BABY AT RISK

PRESENTED BY
CLARE LUTTA
OUTLINE

Discuss the complications of the neonate:

 Neonatal sepsis
 Opthalmia neonatorum
 Neonatal tetanus
 Hypothermia
 Hypoglycemia
 Respiratory distress syndrome
 Low birth weight (premature)
 Asphyxia neonatorum/poor APGAR score
 Neonatal jaundice
…ct

Birth injuries:
 Caput succedaneum
 Cephalo hematoma
 Intracranial injury
 Fractures
 Nerve injuries
 Convulsions in the newborn
 Vomiting in the newborn
Infection prevention
 Care of incubators and other equipment
 Prevention of infection in the newborn unit
 Alcohol withdrawal
 Abandoned baby
 Born before arrival
 Metabolic disorders ; inborn errors of metabolism, acquired metabolic
disorders,
 congenital abnormalities and their surgery: disorders of the CNS, GIT
malformation, genetic disorders, chromosomal abnormalities,
musculoskeletal , drug dependency and their effects.
Expected learning outcomes

 By the end of the unit, the learner should be able to:

 Diagnose and manage an abnormal neonate
 Manage newborn unit and its equipment
 Practice infection prevention in the newborn unit.
 Definition
A high risk infant is any neonate ,
regardless of weight ,size or gestational
age who has a greater than average chance of
morbidity, or mortality, , especially within the
first 28 days of life.
 Risk factors: include
preconception,
prenatal,
postnatal conditions or conditions that
interfere with the normal birth process.
6
Classification of high risk infant by
weight and gestation
Classification by weight
 Low birth weight (LBW)- any live infant whose weight is below 2500g
at birth.
 Very low birth weight (VLBW)- babies weighing <1500g at birth.
 Extremely low birth weight (ELBW)- babies who weigh below 1000g at
birth.
TYPES OF LOW BIRTH WEIGHT
a) Appropriate for gestational age- baby whose weight falls between
10th and 90th percentile on intrauterine growth chart.
..ct

b) Small for gestation (SGA)- Infant whose rate of intrauterine growth

was slowed and whose birth weight falls below the 10th percentile on
the intrauterine growth chart.
c) Large for gestational age (LGA)- infant whose birth weight falls above
the 90th percentile on intrauterine growth charts.
NB :Intrauterine growth restriction (IUGR)- infants whose intrauterine
growth is restricted.
Classification by gestation

 Pre-term baby- one born before completion of 37th gestational week.

 Full term baby- born btwn 38-42 weeks gestation.
 Post term baby- born after 42 weeks of gestation.
LOW BIRTH WEIGHT
 Definition

Low birth weight:- Any baby weighing

2500g or less at birth regardless of the
gestational age/period.
Preterm Baby:- Any baby born before 37 completed
weeks of gestation.
 Small for Gestational Age Baby
Any baby whose birth weight falls below the 10th percentile for that
gestational age.

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Low birth weight cont’d..

Causes
 Premature delivery or delivery before term 50% of cases are not known. Others are
associated with
 Multiple pregnancy – uterus becomes overstretched .
 Polyhydramnious – excessive amniotic fluid which causes premature labour due to
overdistension of uterus.
 Rhesus incompatibility

11
Low birth weight cont’d…

 Hypertensive conditions – pre-eclampsia-induction of

labour.
 APH- mother may go into premature labour due to
heavy bleeding
 Fetal abnormalities eg hydrocephalus labour may be
induced early.
 Overworking- mother may go into premature labour
 Mother age- very young(bone not developed)
 Infections which may cause pyrexia eg malaria
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
 Complications of low birth weight babies

 Respiratory distress syndrome (RDS)

 Hypothermia neonatorum
 Hypoglycaemia
 Neonatal jaundice
 Hypocalcaemia
 Infections
 Heammorhaegic disease and anaemia
 Prolonged failure to gain weight

13
 Complications of low birth weight babies

 Delayed milestones
 Rickets in infancy
 Retro-tental fibrophoxia (retinal damage) due to increased concentration
of oxygen.
 Apnoeic attacks
 Opthalmia neonatorum

14
Diagnosis of pre-term baby

Diagnosis is made through:

History taking to determine
maturity by dates
Neonatal assessment to
determine gestational age
clinically
15
Principles of care of LBW

 All neonates weighing <2000g admit to NBU.

 Prevent infections
 Adequate feeding
 Provide warmth
 Respiratory support-
 establish and maintain respiration in the infant if need give oxygen.
 Explain to the parents the equipment.
Prevention of infection

 Avoid unnecessary interventions e.g iv lines

 Care of umbilical stump
 One baby per incubator
 Gowning by visitors and hospital staffs
 Cleaning of equipment used.
Provide warmth/ thermoregulation

 Prevention of heat loss and maintenance of neutral thermal

environment is crucial for infants. Ideal body temps shld be 36.5- 37.3
degrees celcius
 LBW infants have smaller muscle mass and fewer deposits of brown
fat for heat production
 Prevention of cold stress which may lead to hypothermia ( temps<36)
is critical for intact survival of LBW baby.
Long term complications of LBW

 Cerebral palsy 45%

 Vision impairement 35%
 Hearing impairement 25%
 Neurodevelopment impairement
 PREMATURE BABY
 Preterm baby is defined as babies born before
37 weeks of pregnancy are completed.
 Some of them may have growth retardation and therefore
be small for gestation, while others may be exessively large
for gestational age (macrosomia).

20
 Sub categories of premature
births

Sub-categories of preterm birth, based on

gestational age:
Extremely preterm (<28 weeks)
Very preterm (28 to <32 weeks)
Moderate to late preterm (32 to <37
weeks).

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 Predisposing factors to prematurity
1.Maternal factors: Maternal age e.g. primigravida below 17 years
or above 35 years ; maternal disease in pregnancy such as
anaemia,hypertention,pre-eclampsia.
2.Foetal factors: Congenital abnormalities; multiple pregnancy and
polyhydamnios due to over digestion of the uterus ;Rhesus
incompactibility interfering with foetal viability.
3.Placental factors: APH due to placenta praevia and placenta
abruption.
4.Social factors: Straineous exercises, excessive drinking of alcohol
and smoking, previous history of miscarriage, psychological stress.
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Characteristics of a preterm baby

1.Gestational age
weeks Length Grams

28 38 cm 1400
34 45 cm 2500
37 47 cm 3000
2.The head- on examination the head appears larger in comparison with the rest of the body.
Sutures and fontanelles are widely separated, ears look flat, cartilage not yet formed

23
Characteristics of a preterm baby cont’d…

3. The skin: red and shinny, blood vessels are easily

seen.vernix caseosa and lanugo covers the body
4. The chest is narrow with weak thoracic muscles.
5.Breast tissue absent below 35 weeks, below 32 weeks
no nipple.
6. Abdomen usually distended
7. Genitalia : male- before 30 weeks testes are
undescended, scrotum very smooth.
Female : before 36 weeks the labia majora are widely
separated and are smaller than labia minora. 24
Characteristics of a preterm baby cont’d…

8. The limbs: both lower and upper are thin

compared to the rest of the body. The nails
are very soft, short or normal
9. Activity/mobility: a preterm is hyportonic
(innactive),weak cry.
10. Reflexes : swallowing, suckling, cough
reflexes before 29 weeks- most are absent.
25
Characteristics of a preterm baby cont’d…

11.Respiratory system: respiratory centre

underdeveloped, lung tissue poorly, weak
respiratory muscles. Respirations are
irregular and can be apnoea, mucus
membrane delicate and can easily be
damaged.
12. Nervous system: poorly developed, heat
regulating centre, and vomiting centre.
26
Characteristics of a preterm baby cont’d…

