery. As many as half
require analgesia for breast-pain relief. Up to 10
percent of women report severe pain up to 14 days.
Breasts should be supported with a well-fitting
brassiere. Pharmacological or hormonal agents are
not recommended to suppress lactation. Instead, ice
packs and oral analgesics for 12 to 24 hours can be
used to relieve discomfort.
Milk Fever
Puerperal fever from breast engorgement is common.
Fever seldom persisted for longer than 4 to 16 hours.
The incidence and severity of engorgement, and fever
associated with it, are much lower if women breast
feed. Other causes of fever, especially those due to
infection, must be excluded.
87. Contraception for Breast-
Feeding Women
Ovulation may resume as
early as 3 weeks after
delivery, even in lactating
women.
Its timing depends on individual
biological variation as well as the
intensity of breast feeding.
Progestin-only contraceptives—
"mini-pills," depot
medroxyprogesterone, or
progestin implants—do not affect
the quality or quantity of milk.
88. Progestin-only oral contraceptives prescribed or
dispensed at discharge from the hospital to be
started 2–3 weeks postpartum—for example,
the first Sunday after the newborn is 2 weeks
old.
Depot medroxyprogesterone acetate initiated at
6 weeks postpartum.
Hormonal implants inserted at 6 weeks
postpartum.
The levonorgestrel intrauterine system can be
inserted at 6 weeks postpartum.
89. Contraindications to Breast Feeding
Nursing is contraindicated:
in women who take street drugs or do not
control their alcohol use;
have an infant with galactosemia;
have human immunodeficiency virus (HIV)
infection;
have active, untreated tuberculosis;
take certain medications;
or are undergoing treatment for breast cancer.
Breast feeding has been recognized for some time
as a mode of HIV transmission.
90. Other viral infections do not contraindicate breast
feeding.
For example, with maternal cytomegalovirus
infection, both virus and antibodies are present
in breast milk.
And although hepatitis B virus is excreted in milk,
breast feeding is not contraindicated if hepatitis
B immune globulin is given to these infants.
Maternal hepatitis C infection is not a
contraindication because the 4-percent risk of
infant transmission is the same for breast- and
bottle-fed infants.
Women with active herpes simplex virus may
suckle their infants if there are no breast lesions
and if particular care is directed to hand washing
before nursing.
91. Care of Breasts
1. The nipples require little attention other than
cleanliness and attention to skin fissures.
2. Fissured nipples render nursing painful, and they
may have a deleterious influence on milk
production.
3. These cracks also provide a portal of entry for
pyogenic bacteria.
4. Because dried milk is likely to accumulate and
irritate the nipples, washing the areola with water
and mild soap is helpful before and after nursing.
5. When the nipples are irritated or fissured, it may be
necessary to use topical lanolin and a nipple shield
for 24 hours or longer.
6. If fissuring is severe, the infant should not be
permitted to nurse on the affected side.
7. Instead, the breast should be emptied regularly with
a pump until the lesions are healed.
92.
93. LATCH was created to provide a systematic method for
breastfeeding assessment and charting.
94.
95. Drugs Secreted in Milk
Most drugs given to the mother are secreted in breast milk.
However, the amount of drug ingested by the infant
typically is small.
Many factors influence drug excretion, including plasma
concentration, degree of protein binding, plasma and milk
pH, degree of ionization, lipid solubility, and molecular
weight.
The ratio of drug concentrations in breast milk to those in
maternal plasma is the milk-to-plasma drug-concentration
ratio.
Most drugs have a milk-to-plasma ratio of 1 or less, about
25% have a ratio of more than 1, and about 15 percent have
a ratio greater than 2.
Ideally, to minimize infant exposure, medication selection
for the mother should favor drugs with a shorter half-life,
poorer oral absorption, and lower lipid solubility.
If multiple, daily drug doses are required, then each is
taken by the mother after the closest feed.
Single daily-dosed drugs may be taken just prior to the
longest infant sleep interval—usually at bedtime.
96. There are only a few drugs that need to be avoided
while breast feeding.
Cytotoxic drugs may interfere with cellular
metabolism and potentially cause immune
suppression or neutropenia, affect growth, or at
least theoretically, increase the risk of childhood
cancer.
Examples include cyclophosphamide, cyclosporine,
doxorubicin, and methotrexate.
