1. Mariechen Puchert 2010
NOTE/Disclaimer: These are notes I made for myself during my second year. I cannot
guarantee that there aren’t mistakes. I do know that studying them were great help to me. I
used notes and powerpoints given to my class by lecturers (University of Stellenbosch,
Tygerberg Campus, South Africa) as well as the following textbooks:
Clinical Gynaecology : TF Kruger, MH Botha
Ostetrics in South Africa: Cronje
Neonatology
Routine care of Newborn Baby
APGAR SCORE
Activity muscle tone
Pulse
Grimace reaction to stimuli
Appearance colour
Respiration breathing
Heart rate 120 – 160 BPM
Respiratory rate 40 – 60 BPM
Temperature axillary 36.5 – 37°C
Glucose 2.5 – 6.7 mmol/ℓ
Large for GA > 90th
percentile
Average for GA 10th
– 90th
percentile
Small for GA <10th
percentile
LBW < 2500g
VLBW < 1500g
ELBW < 1000g
Basic needs
1. Warmth
2. Feeding
3. Cross-infection control
4. Affection
HIV infection-control
• Wear gloves
• Hands above cord when cutting
• Do not use mouth for suctioning
• Wipe baby from maternal and amniotic fluid
• Avoid invasive procedures
2. Mariechen Puchert 2010
For every baby...
o Prevent hypothermia
o Suction mouth and nose
o Assess resuscitation
o Apgar score
o Umbilical cord clamping
o Eye-drops – prophylaxis
o Vitamin K administration
o Identify
o Initiate breastfeeding
o Cord blood
o Examine placenta
Side-room investigations
1. Haemoglobin
2. Blood glucose
♫ Total body fluid composition decreases after birth
Over 5-7 days, term infant can lose 5-10% weight and preterm 5-15%.
Newborn voids 4-6 times a day.
Term baby conserves sodium effectively
Discharge Criteria
• Stable
• Maintain body temperature
• Urine and stools passed
• Feeding and weight gain
• Gestational age >35 weeks
• Approximately 1800g
• VDRL and Rhesus known
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3. Mariechen Puchert 2010
Abnormal Findings in the Newborn Baby
Causes for Tachycardia
o High temperature
o Dehydration
o Pain
o Medication
o Cardiac failure
o Cardiac lesions
Causes for Bradycardia
• Hypothermia
• Sedation
• Raised ICP
• Heart block
Causes of Tachypnoea
o Hyaline membrane disease
o Transient tachypnoea of the newborn
o Pneumothorax
o Cardiac failure
o Congenital heart lesions
Causes of Apnoea
• Prematurity
• Infection
• Hypoglycaemia
• Convulsion
• Obstruction
Vomiting of bile, blood or faeces is ALWAYS abnormal.
o Oesophageal atresia
o Duodenal atresia
o Malrotation or volvulus
o Gastroenteritis
Hypotonia decreased resistance to passive range of motion in newborn due to
a defect in any level of the nervous system
Omphalitis infection of umbilical stump (redness, discharge, foul smell)
Causes of neonatal conjunctivitis
1. Neisseria Gonorrhoea
2. Chlamydia Trachomatis
3. Group β-streptococcus
4. Staphylococcus Aureus
5. Herpes Virus
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4. Mariechen Puchert 2010
Temperature Regulation in the Newborn
NORMAL: 36.5-37C
1. Voluntary muscle activity
2. Involuntary muscle activity
3. Non-shivering chemical thermogenesis
Major mechanisms of heat loss
• Radiation
• Convection
• Evaporation
• Conduction
♫ Infant neutral thermal zone: 33-35°C
Why are premature infants colder quicker?
i. Higher surface area to weight ratio
ii. Decreased subcutaneous fat i.e. less insulation
iii. Brown fat less well developed
iv. Can’t ingest enough calories for thermogenesis
Hypothermia <35°C
Outcomes of Neonatal Cold Injury
1. Metabolic acidosis
2. Pulmonary artery constriction
3. Hypoxia
4. Hypoglycaemia
5. Pulmonary haemorrhage
6. Apnoea
7. Death
Preventing Cold Injury
o Dry and wrap after birth
o Radiant heater
o Cap
o Kangaroo Mother Care
♫ Hyperthermia (38-39°C) are sometimes noted on the second or third day.
Causes of hyperthermia
Infection
Dehydration
Medication
CNS-dysfunction
Environment
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5. Mariechen Puchert 2010
Birth Injuries
Iatrogenic events an event that compromises the safety of the patient, whether or
not it was preventable or due to error.