13. Body temperature:

(i) Have less ability to produce heat due to slow
circulation i.e respirations- feeble, muscle
activity poor, poor feeding
ii) High heat loss due to little subcutaneous fat,
little brown fat, large surface area.
iii) Poorly developed heat regulating centre in
the medulla 27
Characteristics of a preterm baby cont’d…

14. Cardiovascular system

i) Apex beat range between 100-160/m, poor peripheral blood
circulation, oedema of feets and limbs.
ii)Bleed very easily due to weak walls of blood vessels and deficient of
clotting factors.
iii) Prone to low blood sugar soon after birth.
iv) Low antibody level hence susceptible to infection.
v) Hb low because baby baby starts to store iron from 36 weeks and
after
v) Have low calcium level in blood

28
Characteristics of a preterm baby cont’d…

15. Urinary system:

(i) preterm passes scanty urine, very infrequent
for the first few days of life and is not
concentrated.
(ii)The kidney is poor hence presents with
oedema especially lower limbs.
(iii) Poor ability to excrete drugs- avoid
overdose 29
Characteristics of a preterm baby cont’d…

16. Digestive system:

 unable to feed due to lack of suckling reflexes,
regurgitation is poor
 Absorption rate is poor hence can not absorb some
nutrients
 Liver function is poor(immature liver)
 Needs high caloric value for survival

30
Management of a preterm baby

Principles of managemt
 Good care during labour i.e 1st stage of labour
 Efficient care at birth i.e 2nd stage of labour
 Establish and maintain respirations
 Maintenance of body temperature
 Observation and gentle handling of baby
 Feeding/nutrition
 Prevention of infection and Plan of follow up care

31
 Nursing management
1. Warmth: Delivery of a preterm baby should be conducted in a warm room and
subsequently nursed in preterm incubator.
2. Temperatures of the incubator should be maintained within normal range of
about 36 – 37oC. perform first examination of the baby to assess maturity.
3. Feeding: Fix NG tube and feed the baby with expressed breast milk (EBM) and
substitute only where breast milk is not available.

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3. Feeding
Feed the baby using the oral feeding regime,

a. Baby is given 60 – 65 m/s per kg of body weight in 24 hours in 8

divided doses eg 2.5 kg baby will have 2.5 x 60/8 = 18.99 mls
per feeding thus baby should be fed 3 hourly.
b. Babies below 1500gms feed 2 hourly.
c. If the baby tolerates the feed can be increased.
d. If the baby cannot tolerate the oral feeds, give IV fluids e.g. 10%
dextrose day one then (HSD/10%D ratio of 1:2 ) day 2 if there is
normal renal function.
e. Introduce cup feeding gradually as the baby gains weight.
f. Aspirate the gastric content to rule out indigestion.
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4. Close observation to include:
 Vital signs Temperature, pulse and respiration
 Respiration rhythm to note apnoeic attack
 Umbilical stump for signs of infection.
 Vomiting or retaining food
 General activity and emotional status
5. Prevention of infection by care of IV lines i.e. Securing, cleaning and dressing,
hand hygiene, cord care, giving prophylactic antibiotics, top tailing the infant daily.
6. Give nutritional suplements from 14 days i.e.
 Folic acid 2.5mgs weekly for 6 months,
 Multivitamin 2.5 mls daily for 6 months,

 Vitmin D drops 400iu (2 drops) daily for 6 months,

 Then at 28 days stat giving Iron suppliment 2.5mls daily for 6 months,
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7. Initiate kangaroo mother care (KMC) for all babies below 2500gms, if the baby is
stable and the mother mentally stable and is willing.

Kangaroo Mother Care is defined

continuous skin-to-skin contact between a
mother (or her surrogate) and her low
birth weight infant.
It is a simple, inexpensive and safe method
of caring for low birth weight infants.
Babies below 1200gms are nursed in an
incubator ( not stable for KMC)

35
8. Administer broad spectrum antibiotics prophylactically for prevention of infection.
9. Take weight on alternate days to monitor the progress.
10. Teach the mother on how to care for the premature infant
11. Discharge the baby at 2000 – 2500 g on KMC.
12. Give BCG vaccine on discharge or advice the mother to take the child for
immunization regardless of weight.
13. Advice the mother on family planning so that she should not conceive another baby
when she is stressed.

36
 Complications of premature babies

1. Hypothermia neonatorum 6. Anaemia

2. Jaundice 7. Retrolental-fibroplasia
3. Haemorrhagic disease of new born
8. Rickets
4. Infections
9. Failure to thrive
5. Respiratory distress syndrome

37
 Prevention of premature birth
 One way to prevent premature births is to give early and continued prenatal care with
advice on dietary and general hygienic education to the expectant mother.
 Prolonged bed rest should be encouraged, especially where the mother has any of the
conditions that predispose to preterm labour
 Use of sedatives during preterm labour to ensure complete bed rest
 Avoidance of strenuous exercise and reassure the mother, because any strain or stress may
aggravate preterm labour

38
 Kangaroo mother
care
• Kangaroo Mother Care is defined
continuous skin-to-skin contact
between a mother (or her surrogate)
• It is a simple, inexpensive and safe
method of caring for low birth weight
infants.

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 Benefits of KMC

1. Decreases the occurrence of apnoeic attacks

and irregular breathing
2. Associated with less infections and when they
occur, they are less severe
3. Decreases mortality of low birth weight babies
4. Increases mother’s confidence in caring for her
small new-born and improves bonding
5. Reduces hospital stay for mother and baby
(early discharge)
40
 Benefits of KMC
6. Helps maintain an appropriate body
temperature for the new-born
7. Promotes exclusive breastfeeding, resulting in a
higher rate and longer duration of breastfeeding
8. Babies gain weight and grow faster as KMC
promotes GI growth Reduces costs for the
health facility and the mother/guardian as
minimal equipment is required and is less
expensive than incubator care
9. Enables fewer nursing staff to care for larger
numbers of low birth weight new-borns41
 2. Small For Gestational baby /small for dates

 Small for gestation/ small for dates: This

term refers to a baby whose birth weight is
below 10 th centile for his gestational age.
 Commonly referred to as low birth weight but
this includes preterm babies.

42
Small for date/gestational age (SGA) baby

Causes
They are divided into
1.Maternal causes
2. Placental causes
3. Fetal causes
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Maternal causes

 Maternal conditions such as chronic maternal

malnutrition may lead to severe anaemia.
Chronic systemic diseases especially if they
interfere with fetal placental circulation e.g
renal disease, asthma, cardiac disease, T.B,
anaemia, use of tobacco or other narcotic
drugs.
44
Placental causes

 placental insufficiency eg pre-eclampsia,

eclampsia, essential hypertension.
Multiple pregnancy; - competing for
nutritional requirements and after 35 weeks of
gestation, the placenta can not supply them
with adequate nutritional or oxygen and other
requirements (sharing placenta).

45
Fetal causes

Genetic and chromosomal disorders ie may

be born with congenital abnormalities.

46
Common problems of SGA

1.Fetal or intra-uterine hypoxia and intra-uterine death due to placental insufficiency.

2.Intr-uterine aspiration/inhalation – may inhale meconium stained liquor.
3. Born with birth asphexia
4. Hypoglycaemia due to poor glycogen storage. They feed poorly and also first feed may be
delayed.
5. Prone to hypothermia due to lack of enough brown fat. They have little or no glucose reserve.