If a medication presents a concern, then the
importance of therapy should be ascertained, as
well as whether a safer alternative is available and
whether neonatal exposure can be minimized if
the medication dose is taken immediately after
each breast feeding.
97. Drugs Have Been Associated with Significant Effects on Nursing Infants
Drug Reported Effect
Acebutolol Hypotension, bradycardia, tachypnea
5-Aminosalicylic acid Diarrhea (onecase)
Atenolol Cyanosis, bradycardia
Bromocriptine Suppresses lactation, may be hazardous to the mother
Aspirin (salicylates) Metabolicacidosis (onecase)
Clemastine Drowsiness, irritability, refusal to feed, high-pitched cry, neck stiffness (one
case)
Ergotamine Vomiting, diarrhea, convulsions—doses used in migraine medications
Lithium A third to half therapeutic blood concentration in infants
Phenindione Anticoagulant—increased prothrombin and partial thromboplastin time in one
infant—not used in United States
Phenobarbital Sedation; infantile spasms after weaning from milk containing phenobarbital;
methemoglobinemia (one case)
Primidone Sedation, feedingproblems
Sulfasalazine Bloody diarrhea (one case)
98. Radioactive isotopes of copper, gallium, indium,
iodine, sodium, and technetium rapidly appear in
breast milk.
Consultation with a nuclear medicine specialist is
recommended before performing a diagnostic study
with these isotopes.
The goal is to use a radionuclide with the shortest
excretion time in breast milk.
The mother should pump her breasts before the
study and store enough milk in a freezer for feeding
the infant.
After the study, she should pump her breasts to
maintain milk production but discard all milk
produced during the time that radioactivity is
present.
This ranges from 15 hours up to 2 weeks, depending
on the isotope used.
99. Galactocele
Occasionally a milk duct
becomes obstructed by
inspissated secretions,
and milk may accumulate
in one or more mammary
lobes.
The amount is ordinarily limited, but an
excess may form a fluctuant mass – a
galactocele – that may cause pressure
symptoms and have the appearance of an
abscess.
It may resolve spontaneously or require
aspiration.
100. Accessory Breast Tissue
Extra breasts—polymastia, or extra nipples—
polythelia, may develop along the former
embryonic mammary ridge.
Also termed the milk line, this line extends from
the axilla to the groin bilaterally.
The incidence of accessory breast tissue ranges
from 0.22 to 6% in the general population.
Breasts may be so small as to be mistaken for
pigmented moles, or when without a nipple, for
lymphadenopathy or a lipoma.
Polymastia has no obstetrical significance,
although occasionally their enlargement during
pregnancy or engorgement postpartum may
result in discomfort and anxiety.
101. Abnormalities of Secretion
There are marked individual variations in the
amount of milk secreted.
Many of these are dependent not on general
maternal health but on breast glandular
development.
Rarely, there is complete lack of mammary
secretion—agalactia.
Occasionally, mammary secretion is
excessive—polygalactia.
102. Hospital Care
For the first 2 hours after delivery, blood pressure and
pulse should be taken every 15 minutes, or more
frequently if indicated.
The amount of vaginal bleeding is monitored, and the
fundus palpated to ensure that it is well contracted.
103. If relaxation is detected, the uterus should be
massaged through the abdominal wall until it
remains contracted. The addition of uterotonins
is sometimes required.
Blood may accumulate within the uterus without
external bleeding. This may be detected early by
detecting uterine enlargement during fundal
palpation in the first postdelivery hours.
Because the likelihood of significant hemorrhage is
greatest immediately postpartum, even in normal
cases, the uterus is closely monitored for at least
2 hours after delivery.
If regional analgesia or general anesthesia is used
for delivery, the mother should be observed in an
appropriately equipped and staffed recovery
area.
104. Early Ambulation
Women are out of bed within a 4-6 hours after
delivery.
An attendant should be present for at least the
first time, in case the woman becomes
syncopal.
The many confirmed advantages of early
ambulation include fewer bladder
complications and less frequent constipation.
Early ambulation has reduced the frequency of
puerperal venous thrombosis and pulmonary
embolism.
105. Perineal Care
The woman is instructed to cleanse the vulva from
anterior to posterior—the vulva toward the anus.
An ice bag applied to the perineum may help
reduce edema and discomfort during the first
several hours if there is a laceration or an
episiotomy.
