After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.

1. OPTIMISING DELIVERY OF 1KG FETUS
- SPECIAL CONSIDERATION
FOGSI PERINATOLOGY CONCLAVE 2024
Perinatology Committee FOGSI & Obstetric And Gynaecological Society
Of Pondicherry & in collaboration with Department Of OBGYN, JIPMER.
Date: 27th January 2024
Venue: JIPMER, Pondicherry

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
74 publications in International and National Journals with 184 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS)
at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)

4. LOW BIRTH WEIGHT BABIES
Birth weight < 2500 g
Birth weight- most important marker of neonatal outcome
India - Harbour of highest number of LBW babies in South-
East Asia region
28 per cent of babies in India are Low birth weight
approximating 7.5 million births
42% of global burden

5. BIRTH WEIGHT CLASSIFICATION
Description Birth Weight
Normal Birth Weight(NBW) 2500 – 4000 g
Low birth Weight(LBW) < 2500 g
Very Low Birth weight(VLBW) < 1500 g
Extremely Low Birth Weight(ELBW) < 1000 g

6. • An extremely low birth weight (ELBW)
infant is defined as one with a birth weight of
less than 1000 g (2 lb, 3 oz).
• Most extremely low birth weight infants are
also the youngest of premature newborns,
usually born at 27 weeks' gestational age or
younger.
WHICH ARE ONE KG
BABIES?

7. • Abruptio Placenta
• Bleeding placenta previa.
• Cervical incompetence
• Maternal genital colonization and infections
• Cigarette smoking
• Threatened abortion
• Past history of preterm birth
• Acute emotional stress
• Physical exertion
• Sexual activity
• Trauma
• Bicornuate uterus
• Multiple pregnancy
• Congenital malformations
CAUSES OF ONE KG BABY

8. CASE SCENARIO - 1
• 28 years old G3P1L1A1 with 31 weeks gestation came with complains of pain in
abdomen. Patient also has burning micturation since 1 week.
• On Examination -
• Per Abdomen - Uterus 28 - 30 weeks gestation
- Cephalic
- FHS- 150bpm/ Regular/Irritable.
What is your diagnosis?

9. THREATENED PRETERM DUE TO
URINARY TRACT INFECTION

10. THREATENED PRETERM LABOR
• Treat the cause.
• Treat urinary tract infections by 3rd Generation Cephalosporins and then modify
according to the urine culture sensitivity report.
• Antenatal steroids.
• Tocolytics like Inj Isoxsuprine.
• Erythromycin.

11. CASE SCENARIO -2
• G2P1L1 with 30 weeks gestation with twin gestation with polyhydramnios goes
into labor. What is your management?
• Per abdomen - Uterus 32 – 34 weeks gestation
- Multiple fetal parts felt
- A - FHS / 144BPM / Regular.
- B - FHS / 142BPM / Regular
- 3 / 10’/20”
Per Vaginum Os 4 cm dilated , well effaced.
vertex presentation.

12. • Counsel Parents.
• Inform neonatologist.
• Give antenatal rescue doses of corticosteroids.
• Watch for spontaneous labor and deliver her.

14. CASE SCENARIO - 3
• G2P1L1 with 29 weeks gestation came to labor ward with complains of intermittent
bleeding per vaginum. There is no pain in abdomen associated with it.
• On examination -
• Per abdomen - Uterus 30 weeks size
- Cephalic
- FHS – 142 BPM
- Relaxed.

15. • Per speculum or vaginal examination NOT DONE
• USG Scan suggestive of COMPLETE PLACENTA
PREVIA covering the Os.

16. HOW WILL YOU MANAGE THIS
PATIENT?

17. EXPECTANT LINE OF
MANAGEMENT
Mc-cafee Johnson's regime (1945):
• Aim is to continue pregnancy for fetal lungs to mature
without compromising maternal health.
VITAL PREREQUISITES:
• Availability of blood transfusion.
• Facilities for caesarean section should be available24
hrs.

18. CONDUCT OF EXPECTANT
TREATMENT
• Bed rest.
• Mother and fetus monitoring.
• Hb%, blood grouping.
• Blood transfusion to correct anemia.
• Proper ultrasonography localization of placenta.