Soft Tissue Injury of the Scalp
1. Caput Succedaneum – subcutaneous extraperiosteal fluid collection
2. Subaponeurotic haemorrhage – bleeding
beneath epicranial aponeurosis,
swollen purple-blue eyelids
3. Cephalohaematoma – subperiosteal collection of blood, parietal bone
Complications of Cephalohaematoma
• Anaemia
• Jaundice
• Infection
• Underlying linear skull fracture
• Calcification
Injuries of skull bones
1. Moulding – spontaneous resolution
2. Linear fracture – asymptomatic unless meninges herniate
3. Depressed fracture – consult if intracranial haemorrhage of CSF leakage
Facial Nerve Injury
Lower MNP Entire one side of face involved
Good prognosis
Upper MNP Lower half of contralateral side paralysed
Poor prognosis
Cayler Syndrome Congenital absence of depressor anguli oris muscle
Not birth injury
LMNP UMNP Cayler
Mouth Corner Droops Droops Droops
Nasolabial Fold Flattened Flattened Normal
Eye closure No Yes Yes
Forehead wrinkles No Yes Yes
Traumatic Cyanosis
o Transient blue discolouration of face and neck
o Petechiae limited to face and scalp
o Subconjuntival haemorrhage
6. Mariechen Puchert 2010
o Due to venous congestion after shoulder dystochia or cord around neck
o Tongue not blue therefore no cyanosis
o Resolves within days
Sternocleidomastoid Injury
• Firm, non-tender mass in SCM region
• Head tilted to side of lesion
• Haematoma and fibrosis of SCM
• Stretching done promptly, several times a day
• Resolves after six months
Common fractures
a. Clavicle
b. Humeral
c. Femoral
Brachial Plexus Injuries
1. C5, C6, C7, C8, T1
2. Risks: Macrosomia, Shoulder dystochia, Breech
3. Causes: Excessive traction of head, neck and arm during birth
Erb-Duchenne Palsy
o C5, C6
o Shoulder and elbow paralysed and turned inwards
o Prognosis good
Klumke’s Palsy
o C7, C8
o Weakness of writs and hand – no grasp reflex
o Ipsilateral Horner’s Syndrome
Total Brachial Palsy
o Entire arm flaccid
o Seldom complete recovery
Subcutaneous fat necrosis: sharply demarcated, non-tender, firm
subcutaneous plaques or nodules
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7. Mariechen Puchert 2010
Special Category Babies
Prematurity Complications
• Apnoea
• RDS
• Intraventricular bleeding
• Hypotension
• Patent Ductus Arteriosus
• Anaemia
• Feeding Intolerance
• Glycaemic abnormalities
• Unconjugated jaundice
• Electrolyte disturbances
• Temperature dysregulation
• Prone to infection
• Retinopathy of immaturity
Small for Gestational Age Complications
o Asphyxia
o Hypothermia
o Infections
o Polycythaemia
o Electrolyte disturbances
o Neurological difficulty
Post-mature Complications
• Meconium aspiration
• Persistent pulmonary hypertension of the newborn
• Hypoglycaemia
• Hypocalcaemia
• Polycythaemia
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9. Mariechen Puchert 2010
Kangaroo Mother Care
Prolonged and continuous skin-to-skin contact between mom and LBW-infant, in
hospital and after discharge, until at least 10th
week postnatal gestational age, with
exclusive breastfeeding and proper follow up.
Benefits to baby
1. Improved bonding
2. Faster growth and development
3. Comfort from hearing heart beat
4. Earlier breast feeding
5. Decreased hospital time
6. Increased deep sleep states
7. Decreased apnoea and bradycardia
8. Increased saturation levels
Benefits to parents
1. Increased milk supply
2. Increased confidence
3. Increased sense of control
4. Increased readiness for discharge
5. Increased ability to cope
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10. Mariechen Puchert 2010
Unexplained Early Infant Crying
Inconsolable crying or >3hours a day, >3days a week, for one week.
1. Cry longer during each bout than other babies
2. Cries are louder
3. Difficult to console
4. Particular time of day
Tips on soothing
• Rocking, rhythm, rolling in pram
• White noise sounds
• Try to calm
Address parents’ needs!