47
 Signs And Symptoms

Mostly they are born after 37th Eyes are alert and has mature

week gestation facial expression

Pale, dry, loose skin with Skull bones are hard and allow

wrinkles and have no lanugo little mobility

Subcutaneous fat is minimal Have strong cry
Umbilical cord is thin
Show features of retarded gowth
Swallowing and sucking reflexes
The abdomen appears sunken
Sutures and fontanelles are are present so they feed well
Normal muscle tone and are
normal
48

active
 Nursing management
The baby is predisposed to the risks similar to those of preterm baby thus the management principles are
the same:
1. Management should start in labour by closely monitoring foetal condition for signs of foetal distress
2. In case of foetal distress in first stage, administer oxygen to the mother and start IV drip of 10% dextrose
as you prepare the mother for emergency c/s.

3. If she is in the second stage the delivery is hastened by giving a

generous episiotomy.

49
4. Since the baby is prone to hypoglycaemia, it should be started on
breast feeding as soon as possible.
5. Substitutes are given if there is no breast milk, the feed is calculated
at 80mls/kg body weight in 24 hours in 8 divided doses ie 3 hourly
feeding
6. Closely observe vital signs Temp,Pulse,Resp and signs of infection,
give vitamin K to prevent haemorrhagic disease of the newborn,
TetracycleEye Ointement to prevent opthalmia neonatorium, and
methylate spirit to clean the umbilical cord .

50
8. The baby should be nursed in a warm environment to prevent hypothermia although it has temperature
regulation mechanism.
9. Closely monitor blood sugar to rule out hypoglycaemia.
10. Weigh the baby on alternate days to monitor the progress. Usually weight loss is minimal and it gains
weight more rapidly and steadily than preterm.
11. Teach the mother how to take care of the delicate skin that may be dry , cracked or peeling
12. Discharge at 2000-2500gms if newborn is stable.

51
 complications

1. Hypoglycaemia
2. Respiratory distress syndrome
3. Aspiration pneumonia
4. Brain damage

52
 Large for Gestational age(LGA)
Baby of a diabetic mother.

 Definition
 This is a baby with a birth weight of more than 4.0kg; OR
 A baby whose birth weight is above the 90th percentile for the gestation.

53
 Diagnosis

 Suspect or expect LGA if there is:

 History of diabetes in pregnancy
 History of previous large babies

54
 Associated problems:

 The following complications are associated with LGA babies

Hypoglycemia
Birth Asphyxia
Birth injuries
Jaundice
In addition, babies born of a diabetic
mother are prone to Infections and
Respiratory distress syndrome
55
 Prevention

 Adequate control of diabetes in pregnancy

 Anticipate and refer early to deliver in a health facility

56
 Management

Initiatebreastfeeding immediately
and continue feeding on demand. If
the baby sleeps, wake him/her up
and feed at least every three hours
Closely monitor the baby to
promptly recognize the associated
problems
Manage any complications detected
57
 Management
Test the blood sugar levels where
possible
Keep the baby warm
If the mother is not already
diagnosed as diabetic, investigate to
rule out diabetes mellitus. If
confirmed positive, manage the
diabetic mother or refer.
58
 RESPIRATORY DISTRESS SYNDROME

 Is a condition of the respiratory centre commonly found in the preterm

baby although not exclusively.
 Is a condition that occurs due to lack of or inadequate surfactant in the lung tissue.
 Mature lungs have adequate surfactant that lowers surface tension in the alveoli, stabilises
the alveoli and prevents them from adhering together and collapse. This leads to breathing
with ease.
 Respiratory distress syndrome is a disease of prematurity and self – limiting with recovery
phase or death.

 Other names
 Hyaline membrane disease
 Pulmonary syndrome of the newborn
 Developmental respiratory distress.
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 Predisposing factors
 RDS may may be a complication of asphyxia and develops within
4 hours of birth
 Prematurity due to inadequate surfactant factor
 Prenatal hypoxia eg due to APH which reduces surfactant
synthesis
 Trauma to CNS due to difficult delivery or precipitate labour
 Perinatal hypoxia
 Profound hypothermia: leads to injury of cells that produce
surfactant
 Congenital heart disease 60
 Signs and Symptoms of RDS

1. Difficult in breathing and respiratory centre is involved. Includes all signs

of RDS
 Rapid respirations 60-80 breaths per minute
 Chest indrawing
 Cynosis
 Flaring of the nostrils
 Grunting noisy- respirations

61
 Signs and Symptoms of RDS cont’d…

. Increased heart rate (tachycardia)

2

3. Hypothermia of varying degree

4. May develop jaundice especially where
there is hypothermia

62
 Signs and Symptoms of RDS cont’d..

5. Onset is characteristic.
 May be breathing well at birth, then laboured
breathing develops gradually for next 3-4
hours. RDS may manifest in 3-4 hours and
may last for 3-5 days.
Sometimes onset may be immediate. It is self
limiting disease and may progress to death or
resolve its own up to 5 days
63
 management
1. The principle of management during care of babies with RDS are observations, oxygenation, positioning,
nutrition, and hydration.
2. Management is symptomatic until the disease dissolves.
3. If RDS is anticipated,inform a paediatrician to resuscitate the baby.
4. Nurse the baby in an incubator to avoid hypothermia by controling body temperature
5. Administer oxygen or do artificial ventilation to prevent hypoxia
6. Closely monitor the blood pH to prevent acidosis and support pulmonary circulation because high carbon
dioxide levels lead to constriction of pulmonary arterioles leading to poor pulmonary blood flow.
7. Incase there is acidosis , sodium bicarbonate is added to 10 % dextrose drip
8. Keep the baby nil per oral till the distress resolves
9. Administer IV fluids eg.10% dextrose and add calcium gluconate to strengthen heart muscles ; sodium
bicarbonate to ensure fluid electrolyte balance
64
9. Check haematocrit (PVC) and if less than 40% transfuse with blood.
10. Maintain the normal BP with volume expanders
11. Position the baby to provide greatest air entry (prone position with extended head neutral ponormaly )
12. Suction and do postural drainage to remove secretions and keep the airway patent.
13. Close observations to monitor the process whether improving or deteroriating ie. heart
rate,respiration,cyanosis.
14. When the condition resolves,introduce oral feeds gradually. In case the baby developes abdominal
distension due to indigestion, stope oral feeds and start IV fluids.

65
 Prevention of RDS
 Early detection and management of high risk pregnancies to prevent premature delivery.
Conditions such as diabetes mellitus should be properly managed so that delivery can be prolonged to 36 –
38 weeks.The mother is then given Dexamethasone to stimulate lung maturity.
Prevent perinatal hypoxia by ensuring there is no intracranial injury at birth.
Effective resuscitation at birth of high risk babies.
Assesment of gestational age and lung maturity through amniocentesis so that elective c/s or delivery can
be delayed if lungs are not mature enough.

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 Complications of RDS

 Hypothermia.
 Hypoglycemia
 Retro-retinal fibroxia (Excessive adminstration of
oxygen)
 Neonatal jaundice.
 Intravascular hemorrhage due to hypoxia especially in
brain which may lead to bleeding in the brain tissue.
 Hypocalcaemia (low calcium level)
 Infections.
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 3. ASPHIXIA NEONATORUM
 Asphyxia is a term used when the baby fails to breath at birth.
Types of Asphyxia :
The degree of asphyxia is determined by Apgar score in which the following features are

observed and scored 0-2

 Appearance( A): Note colour of the skin
 Pulse (P) (heart rate):
 Grimance (G): Note response to stimulation. Gently rub on to the sole of foot

and note grimace.

 Activity (A) : Note activity and muscle tone of the baby by stimulating the

arms and legs by pulling the

 Respiration (R) / respiratory effort: Note respiration by looking at the

abdomen and chest.

For further reading on APGAR score refer NCK procedure manual pg 271
68

A score between 8-10 does not show asphyxia.