Most women also appear to obtain a measure of
relief from the periodic application of a local
anesthetic spray.
Severe discomfort usually indicates a problem,
such as a hematoma within the first day or so,
and infection after the third or fourth day.
Severe perineal, vaginal, or rectal pain always
warrants careful inspection and palpation.
106. Bladder Function
Bladder filling after delivery may be variable. In most units,
intravenous fluids are infused during labor and for an hour
after delivery.
Oxytocin, in doses that have an antidiuretic effect, is
commonly infused postpartum, and rapid bladder filling is
common.
Moreover, both bladder sensation and capability to empty
spontaneously may be diminished by local or conduction
analgesia, by episiotomy or lacerations, and by
instrumented delivery.
Risk factors that increased likelihood of retention are
primiparity, oxytocin-induced or -augmented labor,
perineal lacerations, instrumented delivery, catheterization
during labor, and labor with duration over 10 hours.
Prevention of bladder overdistension demands observation
after delivery to ensure that the bladder does not overfill
and that with each voiding, it empties adequately.
The enlarged bladder can be palpated suprapubically, or it is
evident abdominally indirectly as it elevates the fundus
above the umbilicus.
107. Management
If a woman has not voided within 4 hours after delivery, it
is likely that she cannot.
An examination for perineal and genital-tract hematomas
is made.
With an overdistended bladder, an indwelling catheter
should be left in place until the factors causing
retention have abated.
When the catheter is removed, it is necessary
subsequently to demonstrate ability to void
appropriately.
If a woman cannot void after 4 hours, she should be
catheterized and the urine volume measured.
If more than 200 mL, the bladder is not functioning
appropriately, and the catheter is left for a day.
If less than 200 mL of urine is obtained, the catheter can
be removed and the bladder rechecked subsequently as
described.
108. Subsequent Discomfort
During the first few days after vaginal delivery, the
mother may be uncomfortable for a variety of
reasons, including afterpains, episiotomy and
lacerations, breast engorgement, and at times,
postdural puncture headache.
Mild analgesics containing codeine, aspirin, or
acetaminophen, preferably in combinations, are given
as frequently as every 3 hours during the first few
days.
Abdominal Wall Relaxation
If the abdomen is unusually flabby or pendulous, an
ordinary girdle is often satisfactory.
An abdominal binder is at best a temporary measure.
Exercises to restore abdominal wall tone may be
started anytime after vaginal delivery and as soon as
abdominal soreness diminishes after cesarean
delivery.
109. Diet
There are no dietary restrictions for
women who have been delivered
vaginally.
Two hours after a normal vaginal delivery,
if there are no complications, a woman
should be allowed to eat.
With breast feeding, the number of
calories and protein consumed during
pregnancy should be increased slightly.
If the mother does not breast feed, dietary
requirements are the same as for a
nonpregnant woman.
110.
111. Time of Discharge
Following uncomplicated vaginal delivery,
hospitalization is seldom warranted for more
than 48 hours.
A woman should receive instructions concerning
anticipated normal physiological changes of
the puerperium, including lochia patterns,
weight loss from diuresis, and milk let-down.
She also should receive instructions concerning
fever, excessive vaginal bleeding, or leg pain,
swelling, or tenderness.
Shortness of breath or chest pain warrants
immediate concern.
112. Breast Feeding and Ovulation
Women who breast feed ovulate much less frequently
compared with those who do not, and there are great
variations.
Lactating women may first menstruate as early as the second
or as late as the 12 month after delivery (Lactational
amenorrhea).
Breast feeding in general delays resumption of ovulation,
although as already emphasized, it does not invariably
forestall it.
Postpartum Follow-Up Care
By discharge, women who had an uncomplicated course can
resume most activities, including bathing, driving, and
household functions. Ideally, the care and nurturing of the
infant should be provided by the mother with ample help
from the father.
The postpartum visit is recommended between 4 and 6 weeks.
This has proven quite satisfactory to identify abnormalities
beyond the immediate puerperium as well as to initiate
contraceptive practices.
113.
114. Immediately following birth, infant survival depends on
a prompt and orderly conversion to air breathing.
Fluid-filled alveoli expand with air, perfusion must be
established, and oxygen and carbon dioxide
exchanged.