19. MEASURES FOR BETTER
FOETAL OUTCOME
• Tocolytics- Given if vaginal bleeding is associated with
uterine contractions.
• Corticosteroids to improve fetal lung maturity and
reduce respiratory distress.
• Rh immunoglobulin given to all Rh negative mothers.

20. CASE SCENARIO - 4
24 years old Primigravida with 31.3 weeks gestation came to labor room complaining
of bleeding per vaginum since last 20 mins associated with severe pain in abdomen .
• O/E-
• GC fair
• P-120bpm
• BP - 180/100 mm of Hg
• CVS- S1 S2+
• RS- AEBE
• Urine albumin - +2
• Edema feet ++

21. • Per abdomen - Uterus size 28 to 30 weeks size
- Tonically contracted
- FHS- 100 bpm/ Regular
• LE- Bleeding ++, Clots ++
• What is the next step of management??

22. MANAGEMENT
ABRUPTIO PLACENTA:
• Give rescue dose of antenatal corticosteroids.
• Inform neonatologist.
• Prepare patient for Emergency lower segment C –
section.

24. CASE SCENARIO - 5
• 30 years old G4A3 with 28 weeks gestation came to labour room with pain in
abdomen.
• On examination -
Per abdomen - Uterus 26 to 28 weeks gestation
Cephalic
Fhs 145 bpm/ regular
Irritable

25. • Per vaginum - Cervical os 2 cm dilated
- Cervical length 2 cm
- Bag of membranes felt.
• On USG Scan- ‘ Y’ shaped cervix seen. Funneling
Bag of membranes seen coming out of os

26. CERVICAL INSUFFICIENCY
• Cervical insufficiency is the inability of the cervix to retain fetus, in the absence of
uterine contractions or labor (painless cervical dilatation), owing to a functional or
structural defect.
• It is rarely a distinct and well defined clinical entity but only part of a large and more
complex spontaneous preterm birth syndrome.
• It is cervical ripening that occurs far from the term.

27. SURGICALAPPROACHES FOR
CERVICAL INSUFFICIENCY
• Surgical approaches include transvaginal and
transabdominal cervical cerclage.
• The two types of this commonly used
vaginal procedure include McDonald and
Shirodkar cerclage.
• McDonald involves taking four or five bites
of number 2 monofilament suture as high as
possible in the cervix, trying to avoid injury
to the bladder or the rectum, with
a placement of a knot posteriorly to facilitate
the removal.

28. • The Shirodkar procedure involves the dissection of
the vesical-cervical mucosa in an attempt to place the
suture as close to the cervical internal os as close,
otherwise, as possible.
• The bladder and rectum are dissected from the cervix
in a cephalad manner, the suture is placed and tied,
and mucosa is replaced over the knot.
• Nonresorbable sutures should be used for cerclage
placement using the Shirodkar procedure.

29. The risk of preterm delivery is inversely proportional to cervical length.
• 18% for <25 mm
• 25% for <20 mm
• 50% for <15 mm

30. CASE SCENARIO - 6
• G3A2 with 32.3 weeks gestation presented to labor room with severe pain in
abdomen since 3 hours.
• On examination -
• Per Abdomen - Uterus 30 to 32 weeks size
• Breech presentation
• FHS- 144 bpm/Regular
• Irritable.

31. • Per vaginum- Os 2 cm dilated
Cx poorly effaced
Buttocks felt
Membranes present.
On USG scan- Two separate horns of uterus
seen. (Bicornuate Uterus). Single live
intrauterine gestation in one horn with 32 weeks
gestation.

32. BICORNUATE UTERUS WITH NORMAL PREGNANCY

33.  7.5 million births are low birth weight in India.
 60% of LBW in India are Term Small for
Gestation (SGA).
 40% of LBW in India are Preterm deliveries.
INDIAN SCENARIO
(SAMPLE REGISTRATION SYSTEM 2022)

34. Management of 1KG Foetus
Prenatal consultation
• Parents at risk of delivery of premature baby should meet in consultation with
neonatologist, preferably along with perinatologist caring for the mother.
• Inform the parents about proposed management of pregnancy and delivery.
• Discuss the advantages of antenatal glucocorticoids, possible need for caesarean
delivery, delivery room care and resuscitation.
• Potential risks of prematurity and therapeutic interventions.
• Investigate parents’ beliefs and attitudes about delivery of extremely premature baby.