 Types of
asphyxia
There are three types of asphyxia namely:
1. Mild asphyxia: Apgar score is 6 – 7 .It requires clearing of the airway and application
of external stimuli to initiate breathing.
2. Moderate asphyxia: Apgar score is 4 – 5. It requires resuscitation , administration of
oxygen and drugs to initiate breathing.
3. Severe asphyxia: Apgar score is 1 – 3 . It requires intensive resuscitative measures
and intubation to survive.

69
 Predisposing factors

1. Any condition causing foetal distress e.g. cord prolapse,

prolonged labour, Antepartum haemorrhage.
2. Intrauterine hypoxia due to placental insufficiency, postmaturity,
placenta abruption, anaemia and pre-eclampsia
3. Prematurity due to underdeveloped respiratory centre
4. Blockage of airway by mucus or liquor amnia at birth.
5. Birth injuries e.g. intracranial injury
6. Severe maternal disease in pregnancy eg sickle cell anaemia,
cardiac disease in pregnancy.
7. Depression of respiratory centre due to drugs e.g. General
70

Anaesthesia and narcotics

 Signs and symptoms of asphyxia
Mild and moderate asphyxia Severe asphyxia
 Apex beat (pulse rate )  No attempt to breath and may
100/min or less gasp periodically
 Skin colour is pink with blue  It does not cry
extremities.  Entire body skin is blue ie.
 Response to stimuli may be
cyanosed
present  No response to stimuli .
 Cry may be weak or strong  Pulse rate very slow or absent
 Makes effort to breath and may  Poor muscle tone
gasp with irregular respiration
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 management
1. Clear the airway as soon as the baby is born.
2. Nurse the baby in an incubator for at least 48 hours to keep it warm at body temperature.
3. Resuscitation may be needed to promote ventilation and ensure effective circulation to prevent
acidosis,hypoglycaemia and intracranial haemorrhage
4. Do suctioning whenever necessary
5. Closely observe the baby for skin colour temperature.
6. Administer oxygen by mask, ambu bag or nasal catheter whenever there is an apnoetic attack
7. Aspirate mucus to unblock the airway or may intubate the baby
8. Give IV fluids 10%Dextrose for rehydration calculate as for feeds day 1
9. Give fluids with electrolytes to maintain fluid – electrolyte balance i.e.half strength darrows day 2.
10. If the mother was given narcotics during labour, administer its antidote. Naloxone through the umbilical
vein,
11. Give anticonvulsants to control convulsions if present,

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10. Administer the following drugs:
 Sodium bicarbonate 1 – 2 mls to combat acidosis
 Vitamin K 0.5 – 1 mg i.m to prevent haemorrhagic disorders
 Aminophylline to strengthen heart muscles
11. Maintain accurate input output charts to prevent overhydration or underhydration
12. When the baby is stable, pass the NG tube and start feeding
13. Observe hand hygiene, aseptic technique to prevent cross infection
14. Administer broad spectrum antibiotics prophylatically

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 Prevention of asphyxia

Antinatal period:
 Proper screening of mothers to detect those at risk and advice on delivery in hospital for proper management.
 Pelvic assesment should be done at 36 weeks to rule out cephalo pelvic dispropation (CPD)

Intrapartum:

Drugs that depress respiratory centre eg.sedatives, General

Anaesthsia ,narcotics should be avoided in late first stage;
Early detection and management of foetal distress ;
Clearing baby’s airway as soon as the head is born;
Avoid instrumental deliveries but rather prepare for c/s;

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 Complications

1. Brain damage
2. Cardiac arrest
3. Respiratory distress syndrome
4. Respiratory acidosis

75
NEONATAL JAUNDICE

76
Neonatal jaundice

 Definition
 Is a yellow discoloration of the skin and the mucus membrane
of the newborn.
 It is usually caused by accumulation of bilirubin in the blood and
tissues. The accumulation occurs due to:-

Excessive breakdown of Red Blood

Cells
Abnormality of conjugation of
bilirubin
Abnormal transportation of bilirubin
Formation of bilirubin

 Bilirubin is formed from the breakdown of red blood cells.

 When red blood cell is broken down, two components are formed i.e
Globin and haem
 Globin – is a protein released from hemoglobin and goes back
to body to be used as a protein.
 haemo.- undergoes various reaction to form an unconjugated
bilirubin usually in the reticuloendothelial cells especially in
the liver and spleen.
 It is estimated that 1g of hemoglobin yields 35mg of
unconjugated bilirubin.
Bilirubin in blood (serum bilirubin)
 Once bilirubin has been formed in the liver and spleen, it is transported
in plasma as unconjugated bilirubin. It is taken to the liver for
conjugation.
 During the transportation process, the unconjugated bilirubin is bound
by a special albumin in the vascular space.
 When it reaches in the liver, it is diffused into the liver cells.
 It is mixed with an enzyme gluconic acid to form glucoronide. This is a
complex reaction that takes place in the presence of enzyme
glucoronyl transferase resulting to conjugated bilirubin.
 If albumin is less, there will be a reduction in binding capacity hence
higher unconjugated bilirubin in circulation (plasma) resulting to yellow
disclouration (Jaundice)
Types of Bilirubin
There are two types
a) Conjugated bilirubin (glucolonide or direct bilirubin).
 It is conjugated because it has free molecules which
have undergone conjugation in the liver.
It is water soluble and easily excreted.
b)unconjugated bilirubin (glucolon indirect
bilirubin).
 It is unconjugated because it has not been converted
to gluconide form in the liver. It is insoluble in water
and can not be excreted. It is fat soluble. Being
soluble in fats, it has high affinity to fatty tissue and
the brain (hence discolours the skin).
Conjugation of Bilirubin
 It is a complex process which occurs in the liver
through a series of reactions.
 Unconjugated bilirubin combines with gluconic acid in
the presence of glucoronide transferase resulting to
conjugated bilirubin or gluconide which is water
soluble.
 It then leaves via the biliary tract as bile passed into
small intestine where it is changed to
stercobilirubinogen(substance that covers the
stool).
 Some of it is re-absorbed from the intestine into blood
stream and can be excreted in urine as urobilinogen
Causes of slow conjugation process of urine

 In a normal health term baby,some degree of jaundice may develop

between the 2nd and 7th day of life due to combination of factors.
 Slow conjugation of bilirubin.
 Increased re-absorption from the small intestine.
 The level of bilirubin lie below the acceptable limits and should not go
beyond 12mg/mmols of blood. This is called physiological jaundice.
Types of neonatal jaundice

Is classified as
Physiological or gestational
Pathological or disease or
trauma
1.Physiological Jaundice

Itcomprises about 85% of all cases

of neonatal jaundice
This is due to immaturity of liver
cells which are not able to
conjugate the indirect bilirubin
There can be also excessive
breakdown of RBCs and increased
re-absorption of bilirubin
Physiological jaundice cont’d…..

 Usually occurs after 48 hours of birth or early in the very preterm baby
and resolves in 7-10 days or little longer in the preterm baby.
 Mainly occurs in the skin and eyes.
 Baby looks well and feeds well.
 The levels of conjugated bilirubin are not too high and they hardily
exceed 12g/mmol.
 The bilirubin level will gradually but daily needs will hardily exceed
5g/100mls of blood.
CAUSES OF PHYSIOLOGICAL
1. Jaundice due to trauma
 This is due to large cephalohematoma or severe bruises on the body of a
baby.
 The hematoma is absorbed slowly leading to the breakdown of RBCs,
hence high levels of bilirubin thus baby presents with jaundice.
 It can be last for weeks or as long as the cephalohematoma remains.
2. Blood incompatibility

A) ABO incompatibility
 This type occurs when maternal blood is group ‘o’ i.e the mother has no
antigen ‘a’ and ‘b’ and if she is transfused with wrong blood group e.g
transfused with A,B,AB which have antigen ‘a’ and ‘b’.
 The mother’s immune system produces antibodies against antigen ‘a’
and ‘b’.
 It can also be due to use of certain foods, infections etc.
 If she conceives the fetus will be carrying antigen ‘a’ and ‘b’.
 The antibodies circulating in blood will get attached to the antigen ‘a’
and ‘b’ in the fetal blood.
 This leads to hemolysis of RBCs.
Blood incompatibility cont’d…..