115. Stimuli to Breathe Air
The newborn begins to breathe and cry almost
immediately after birth, indicating the establishment
of active respiration. Factors that appear to influence
the first breath of air include:
Physical stimulation, such as handling the neonate
during delivery
Deprivation of oxygen and accumulation of carbon
dioxide, which serve to increase the frequency and
magnitude of breathing movements both before and
after birth
Compression of the thorax, which during pelvic
descent and vaginal birth forces an amount of fluid
from the respiratory tract equivalent to about a fourth
of the ultimate functional residual capacity.
116. Aeration of the newborn lung does not involve the
inflation of a collapsed structure, but instead, the
rapid replacement of bronchial and alveolar fluid
by air.
After delivery, the residual alveolar fluid is cleared
through the pulmonary circulation and to a lesser
degree, through the pulmonary lymphatics.
Delay in removal of fluid from the alveoli probably
contributes to the syndrome of transient
tachypnea of the newborn (TTN).
As fluid is replaced by air, the compression of the
pulmonary vasculature is reduced considerably
and in turn, resistance to blood flow is lowered.
With the fall in pulmonary arterial blood pressure,
the ductus arteriosus normally closes.
117. High negative intrathoracic pressures are required to bring
about the initial entry of air into the fluid-filled alveoli.
Normally, from the first breath after birth, progressively more
residual air accumulates in the lung, and with each
successive breath, lower pulmonary opening pressure is
required.
In the normal mature newborn, by approximately the fifth
breath, pressure-volume changes achieved with each
respiration are very similar to those of the adult.
Thus, the breathing pattern shifts from the shallow episodic
inspirations characteristic of the fetus to regular, deeper
inhalations.
Surfactant – synthesized by type II pneumocytes and already
present – lowers alveolar surface tension and thereby
prevents collapse of the lung with each expiration.
Lack of sufficient surfactant, common in preterm infants,
leads to the prompt development of respiratory distress
syndrome.
118.
119. Apgar Scoring System
Sign 0 Points 1 Point 2 Points
Heart rate Absent <100 bpm >100 bpm
Respiratory effort Absent Slow, irregular Good, crying
Muscle tone Flaccid Some flexion of
extremities
Active motion
Reflex irritability No response Grimace Vigorouscry
Color Blue, pale Body pink,
extremities blue
Completely pink
120. Apgar Score
This scoring system is a useful clinical tool to identify
those neonates who require resuscitation as well as to
assess the effectiveness of any resuscitative measures.
Each of the five easily identifiable characteristics – heart
rate, respiratory effort, muscle tone, reflex irritability,
and color – is assessed and assigned a value of 0 to 2.
The total score, based on the sum of the five
components, is determined 1 and 5 minutes after
delivery.
The 1-minute Apgar score reflects the need for
immediate resuscitation.
The 5-minute score, and particularly the change in score
between 1 and 5 minutes, is a useful index of the
effectiveness of resuscitative efforts.
The 5-minute Apgar score also has prognostic
significance for neonatal survival, because survival is
related closely to the condition of the neonate in the
delivery room.
121. The American College of Obstetricians and
Gynecologists and the American Academy of
Pediatrics prepare and release recommendation
"Use and Abuse of the Apgar Score." Important
caveats regarding Apgar score interpretation
addressed in this statement include the following:
1. Because certain elements of the Apgar score are
partially dependent on the physiological maturity
of the newborn, a healthy preterm infant may
receive a low score only because of immaturity.
2. Given that Apgar scores may be influenced by a
variety of factors including, but not limited to, fetal
malformations, maternal medications, and
infection, to equate the presence of a low Apgar
score solely with asphyxia or hypoxia represents a
misuse of the score.
122. 3. Correlation of the Apgar score with adverse future
neurological outcome increases when the score
remains 3 or less at 10, 15, and 20 minutes, but still
does not indicate the cause of future disability.
4. The Apgar score alone cannot establish hypoxia as
the cause of cerebral palsy. A neonate who has had
an asphyxial insult proximate to delivery that is
severe enough to result in acute neurological injury
should demonstrate all of the following: (1) profound
acidemia with cord artery blood pH < 7 and acid-
base deficit 12mmol/L; (2) Apgar score of 0–3
persisting for 10 minutes or longer; (3) neurological
manifestations such as seizures, coma, or hypotonia;
and (4) multisystem organ dysfunction—
cardiovascular, gastrointestinal, hematological,
pulmonary, or renal.