o Identify stress and fatigue
o Recognise effects
o Schedule free time
o Mention help if they feel overwhelmed
Shaken baby syndrome
• Lethargy, irritability
• Decreased feeding, vomiting
• Respiratory distress
• Seizures
• Retinal haemorrhage
Peak pattern
Unpredictable crying bouts
Resistance to soothing
Pain-like expression
Long crying bouts
Evening clustering
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11. Mariechen Puchert 2010
Neonatal Haematology
After birth HbF decreases and HbA increases
Physiological Anaemia
• High EPO in utero
• After birth saturation increases so EPO decreases till undetectable
• Haemoglobin drops
• 6-12 weeks EPO synthesis starts again
Causes of Anaemia
1. Blood loss
2. Increased destruction
3. Inadequate production
Causes of haemolysis
a. Immune
b. Hereditary
c. Acquired
Polycythaemia: venous haematocrit >65%
Causes of Polycythaemia
• Placental RBC transfusion
• Placental insufficiency
Polycythaemia Management
Symptomatic partial exchange transfusion
Asymptomatic increased fluid intake
Causes of abnormal WCC
1. Maternal fever
2. Antenatal steroids
3. Leukaemia
Thrombocytopaenia decreased platelets
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12. Mariechen Puchert 2010
Neurological Aspects in the Newborn
1. Encephalopathy
2. Seizures
3. Infection
4. Hypotonia
5. Intracranial haemorrhage
6. Malformations
Neonatal Encephalopathy abnormal neurological behaviour in newborn
Hypoxic Ischaemic Encephalopathy
• Due to impaired placental blood flow
• Interruption of umbilical blood flow
• Seizures, hypotonia, coma
• Resuscitate, control seizures
• Neuroprotective strategies – hypothermia, drugs
Causes of seizures
o HIE
o Intracranial haemorrhage
o Meningitis, infection
o Hypoglycaemia
o Electrolyte abnormalities
o Congenital malformations of brain
Causative organisms of Meningitis
1. β-heamolytic streptococci
2. E.Coli
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13. Mariechen Puchert 2010
HIV in the Perinatal Period
Transmission Risk Factors
a. Viral load vs CD4-count
b. Duration of exposure
c. Breastfeeding
d. Obstetric interventions
e. Viral characteristics
f. Foetal susceptibility
Preventing Mother to Child Transmission
1. Do not rupture membranes
2. No invasive procedures
3. Avoid episiotomy
4. HAART if CD4 <250
5. AZT from 28 weeks if CD4 >250
6. Oral Nevirapine when labour starts
7. AZT three-hourly till delivery
Signs of infant HIV-infection
• Failure to thrive
• Recurrent infections
• Lymphadenopathy
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14. Mariechen Puchert 2010
Perinatal Asphyxia
Insult to newborn due to lack of oxygen or lack of perfusion during perinatal period
Aetiology
1. Placental infarcts
2. Placental insufficiency
3. Cord compression
4. Maternal dehydration
5. Impaired maternal oxygenation
1°Apnoea baby starts breathing in response to stimuli and oxygen
2°Apnoea baby needs resuscitation, does not respond to stimuli
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15. Mariechen Puchert 2010
Neonatal Emergencies
Airways
Breathing
Circulation
Don’t Ever Forget Glucose
Gastroschisis abdominal contents outside body, not covered by sac
Omphalocele abdominal contents outside body, covered in membrane
Transport of very ill infant
Tubing – airway and nasogastric
Warmth – temperature control
Oxygen
Stabilisation - neurological
Sepsis - infection
Intravenous - access
Documentation – letter, lab results
Escort – mom not enough
Samples – blood glucose
Beware aircraft that aren’t pressure-stable!
Problematic for volvulus, pneumothorax etc.
As pressure decreases, gas volume increases.
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16. Mariechen Puchert 2010
SIDS
Sudden Infant Death Syndrome
Sudden death of an infant or young child, unexpected in history, thorough post-
mortem fails to demonstrate adequate cause of death.
Risk factors
• Prone sleeping
• Soft sleeping surface
• Smoking
• Overheating
• Preterm birth
• LBW
• Male sex
Support to parents
1. Console as soon as possible
2. Explain about post-mortem – required by law
3. Explain possibility of inquest
4. Offer medication for shock
5. Give advice for suppression of lactation
6. Allow and enable to grieve. Refer to psychologist.
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17. Mariechen Puchert 2010
Adoption
Legal procedure creating valid legal relationship between parent and child
Disclosure adoption applicant knows adoptive parents
Non-disclosure adoption identity of biological parents not disclosed
Role of Doctor
1. Cooperation with social worker
2. Maintain confidentiality
3. Evaluate family history
4. Complete physical examination of baby
5. Suppress lactation of biological mother
6. Special investigations: HIV, Syphilis, TSH
Requirements of adoption
1. Means to support child
2. Written consent from both biological parents
3. Consent by children 10 years or older
4. South African citizens
No consent required when
• Child’s parents deceased and no guardian
• Parents suffer mental illness
• Child deserted
• Child abused
• Sexual exploitation
• Unfair withholding of consent
Foster care legal process where child is placed in custody of suitable family
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