 B) rhesus incompatibility
 This occurs when the mother is rhesus negative (rh-ve) and the father is
rhesus positive (rh+ve)
 The fetus will inherit the fathers blood group thus the baby will be rh
+ve.
 The mother will react to the baby’s blood and form antibodies against rh
+ve factor.
 This occurs during labour (third stage) placenta blood leaks and enters
maternal blood or early separation of placenta or during abortion.
 The first baby is not affected because he sensitizes the mother to
develop antibodies.
 The subsequent pregnancies will be affected since the mother has
developed antibodies.
Blood incompatibility cont’d…..

 In subsequent pregnancies rh+ve baby’s blood will cross placental

barrier and attach to RBCs causing haemolysis of RBCs. This forms
bilirubin leading to jaundice.
 The jaundice may be present at birth incase of haemolysis in uteral.
 If not severe it occurs within the first day of life.
 3. Jaundice due to sepsis/infection
 It usually occurs within first week of life mainly from 5 th to 7th day of life. It
is mainly due to septicaemia.
 If the baby presents with an unexplained jaundice should be investigated
for other causes which include:-

Infection of the cord, genital tract, and

gastro-enteritis
Signs of unwilling to feed, lethergic,
signs of drowsness, very sick
 4. Jaundice due to obstruction of biliary tract
or atresia of biliary tract
 Is a disability of the biliary tract and can be due to obstruction.
 Atresia is absence of the biliary tract.
 Is a rare condition and treatment is surgery.
 Nursing management
 Admit the baby into the NBU and and asses the general condition.
Start early and frequent breast feeding for;
 feeding provides glucose to the liver cells
 Feeding also encourages bowel colonisation with normal flora
which are important in formation of stercobilinogen for
excretion in stool.
 Early feeding also leads to increased gut motility leading to
faster excretion of bilirubin.
 Feeding also enhances enzyme production and conjugation.
Closely monitor serum bilirubin levels at 12 - 24 hr interval.
If bilirubin levels take time to clear, put the baby on phototherapy.
92
2. Pathological jaundice
 Pathological jaundice appears within 24 hrs of life and is not self- limiting thus may persist for long.
 There is rapid rise in serum bilirubin.
 It includes both obstructive and haemolytic jaundice.

93
 Causes
 They include pathological disorders that increase bilirubin
production, reduces transportation to and fro the liver or reduces
rate of conjugation.
1. Increased haemolysis – Rhesus and ABO incompatibility, G6PD
enzyme deficiency, bacterial infection.
2. Non-haemolytic causes of increased unconjugated bilirubin – CNS
haemorrhage, cephalohaematoma, polycythaemia, exerggerated
enterohepatic circulation of bilirubin due to functional ileus.
3. Decreased rate of conjugation – Cliggler Nagar Syndrome,Gilbert’s
syndrome.
4. Hepatotoxic drugs
5. Biliary obstruction that prevents transport of conjugated bilirubin to
GIT for excretion 94
6. Reduced bilirubin binding sites on the albumin
7. Malnutrition
8. Increased reconversion of conjugated to unconjugated bilirubin
if it stays in the GIT.

95
 Nursing management
Asses the baby to determine the degree of jaundice
Do investigation on serum bilirubin levels and Hb
Start the baby on phototherapy
Order for blood exchange transfussion if necessary.
Ct general nursing of newborn baby at risk
Complications of neonatal jaundice
Retinal damage due to light used in treatment
Anaemia
Hyperthermia associated with phototherapy
Hypocalcaemia
Kernicterus which is caused by excessive bilirubin in brain cells. that
is characterised by seizures, hyper – tonicity , lethargy, stiff neck with hyper –
96
extended head.
 Specific management
A) Investigations
i) blood – for Hb level, bilirubin levels, blood group, rhesus factor, for c/s
 For combs test (cord blood at birth is taken for estimation or presence of
maternal antibodies) especially on the RH-ve mother
ii) Stool for c/s
iii) Urine for c/s
iv) Serum swab from cord for c/s
 Specific management
B) phototherapy
 A florescent tube that emits light is placed about 45cm (18 inch) above
the baby.
 The light disintegrates unconjugated bilirubin to simple bio-pigments
which are water soluble which is easily excreted.
PHOTOTHERAPY
Definition of Phototherapy

Application of
fluorescent light to
the infant’s
exposed skin.
Indications.
Preterm with jaundice appearing after 48 hrs and bilirubin levels are 260 – 265 mol/l
Preterm with weight less than 1500g and bilirubin levels are 85 – 114 mol/l
Preterm with weight more than 1500g and bilirubin levels are 14 – 165 mol/l

101
 Minor side effect of phototherapy

1. Bronze – baby syndrome.

2. Loss , greenish stool .
3. Transient skin rashes.
4. Hyperthermia .
5. Increasing metabolic rate.
6. Dehydration .
7. Electrolyte disturbance .
Nursing Care for Infant Receiving
Phototherapy.
 1- Assure effective of phototherapy: Keep record of number of hours exposure to
phototherapy
 Baby should be turned 2-3 hourly to ensure maximum exposure
Nursing Care for Infant Receiving
Phototherapy.
2- provide eye protection .
Pad the eyes with
special eye pad or
improvise a gauze
to prevent injury
to the eyes.
Nursing Care for Infant Receiving
Phototherapy.
3.Proper shielding and
Covering of the
gonads
 Nursing Care for Infant Receiving
Phototherapy Cont’
4.Assess skin exposure .
Keep record of number of hours exposure to
phototherapy
Baby should be turned 2-3 hourly to ensure
maximum exposure
Nursing Care for Infant Receiving
Phototherapy Cont’
5. Proper position .
Nursing Care for Infant Receiving
Phototherapy Cont’

6.Assess and adjust thermoregulation

device .
 Ensure warmth guard against
overheating can be indicated by rise in
body temperature.
 Monitor baby’s body temperature or
incubator temperature
Nursing Care for Infant Receiving
Phototherapy Cont’
7. Promoting elimination and skin integrity .
Nursing Care for Infant Receiving
Phototherapy Cont’

8. Hydration.
Dehydration may be due to overheating and
diarrphresis take observations for signs
of dehydration.
If dehydrated, put on i.v fluids to ensure
adequate fluid and electrolyte balance.
 Nursing Care for Infant Receiving Phototherapy
Cont’

9. Promoting infant parent interaction.

 Nursing Care for Infant Receiving Phototherapy
Cont’

10. Monitoring bilirubin level.

Vital signs and observation of bilirubin

levels should be examined.
 Nursing Care for Infant Receiving Phototherapy Cont’

11.Promotion of nutritional
status
Feeding can be oral or i.v
infusions (breast milk by cup
and spoon or NGT
General care or e.g turn PRN,
change linen, weigh.
Head to toe exam and top tailing
etc
 Prevention of jaundice

Prenatally: - all rhesus -ve mothers are given

anti- D’. immunoglobulin to coat the RBCs of
fetus and prevent breakdown of RBCs
(haemolysis).
Post-natally – mothers with rhesus given
anti-D within 72 hours or 3 days of delivery.
Coats RBCs of fetal cells in the mother.
At 28 wks indirect comb test is done to detect
 When to stop phototherapy

 When serum bilirubin levels is 50 umol/L.

 Repeat serum bilirubin measurements if necessary12-18 hours after
ceasing phototherapy to check for rebound hyperbilirubinaemia.