35. MANAGEMENT
Arrest of premature labor:
• Differentiate between false and true labor pains
• True labor pain
Two or more uterine contractions lasting at least 30
seconds during a 15 minute period associated with
dilatation and effacement of cervix
• Bed rest
• Sedation
• Tocolysis

36. Tocolytic agent Advantage Side effects
Magnesium
sulphate
Effective
Reduced risk of IVH, CP
and MR in preterm
Respiratory depression in newborn
• Isoxsuprine
• Ritodrine
Currently used Apprehension
Palpitation
Hypotension
Foetal tachycardia
Neonatal hypoglycemia
• Salbutamol
• Terbutaline
Maternal tachycardia
Pulmonary edema
Indomethacin Block prostaglandin E production
Decreased uteroplacental perfusion
Premature closure of ductus arteriosus

37. TOCOLYTIC DRUGS

39.  Delivery postponed till pulmonary maturity is assured.
 If delivery can be delayed by 36-48 hours, corticosteroids are
administered to mother.
 Antenatal corticosteroids enhance foetal lung maturity.
 Advantages:
• 50 % reduction in incidence of RDS due to surfactant
deficiency.
• Reduce incidence of IVH and NEC.
• 40% reduction in neonatal mortality.

40. Inj. Betamethasone 12 mg IM every 24 hours for 2 doses
(Or)
Inj. Dexamethasone 6 mg IM every 12 hours for 4 doses
Betamethasone is more potent and associated with less side effects
Optimal effect seen if delivery occurs after 24 hours of initiation of therapy
Therapeutic effect lasts for 7 days
Repeat single dose of Betamethasone may be given if labor becomes active again after 7-
10 days

41. CARE OF PRETERM BABIES
OPTIMAL MANAGEMENT AT BIRTH in Labour Ward/ NICU:
 Senior pediatrician skilled in resuscitation.
 Delayed clamping of the cord- improves iron reserves.
 Promptly dried, effectively covered and kept warm,
ELBW- polythene occlusive skin wrap or
bag immediately after delivery
 Assisted ventilation required in many
Gentle ventilation- low inspiratory pressures
Adequate PEEP
Avoid hyperoxia and hyperventilation
Oxygen saturations between 85-93%

42. Fetal
• Multiple gestation
• Sex of the baby(girls are lighter by 100g)
• Congenital malformations
• TORCH infections
Placental
• Placental dysfunction (PIH, pre-eclampsia)
• Placental mosaicism
• Placental embolization with microspheres
• Abnormal cord insertion
• Placental infections
• Chorioangiomata
• Abruptio placentae
COMMON CORRELATES
OF INTRAUTERINE
GROWTH RESTRICTION

43. Maternal
• Genetic, familial and racial factors
• Low socioeconomic status
• Primigravida
• Teenage pregnancy
• Maternal undernutrition
• Poor dietary intake
• Maternal infection
• PIH, toxemia of pregnancy
• Inter pregnancy interval < 1 year
• Uterine anomalies
• Smoking, tobacco and substance abuse
• Excessive physical workload

44. THERAPEUTIC INTERVENTIONS
Early - onset fetal growth
restriction:
 Congenital anomalies life
threatening--- MTP
 Identification of TORCH
infections and prompt
treatment

45. Late-onset fetal growth restriction
Abnormal utero-placental unit and placental
dysfunction
• Bed rest
• Conserves energy, improves uteroplacental
blood circulation
• No consistent benefits
• Risk of DVT and pulmonary embolism

46. • Avoid early marriage and teenage pregnancy
• Pre-pregnancy health checkup, general and nutritional
guidance and essential vaccines
• Inter-pregnancy interval of at least 3 years
• Good quality antenatal care
STRATEGIES TO REDUCE
INCIDENCE OF LBW
BABIES

47. • Enhance calorie intake, balanced protein
intake, iron, folic acid and micronutrient
supplementation.
• Early recognition and management of
incompetent os, PIH, placental
dysfunction, malaria, tuberculosis, urinary
tract infection, diarrhoea, dysentry, genital
colonization and bacterial vaginosis, etc.
• Avoid physical labor and emotional stress.