123. Methods of heat loss
Evaporation – wet surface exposed to air
Conduction – direct contact with cool objects
Convection- surrounding cool air - drafts
Radiation – transfer of heat to cooler objects
not in direct contact with infant
125. Gonococcal Infection
In the past, blindness was common in children who
developed gonococcal ophthalmia neonatorum
contracted from passage through the infected birth
canal. In 1884, Credé, a German obstetrician,
introduced a 1-percent ophthalmic solution of silver
nitrate that largely eliminated blindness due to
Neisseria gonorrhoeae.
A variety of other antimicrobials have also proven to be
effective, and gonococcal ophthalmia neonatorum
prophylaxis is now mandatory for all neonates (a
single application of either 0.5% erythromycin
ophthalmic ointment or 1% tetracycline ophthalmic
ointment soon after delivery).
126. Chlamydial Infection
Adequate neonatal prophylaxis against
chlamydial conjunctivitis is complex.
From 12 to 25% of neonates delivered vaginally
of mothers with an active chlamydial infection
will develop conjunctivitis.
Any case of conjunctivitis in a newborn less
than 1 month old should prompt
consideration for chlamydial infection. 2.5%
povidone-iodine solution or 1% silver nitrate
solution or 0.5% erythromycin ointment are
effective in preventing chlamydial
conjunctivitis.
127. Hepatitis B Immunization
Routine immunization of all newborns against
hepatitis B prior to hospital discharge has been
recommended since 1991.
If the mother is seropositive for hepatitis B
surface-antigen, the neonate should also be
passively immunized with hepatitis B immune
globulin.
Vitamin K
This injection is provided to prevent vitamin K-
dependent hemorrhagic disease of the newborn.
A 0.5- to 1-mg single-dose intramuscular
administration of vitamin K within 1 hour of birth
is recommended.
128. Universal Newborn Screening
Newborn screening programs began in the
early 1960s when a test for phenylketonuria
(PKU) could be carried out on blood samples
collected on filter paper.
Subsequently, screening for a number of other
disorders has been mandated by various
laws.
Technical advances have made a large number
of relatively simply performed mass screening
tests available for newborn conditions.
The Maternal and Child Health Bureau (2005)
appointed a core panel of 29 congenital
conditions in five categories.
129. Newborn Screening Core Panel
Acylcarnitine Disorders
Organic Acid
Metabolism
Fatty Acid
Metabolism
Amino Acid
Metabolism
Hemoglobin
Disorders
Others
Isovaleric Medium-chain acyl-
CoA dehydrogenase
Phenylketonuria SS disease Congenital
hypothyroidism
Glutaric type I Very long-chain acyl-
CoA dehydrogenase
Maple syrup (urine) S-thalassemia Biotinidase
3-hydroxy-3-methyl
glutaric
Long-chain 3-OH
acyl-CoA
dehydrogenase
Homocystinuria SC disease Congenital adrenal
hyperplasia
Multiple carboxylase Trifunctional protein Citrullinemia Galactosemia
Methylmalonic
mutase
Carnitine uptake Arginosuccinic Hearing loss
3-methylcrotonyl-CoA
carboxylase
Tyrosinemia I Cystic fibrosis
Methylmalonic acid
(cobalamine A, B)
Propionic
3-ketothiolase
130. Skin Care
Following delivery, excess vernix, blood, and meconium should be
gently wiped off. Any remaining vernix is readily absorbed and
disappears entirely within 24 hours.
The first bath should be postponed until the temperature of the
neonate has stabilized.
Umbilical Cord
Loss of water from the Wharton jelly leads to mummification of the
umbilical cord shortly after birth.
Within 24 hours, the cord stump loses its characteristic bluish-white,
moist appearance and soon becomes dry and black.
Within several days to weeks, the stump sloughs and leaves a small,
granulating wound, which after healing forms the umbilicus.
Separation usually takes place within the first 2 weeks, with a range
of 3 to 45 days.
The umbilical cord dries more quickly and separates more readily
when exposed to air. Thus, a dressing is not recommended.