115
 Side effects
loose stool due rapid interstinal transit
 poor feeding
Hypocalcaemia
Fragility
Hyperthermia due to increased fluid loss and dehydration.
 Lethargy
Retinal damage from intensity light
Visual deprivation
Irritability.
Skin rashes and skin burns.

116
 Specific management
C ) drugs
 Antibiotics are usually given (broad spectrum) or depending on c/s
 Anticonvulsants eg phenobarbiton.
 Anti-emetics
 Antihemorrhagic to prevent /stop bleeding e.g vit.K
 Specific management

d) Exchange blood transfusion

 Exchange of fetal blood with donors blood.
 Usually done when the levels of bilirubin rise to dangerous levels.
 This depends on the gestational age and weight.
 Term baby’s levels reach 20mg/100mls of blood
 Preterm baby (1500g) levels reach 12mg/100mls.
 Very low weight (1200g) levels reach 12mg/100mls
 Aim of blood exchange
 To remove most of the maternal antibodies
circulating in the baby’s blood.
 To remove the unconjugated bilirubin which has
accumulated in the baby’s blood.
 To correct anaemia as a result of excessive
destruction of red blood cells.
 In case of Rh-ve incompatibility, blood group ‘o’ is used (universal donor) or baby’s own
group, but the blood must be Rh-ve or baby may be B+ve blood will be B-ve.
 Aim of blood exchange
 Freshcont’d,,,,,,
blood not older than 3 days i.e rich in hemoglobin and about 85% of baby’s blood is
removed/withdrawn and replaced with the donors blood.
 The amount of blood used is calculated according to the body weight of baby – 85ml*weight
of baby.
 If severe double amount is used 170mls.After this bilirubin level in blood is tested – 36 hrs
 Exchange transfusion can be done together with phototherapy.
 Role of the midwife in blood
exchange
Ensure the room is warm
Ensure the equipment are crucifix
Ensure enough linen because may soil the
area
Ensure blood is fresh (counterchecked)
Observation prior to procedure and during
procedure
 Role of the midwife in blood
exchange
Observe for color, respirations, signs of
cardiac involvement i.e rapid pulse rate,heart
failure or cardiac arrest.
Hypoglycemia

 Definition
 This occurs when the Blood glucose level is below 2.6 mmol /l (45
mg/dl) irrespective of gestation and postnatal age.
 Normal levels of blood sugar 3.5 – 6 mmol/litre (70-120mg/100mls)

 At term,the baby’s glucose level is almost equal to that of the mother but gradually
drops within 3 – 4 hours after birth.
 This is why the baby has to be fed within one hour of life.
 The baby’s blood glucose rises steadily following feeds to 2.8 – 4.5 mmol/l in 6 – 12 hrs.
 Term babies can maintain their energy requirements as long as they are kept warm.
This condition is common in infants of diabetic mothers.
Due to excess glucose, the foetus produces more insulin which increases its body fat and muscle mass leading
to large babies (macrosomia).
At birth the glucose level falls rapidly while insulin levels remail relatively high so the baby is at risk os
hypoglycaemia.
This is why such babies are admitted into NBU.

Prolonged hypoglycaemia can lead to:

 Mental retardation,
 Permanent neurological damage and
 Death due to respiratory and metabolic acidosis.

124
 Predisposing factors to
hypoglycaemia
Low birth weight
Prematurity
Birth injuries
Maternal diabetes mellitus
Asphyxia
Septicaemia
Respiratory distress syndrome

125
Hypoglycemia cont’d,,,,,

 Diagnosis
 May be asymptomatic especially in pre-term infants
 Features include jitteriness, sweating, convulsions, apnoea, cyanosis,
hypotonia
Clinical manifestations:
1- Hypotonia.(inactive)
2- Feeding poorly after feeding well.
3- Tremors.
4- Cyanotic spells.(apnoeic attacks)
5- Lethargy.
6- Seizures.(convulsions)

Clinical manifestations (s&s)

1- Hypotonia.(inactive)
2- Feeding poorly after feeding well.
3- Tremors.
4- Cyanotic spells.(apnoeic attacks)
5- Lethargy.
6- Seizures.(convulsions)
7- Hypothermia.
8- Irregular respiratory pattern (Apnea).
9- Irritability, when disturbed - cry
10- High pitched cry followed by weak cry.
11- poor reflexes, especially sucking reflex.
12. rolling of eyes(abnormal movement of
eye balls.
MANAGEMENT
Blood glucose less than 1.1 mmol /L (25 mg/dl)
 Give a bolus of 2 ml/kg body weight of 10% glucose IV slowly over five minutes
 If an IV line cannot be established quickly, give 2 ml/kg body weight of 10% glucose by
gastric tube
 Infuse 10% glucose at the daily maintenance volume according to the baby’s age
 Assess the blood glucose 30 minutes after the bolus of glucose
MANAGEMENT cont’d,,,,,,,,
 - If the blood glucose is less than 1.1mmol/L (25 mg/dl), repeat the bolus of glucose (above)
and continue the infusion then assess blood glucose again after 30 minutes
 - If the blood glucose is between 1.1mmol/L (25mg/dl) and 2.6mmol/L (45 mg/dl) continue
the infusion and repeat the blood glucose testing every three hours until the blood glucose is
2.6mmol/L (45 mg/dl) or more on two consecutive tests
MANAGEMENT cont’d,,,,,,,,

 - Allow the baby to breastfeed. As the baby’s ability to feed improves, slowly decrease
(over a three-day period) the volume of IV glucose while increasing the volume of oral
feeds. Do not discontinue the glucose infusion abruptly
 Blood glucose between 1.1 -2.6m/mol/l
(25-45mg/dl)
 If the blood glucose is between 1.1mmol/L (25mg/dl) and 2.6mmol/L (45 mg/dl) allow the
baby to breastfeed and repeat the blood glucose testing every three hours until the blood
glucose is 2.6mmol/L (45 mg/dl) or more on two consecutive tests
 Once the blood glucose is 2.6mmol/L (45 mg/dl) or more for two consecutive tests;
 - If the baby cannot breastfeed, give expressed breast milk using an alternative feeding
method
 Frequency of blood glucose measurements
after blood glucose returns to normal
 If the baby is receiving IV fluid for any reason, continue blood glucose testing every 12 hours
for as long as the baby requires IV fluid. If the blood glucose is less than 2.6mmol/L (45
mg/dl), treat as described above
 If the baby no longer requires or is not receiving IV fluid, assess blood glucose every 12
hours for 24 hours (two more tests):
 - If the blood glucose remains normal, discontinue testing
Prevention
 Early, adequate and regular feeding for all babies
 Infants at risk
- Pre-term babies
- Small for gestational age
- Large for gestational age
- Infants of diabetic mothers
- Any sick infant e.g. asphyxiated babies, babies with sepsis and babies with hypothermia
Prevention

Taking blood glucose levels at birth and introducing glucose

feeds eg. dextrose and breastfeeding within 1 hours of life.
Prevent hypothermia
Monitoring glucose levels 2hourly for the first 6 – 8 hours.
Infants of diabetic mothers should be admitted to NBU and
blood glucose level regularly checked.
Complications
Hypothermia
Convulsions
Brain damage
Neonatal death as an outcome.
135
 6. NEONATAL HYPOTHERMIA

 This is a condition in which the neonates’body temperature falls

below 36.5 oc. {based on axillary temperature}.

 The infants surface area:body mass ratio pontentiates heat

loss,especially from the head which comprises 25% of his size. T

 he infants subcutaneous layer is thin and provides poor insulation allowing transfer of core heat to the
enviroment and also cooling of blood

136
 hypothermia

The baby loses heat through:

 Evaporation
 Conduction
 Radiation
 Convention
1. Evaporation : cooling of the body by loss of fluid on the skin (amniotic fluid).
2. Conduction: Heat is lost when the baby is in contact with cold surfaces.
2. Radiation: loss of heat to cold objects in the enviroment
3. Convention: loss of heat caused by currents of cold air passing over the surface of the body .

