Mary and Joe are expecting their first baby. The pregnancy has been without complications; routine prenatal screens and ultrasounds have been negative including the screen for Mary’s Group B Streptococcal (GBS) status, the Quad screen for fetal anomalies and cystic fibrosis carrier status. Mary is happy to report strong fetal movements. One week before her due date Mary experiences strong contractions. She is admitted in active labor, membranes rupture spontaneously within 2 hours after arrival in the hospital. Labor progresses uneventfully, pain relief is provided by epidural anesthesia. Ten hours later a vigorous baby girl is born. The only intervention provided for resuscitation is drying followed by skin-to-skin placement on mother’s chest for bonding. Initial physiologic cyanosis is resolved by 5 minutes of life (Figure 4-1). APGAR scores of 8 at 1 min and 9 at 5 min are assigned. Her weight shows that she is appropriate for gestational age. Erythromycin eye ointment is applied to both eyes for prophylaxis of ophthalmia neonatorum, an injection of Vitamin K intramuscularly is given for prophylaxis of hemorrhagic disease of the newborn. Mary chooses to breastfeed that is initiated shortly after delivery with the aid of a lactation consultant. Over the next couple of days, the newborn is breastfeeding about 10 times a day, voiding several times a day and has passed her first meconium stool by 14 hours of life. On day of life # 2 she has lost 6 percent of her birthweight and appears mildly jaundiced. A bilirubin level shows a value within the physiologic range. She is discharged at about 50 hours of life with her mother and a follow-up visit with her pediatrician is arranged for 2 days after discharge.
According to the Center for Disease Control,1 in the US in 2011 there were:
a total of 3,953,593 births recorded.
32.8 percent of infants delivered by Cesarean Section.
11.72 percent of infants preterm.
8.1 percent of low birthweight (<2500g).
The neonatal mortality rate in 2011 was 4.04 neonatal deaths/1,000 live births/year, resulting in ca. 24,000 deaths per year.2
The leading causes of neonatal deaths are preterm related (ca. 35%) and due to congenital malformations, most commonly heart defects.3
Overall, 3 percent of all infants in the US are born with a major structural or genetic birth defect.4
Ten percent of newborns require some degree of assistance in the delivery room; less than 1 percent require extensive resuscitation measures.5
A baby’s due date (Estimated date of Confinement [EDC]) is calculated at 40 weeks after the Last Menstrual Period (LMP).
A baby born at <37 weeks gestational age (GA) is considered preterm; borderline of viability is considered 22 to 23 weeks GA.
Irrespectively of gestational age, a baby weighing less than 2500 g is considered low birthweight; less than 1500 g very low birthweight; and less than 750 g extremely low birthweight.
Transition from intrauterine to extrauterine life.
Intrauterine fetal circulation (Figure 4-2):
Gas exchange occurs through the placenta, which represents the path of lowest resistance in fetal circulation.
Non-ventilated high-resistance lungs are bypassed by the foramen ovale and the patent ductus arteriosus and receive only minimal perfusion.
Uncomplicated transition is characterized by:
Increase in systemic pressure promoted by clamping of the cord and removal of the low resistance placenta.
Surfactant secretion which decreases the surface tension in the alveoli.
Loss of fetal lung fluid.
Establishment of a Functional Residual capacity (FRC) facilitated by the first breaths.
Functional closure of physiologic shunts (Foramen ovale and Ductus arteriosus).
These changes result in a decrease in pulmonary vascular resistance and increase in pulmonary artery blood flow.
Failure of appropriate transitioning into the newborn circulation may result in Persistent Pulmonary Hypertension of the Newborn (PPHN) characterized by hypoxemia due to persistently high pulmonary vascular resistance and decreased pulmonary blood flow.
Common prenatal factors that may result in a need for neonatal intervention at delivery or further intensive care include:
Fetal malformations/chromosomal anomalies.
A variety of hereditary familial disorders.
Multiple gestation (Figure 4-3).
Placental insufficiency due to maternal hypertension/preeclampsia, abnormal cord insertion, placental infarcts, chronic abruption (Figure 4-4).
Exposure to certain maternal medications or illicit drugs.
Poor maternal nutrition.
Maternal obesity/diabetes.
Poor prenatal care.
Inappropriate fetal growth (intrauterine growth retardation or macrosomia).
Known blood group incompatibility.
Untreated maternal sexually transmitted diseases.
Abnormal fetal monitoring (fetal decelerations, poor reactivity, tachycardia).
Abnormal color of amniotic fluid (e.g., meconium as indicator of fetal distress).
Maternal fever.
Maternal colonization with pathogens—GBS, Escherichia coli.
Prolonged rupture of membranes.
Preterm labor.
Abnormal fetal lie.
Cesarean delivery.
Assessment of the newborn in the delivery room (Figures 4-5 to 4-8) include:
Detailed maternal history.
Determination of the gestational age by history.
Identification of risk factors for conditions that require additional monitoring or intervention.
Assignment of APGAR scores by the team attending the delivery:
At 1 minute reflecting the assessment at birth.
At 5 minutes reflecting the response to resuscitation.
At 10 minutes if score at 5 minutes is less than 7.6
A cursory physical examination. Findings of a normal transition may include peripheral cyanosis and mild tachypnea.
Initial assessment in the newborn nursery include:
Length, head circumference, and weight measurements.
Vital signs including temperature, heart rate (HR), and respiratory rate.
Categorization into SGA (small for gestational age, weight <10th percentile), AGA (appropriate for gestational age, weight 10–90th percentile), and LGA (large for gestational age, weight >90th percentile).
Complete physical examination.
Review of maternal medical history, prenatal screens, and prenatal imaging.
Screen for hypoglycemia as indicated:
Infants with risk factors only, asymptomatic: 30 minutes after the first feed. Risk factors include LGA or SGA, infant of diabetic mother (IDM), and prematurity. Symptomatic infants need to be screened earlier.
Target glucose concentration is ≥45 mg/dl; babies should be followed before feedings for 12 (IDM) to 24 hours of life (preterm, SGA)7. SOR C
Ballard exam8 if gestational age is unknown or uncertain. Of note, gestational age is most accurately determined by early ultrasound or LMP. The estimated gestational age by Ballard exam may be inaccurate by as much as 2 weeks.
Screening complete blood count with differential, blood culture as recommended by the CDC algorithm for prevention of early GBS sepsis9 or if risk factors for sepsis are present.10
Assess for risk factors for jaundice, which includes the verification of maternal blood type. Most facilities routinely obtain the infants blood type on cord blood, either universally or selectively if maternal blood type is O, Rh negative, or direct antibody positive.
FIGURE 4-5
Resuscitation table set up for newborn resuscitation: heat source is turned on, several blankets prepared for drying the newborn, suction devices (bulb and wall suction), bag/mask, oxygen source and intubation equipment all available and checked. (Used with permission from Dr. Sabine Iben.)
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