131. The cord is clamped BY HOLLISTER CLAMP and
divided as soon as pulsations have ceased. If ligation is
done carelessly, the baby may lose a great deal of
blood very quickly. The cord is ligated with a special
clamp or rubber bands or tapes. The blood volume of a
term newborn infant is 80-100 ml per kg body weight.
133. Feeding
An exclusive breast feeding is
preferred until 12-18 months.
Usually infants begin breast
feeding in the delivery room.
Most term newborns thrive best
when fed at intervals of every 2
to 4 hours. Preterm or growth-
restricted newborns require feedings at shorter
intervals.
In most instances, a 3-hour interval is satisfactory.
The proper length of each feeding (5-40 minutes)
depends on several factors, such as the quantity
of breast milk, the readiness with which it can be
obtained from the breast, and the avidity with
which the infant nurses.
134. Initial Weight Loss
Because most neonates actually receive little nutriment for the
first 3 or 4 days of life, they progressively lose weight.
Preterm infants lose relatively more weight and regain their
birthweight more slowly than term newborns.
Infants who are small-for-gestational-age but otherwise
healthy regain their initial weight more quickly when fed than
those born preterm.
If the normal newborn is
nourished properly,
birthweight is regained by
the end of the 10th day.
Thereafter, the weight typically
increases steadily at the rate of
about 25 g/day for the first few
months.
Birthweight doubles by 5 months
of age and triples by the end of
the first year.
135. Measuring the head circumference of the newborn.
Measuring the chest circumference of the newborn.
140. Stools and Urine
For the first 2 or 3 days after birth, the
contents of the colon are composed
of soft, brownish-green meconium.
This consists of desquamated epithelial
cells from the intestinal tract, mucus,
epidermal cells, and lanugo (fetal hair)
that have been swallowed along with
amnionic fluid.
The characteristic color results from bile
pigments.
During fetal life and for a few hours after
birth, the intestinal contents are sterile,
but bacteria quickly colonize the bowel.
141. Meconium stooling is seen in 90% of newborns
within the first 24 hours, and most of the rest
within 36 hours.
Newborns first void usually shortly after birth, but
may not until the second day.
The passage of meconium and urine indicates
patency of the gastrointestinal and urinary tracts.
Failure of the newborn to stool or urinate after
these times suggests a congenital defect, such as
imperforate anus or a urethral valve.
After the third or fourth day, as the consequence
of ingesting milk, meconium is replaced by light-
yellow homogenous feces.
142. Icterus Neonatorum
Between the 2 and 5 day of life approximately one third
of all neonates develop so-called physiological
jaundice of the newborn.
Serum bilirubin levels at birth are normally 1.8 to 2.8
mg/dL. These levels increase during the next few
days but with wide individual variation.
Between the 2 and 4 day, the bilirubin in term
newborns commonly exceeds 5 mg/dL, the jaundice
is usually noticeable.
Most of the bilirubin is free, unconjugated. With hepatic
immaturity, less bilirubin is conjugated with
glucuronic acid and leads to reduced excretion in
bile.
Reabsorption of free bilirubin may result from the
enzymatic splitting of bilirubin glucuronide by
intestinal conjugase activity in the newborn intestine.
143. In preterm neonates, jaundice is more common
and usually more severe and prolonged than
in term newborns, because of even lower
hepatic conjugation rates.
Increased erythrocyte destruction from any
cause also contributes to hyperbilirubinemia.
The standard and noninvasive treatment of an
affected newborn is phototherapy.
With this, the neonate is exposed to a specific
light wavelength that is absorbed by the
bilirubin molecule.
As a result, unconjugated bilirubin in the skin is
converted to a water-soluble stereoisomer,
which is then excreted in bile.
144.
145. PHENYLKETONURIA (PKU)
PKU is the best known of a numerous but rare group of congenital
metabolic disorders, in which the baby inherits an inability to
convert the amino-acid phenylalanine (PH) to tyrosine. There
are at least three varieties of the disease which is more properly
called 'hyperphenylalaninaemia'. 'Classical' PKU (97% of cases)
is due to Phenylalanine hydroxylase (PHE) deficiency. This can
be completely controlled by diet.
The Guthrie blood test can also be used to exclude
HYPOTHYROIDISM, by measurement of thyroxine levels or
thyroid stimulating
hormone, the latter being more commonly used.
In the future the blood may also be used
to screen for other conditions such as cystic
fibrosis.