137
 Causes
 Exposure to cold environment (Low temperature, cold surface or draught)
 Wet baby
 Under-dressed baby
 Prematurity
 Delayed feeding
 Infections
 Diagnosis
 Baby feels cold on touch especially the extremities
 Poor feeding
 Axillary temperature below 36.5ºC
 Extremities are blue and may be edematous
 Heart rate may be low
 Difficulty in breathing or slow shallow breathing
 Lethargy
 Hardened skin
 Management
 Keep the baby warm by:
 Removing wet/cold clothes
 Skin-to-skin contact with the mother and cover with warm linen
 Adequately clothe the baby(including hat and socks)
 Keep clothed baby under radiant heat source; Nurse in a warm incubator if possible
 If baby is blue or having difficulty in breathing give oxygen
 Management cont’d,,,,,,,,,
 Pass nasogastric tube and give breast milk or other milk if breast milk is contraindicated
 Re-check the temperature after one hour and repeat hourly until it reaches the normal
range (36.50C -37.40C)
 If after the re-warming procedure the temperature does not rise, refer urgently
 Investigate and treat the cause of hypothermia.
 Management of hypothermia
chart
Hypothermia

Examine temperature:
•Touching the feet of the baby
•Taking rectal/axillary temperature

Low body temperature

Low temp.(35.5-36.4°c) Very Low temp.(35.5-36.4°c)

•Skin to skin contact with the mother or, •Take temperature frequently
•Wrap baby under heat source or incubator / or Naso-Gastric tube feed
•Breast feed or give milk •Fix IV drip of 10% dextrose and
•Identify and treat cause
 Prevention Of Neonatal Hypothermia
 Delivery should be conducted in a room with controlled
temperatures.
 Dry the baby immediately to prevent heat loss through
evaporation.
 Put the baby on resuscitaire or incubator to compensate heat
loss to the environment.
 Baby should not be bathed within 1 hour of life but top – tailing
can be done after one hour.
 Encourage skin to skin contact (KMC) method when carrying
the baby.
 Cover the baby with warmclothing and a cap
 Change diapers whenever soiled to prevent heat loss through
143

conduction.
 Complications

 Convulsions
 Hypoglycaemia
 Brain damage
 Cold syndrome

144
 Warm chain
1. Warm delivery room
2. Immediate drying the newborn
thoroughly
3. Skin to skin contact
4. Breastfeeding the newborn within an hour
5. Bathing and weighing is postponed
6. Appropriate clothing and bending
7. Mother and baby together (rooming in)
8. Warm transportation ( skin to skin)
9. Warm resuscitation 145

10. Training and awareness for the mother.

9. HAEMORRHAGIC DISEASE OF
THE NEW BORN.
This bleeding that occurs during the first few days of life due to vitamin k deficiency.
Vitamin K is synthesised by the bowel normal flora and its role is to convert clotting
factors such as prothrombin, thrombokinase, thromboplastin.
In preterm the liver cells are immature and this leads to diminished
formation of vitamin K and consequently deficiency of vit K leads to
deficiency of clotting factors.

To prevent HDN, all neonates are given vitamin K 0.5 - 1 mg i.m at birth.

146
 Signs and symptoms

 Spontaneous bleeding from various sites in the 1st 3 days of life.

 Bleeding of the mucus membrane of the intestinal tract leading to
maleana stool and haematemesis
 Intracranial damage
 Continuous bleeding from the injection site or any damaged blood
vessel
 Oozing of blood from the umbilical cord
Note: In acute bleed there could be signs of shock
 Predisposing factors
 Prematurity
 Infections
 Birth trauma
 Asphyxia
 Vitamin K deficiency
Disseminated intravascular coagulopathy (DIC)
Birth asphyxia
Mothers who are on drugs like warfarin, heparin, phenobarbital
 Management cont’d,,,,

 Take history and Examine baby; Ensure warmth

 Investigate to identify cause
 Treat the cause immediately.
 - If from cord stump, re-tie or re-clamp
 - If cut, press on bleeding site with sterile gauze
 Management cont’d,,,,,

 Give Vitamin K 1 mg/kg IV even if the baby had already been given
 Transfuse if the signs of shock are present and also give oxygen. Give
enough blood to correct hypovolemia.
 For babies whose Hb is less than 12 gms/100 mls in the first week of life,
transfuse
 For babies whose Hb is less than 10 gms/100 mls after the first week of
life, transfuse
 Review baby at the end of transfusion and decide whether the baby needs
more
 Haemorrhagic disease of the newborn

 Prevention
 Prevent the predisposing factors
 Give Vitamin K at birth

Preterm 0.5mg i.m single dose

Term baby 1mg single dose
 Investigations
 Take blood for full blood count
 Group and cross-match blood
 complications

Anaemia
Hypovolaemic shock
Brain damage

152
NEONATAL INFECTIONS

These include:
Opthalmia neonatorum/Eye
infection
Skin infections
Oral thrush
Cord infection
Septicemia
153
OPTHALMIA NEONATORUM

Is a condition whereby there is

inflammation and discharge from the eye
of the infant within the first two days of
life

154
Causative Clinical
organism features
 Eyes have sticky watery discharge
Neisseria gonorrhoeae
 Eyes are slightly red
Chlamydia trachomatis  Oedematous eyelids
 Yellowish purulent discharge if the infection is by
Staphylococcus aureus
N. Gonorrhoeae
Escherichia coli
Haemophilus influenzae
Streptococcus
pneumoniae
Pseudomonas spp
klebsiella

155
Management cont’d,,,,,

Treatment
 Isolate baby with eye infection and take swab for culture and sensitivity.
 Drugs used
 Chlorophenical eye drops 0.25-0.5% instilled hourly for 8 hours after birth
 Penicillin eye drops 500units(2 drops into the conjuctival sac 5 min for one hour then 2hrly
for 24 hours.

156
Management cont’d,,,,,

 Procaine penicillin 300i.u given i.m once daily for 7 days.

 Other drugs neomycin eye drops or orally
 Observations
 Observe the cornea – if it appears milky is a serious sign which may result to cornea
laceration with blindness.
 General care as other babies.

157
Management cont’d,,,,,

Prevention
 The main cause is infection of the mother during prenatal period. Any vaginal discharge
during pregnancy should be treated.
 1% tetracycline eye ointment should be applied to the eyes of a baby immediately after
birth.
 Observe personal hygiene of the vulva and proper swabbing

158
Management cont’d,,,,,

Prevention cont’d,,,,,,,,,,,,
 Eyes should not be touched, cleaned by sterile equipment or sterile water e.g normal saline
 Advise mother not to apply handkerchiefs or towel to clean baby eyes
 Isolate any baby with eye infection to avoid cross infection to other babies.
 In case of infection take eye swab for culture and sensitivity,

159
SEPTIC SKIN SPOTS

Definition
 This is inflammation of the skin due to bacterial infection.
 Diagnosis:
 Signs and symptoms include:
 Redness of the skin
 Pustules or sores on the skin

160
SEPTIC SKIN SPOTS cont’d,,,,

 Common causative organisms:

 Staphylococcus aureus
 Streptococcus

 Prevention
 Wash hands before and after handling baby
 Educate mother on personal hygiene and skin care of the baby