48. • Women should be accorded due health care, education,
status and empowerment in society.
• Optimal nutrition and health care to girl children throughout
life cycle.
• Impart Family life and mother-craft education to teenage
boys and girls.

49. DELIVERING 1 KG FETUS

50. PRETERM BIRTH BY
VACUUM EXTRACTION /
OUTLET FORCEPS –
NEONATAL OUTCOME?
• Delivery by Vacuum is a common obstetrical procedure, and in many countries it has
replaced the use of forceps. In 1 Kg it can be used.
• VE is used to terminate a protracted second stage of labor and as an intervention for
fetal or maternal distress.
• VE requires vertex presentation, a fully dilated cervix and ruptured membranes.

51. SIDE EFFECTS OF VACUUM
DELIVERY IN PRETERMS
• Intracranial laceration and hemorrhage due to birth
injury
• Intracranial non-traumatic hemorrhage of fetus and
newborn
• Convulsions of newborn.
• Subgaleal hematoma
• Cephalhematoma

52. DIFFICULTIES DURING
DELIVERING PRETERM BY
C - SECTION
• The formation of the lower segment starts at approximately 26 weeks and is not
completed until after 32 weeks.
• During delivering preterm baby by C- section , incision is taken on cervix by mistake
as lower segment is not formed properly.
• Causes excessive blood loss.
• Careful identification of lower segment
is necessary

53. OUTCOME OF 1 KG NEONATES
AT SION HOSPITA L-MUMBAI
YEAR NEW
ADMISSIONS
DISCHARGED DAMA REFERRED DIED
2021 1807 1536 (85%) 151 (8%) 13 (0.7%) 111(6%)
2022 1965 1656 (84%) 158 (8%) 15 (0.7%) 131(6%)
2023 2001 1658 (82%) 135 (6%) 01 (0.04%) 128 (6%)

54. TAKE HOME MESSAGE
• Early Registration.
• Regular antenatal examination with USG followup.
• Bed rest, Tocolytics, Corticosteriods.
• Nutritional supplementation.
• Management of Chronic disorders.
• Early Diagnosis & Treatment of specific conditions.
• Counselling the Patient & her relative regarding survival & prognosis of the 1 kg
foetus.
• Senior neonatologist and PU / NICU backup.

55. REFERENCES
• 1. Committee on Practice Bulletins—Obstetrics, The American College of Obstetricians and Gynecologists
. Practice bulletin no. 130: prediction and prevention of preterm birth. Obstet Gynecol. 2012;120(4):964–
973.
• 2. Matthews T J, MacDorman M F. Infant mortality statistics from the 2010 period linked birth/infant death
data set. Natl Vital Stat Rep. 2013;62(8):1–26.
• 3. Stoelhorst G MSJ, Rijken M, Martens S E. et al. Changes in neonatology: comparison of two cohorts of
very preterm infants (gestational age <32 weeks): the Project On Preterm and Small for Gestational Age
Infants 1983 and the Leiden Follow-Up Project on Prematurity 1996-1997. Pediatrics. 2005;115(2):396–
405.
• 4. Soleimani F, Zaheri F, Abdi F. Long-term neurodevelopmental outcomes after preterm birth. Iran Red
Crescent Med J. 2014;16(6):e17965.
• 5. Harper R G, Rehman K U, Sia C. et al. Neonatal outcome of infants born at 500 to 800 grams from 1990
through 1998 in a tertiary care center. J Perinatol. 2002;22(7):555–562.
• 6. Schlapbach L J, Adams M, Proietti E. et al. Outcome at two years of age in a Swiss national cohort of
extremely preterm infants born between 2000 and 2008. BMC Pediatr. 2012;12(1):198.

56. QUOTE

57. THANK YOU