161
Management

Wash hands with soap and water before

and after handling baby
Clean skin with antiseptic lotions like
Hibitane
For mild cases give syrup Amoxicillin
62.5mg tid x 5/7 or Cloxacillin 62.5mg
tid x 5/7
162
Management cont’d,,,,,
 For extensive skin lesion admit and start treatment with Crystalline Penicillin and
Gentamicin. 1M or IV Crystalline Penicillin 50,000U/kg 12 hourly
 1M or IV Gentamicin 5 mg/kg daily
 Counsel the mother on subsequent care:
 - Return baby for review after 2 days
 - Return immediately if baby becomes sicker. (See features of neonatal
septicemia)

163
oral thrush
 This is diagnosed when there are thick white patches on tongue or inside
the mouth
 Management:
 Wash hands
 Clean baby’s mouth with a clean soft cloth
 Instill Nystatin drops 1 ml 4 times a day

164
Management cont’d,,,,,
 Continue breast feeding
 Treat mother’s breast with the same medicine
 Follow up after 2 days
 Review after 2 days:
 If worse, refer to hospital, if improving, continue treatment for 5 days

165
 cord infection
Definition
Cord infection is inflammation of the
umbilical stump usually occurring in
the first week of life.
Diagnosis
Signs and symptoms may be early or
late
166
 cord infection
Early signs
Redness at base of stump
Wetness of Stump
Offensive smell

167
 cord infection

Late Signs
Baby looks ill
Temperature may be elevated
Baby may refuse to feed
Pus discharge from the umbilicus
Jaundice

168
 Management

 Wash hands before handling the

cord
Wear clean gloves
Clean the cord with antiseptic
solution e.g. povidine (tincture)
iodine with clean gauze/ cotton wool
Apply Gentian Violet four times a day
Keep cord dry 169
 Management cont’d,,,,,
 Keep baby clean
 Continue breast feeding
 Give Amoxicillin 62.5mg/kg – three times a day for 5 days
 Admit baby with late signs
 Review baby after two days
 - Refer or admit if pus or redness remains
 - If improved continue antibiotic for 5 days

170
 Prevention
 Clean hands
 Clean/sterile delivery instruments
 Clean surface
 Clean cutting of the cord
 Clean ligature
 Avoid application of harmful traditional substances (e.g. talcum powder,
saliva, cow dung, etc)
 Educate mother on personal hygiene

171
 NEONATAL SEPTICAEMIA (SEPSIS)

Definition
This is when a baby has generalized
clinical features of a sick infant;
ideally blood culture positive.
Diagnosis
Any sick infant is regarded as having
neonatal sepsis until proved
otherwise. 172
Clinical Features

Poor feeding or refusal to feed

Lethargy or poor cry or unusually
sleepy
Cry excessively (irritable)
Unconscious
Has difficulty in breathing
Frequently stops breathing (apnoeic
173
Clinical Features
Convulsions
Feels too cold or warm (temperature < 35.5oC
or ≥ 37. 5oC)
Diarrhoea and vomiting
Appearance of pustules all over the body
Yellow body (Jaundice)
Periumbilical redness or pus from cord
Note: A baby with any of these features may
have any of the conditions in the section
on neonatal emergencies. 174
 Modes of acquiring infections
 Across the placenta e.g. Rubella virus, HIV, histoplasmosis, syphilis,
cytomegalovirus (CMV), listeria monocytogens
 Intrapartum transmission: herpes simplex virus, hepatitis B, candida albicans,
Ophthalmic neonatorum, pneumonia
 Infections acquired after birth from the environment, from contaminated
equipment’s or from people handling the baby:

175
Infections acquired after birth from the environment, from
contaminated equipment’s or from people handling the baby:

 Nasopharyngitis,
 Eye Infections,
 Rhinitis,
 Mouth-candiba Albicans ,  Pneumonia,
 Buttocks Peri-anal  Gastro Enteritis,
Thrush,  Necrotizing Enterocolitis (NEC),
 Urinary Tract Infections,
 Skin Infections Mostly By  Meningitis
Staphylococcus Aureus
(Septic Spots, Paronychia,
Pemphigus Neonatorum),
 Omphalitis,
 Neonatal Mastitis, 176
 12. CLASSIFICATION OF NEONATAL SEPSIS

Neonatal sepsis can be classified into two major categories depending

up on the onset of symptoms: Early Neonatal Sepsis And Late Neonatal
Sepsis
1. Early Onset Sepsis (EOS):
 It presents within the first 72 hours of life.
In severe cases, the neonate may be symptomatic at birth.
Infants with EOS usually present with respiratory distress and
pneumonia.
 The source of infection is generally the maternal genital tract.
Some maternal/ perinatal conditions have been associated with
an increased risk of EOS. Knowledge about these potential risk
177

factors would help in early diagnosis of sepsis.

 Risk Of Early Onset Sepsis
1. Low birth weight (<2500 grams) or prematurity
2. Febrile illness in the mother with evidence of bacterial infection within 2 weeks
prior to delivery
3. Foul smelling and/or meconium stained liquor
4. Rupture of membranes >24 hours
5. Single unclean or > 3 sterile vaginal examination(s) during labor
6. Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs)
7. Perinatal asphyxia (Apgar score <4 at 1 minute)
 Presence of foul smelling liquor or three of the above mentioned risk
factors warrant initiation of antibiotic treatment.
 Infants with two risk factors should be investigated and then treated
accordingly. 178
2. Late Onset Sepsis (LOS):
 It usually presents after 72 hours of age.
 The source of infection in LOS is either nosocomial (hospital-
acquired) or community-acquired and neonates usually
present with septicemia, pneumonia or meningitis.
Risk factors for nosocomial sepsis include:
 Low birth weight,
 Prematurity,
 Admission in intensive care unit,
 Mechanical ventilation,
 Invasive procedures,
 Administration of parenteral fluids,
 Use of stock solutions. 179
Risk factors for community-acquired late onset
neonatal sepsis (LOS) include:
 poor hygiene,
 poor cord care,
bottle-feeding,
 prelacteal feeds e.g 10% dextrose, glucose, nun
In contrast, breastfeeding helps in prevention of
infections.
180
Investigations

Do a full blood count including WBC

differential
Blood culture
Blood glucose
Chest x-ray if indicated

181
 Management of Neonatal
septicaemia
Immediate Care:
 Give pre-referral treatment (IV Crystalline Penicillin and Gentamicin)
 Keep baby warm
 Prevent hypoglycemia by feeding the baby (breast feeding/ Expressed
Breast Milk)
 If blood sugar low refer to section on hypoglycemia

182
 Management of Neonatal
septicaemia
 Subsequent Care (Hospital)
 Keep baby warm depending on baby size
 Isolate as much as possible
 Give (IV Crystalline Penicillin and Gentamicin), if there is skin infection
use Cloxacillin instead of Crystalline Penicillin
 Ensure adequate feeds - oral or IV (refer to section on fluid
management)

183
 Management of Neonatal
septicaemia
Frequently monitor vital signs
(hourly for the first 6 hours then 3
hourly till stable)
Counsel the mother
On discharge refer to MCH

184
Prevention

Adequate treatment of maternal

infection during pregnancy, labour and
delivery
Vaginal swabbing with antiseptic during
labour (e.g. hibitane)
Clean delivery
Clean/sterile equipment
Observe infection control at all levels of
185
Prevention

Hand washing before and after

handling baby
Early initiation of breast feeding
Exclusive breast feeding
Avoid overcrowding especially in the
newborn unit

186
 NEONATAL TETANUS

Definition
Any neonate with normal ability to
suck and cry during the first 2 days
of life and who, between 3 and 28
days of age, cannot suck normally
and becomes stiff or has spasms
(i.e. jerking of the muscles)
187
 Diagnosis

 Inability to feed orally

Muscle spasms
Clenched mouth – risus sardonicus
Stiff body that is arched backward
like a bow (opisthotonus)
Stiff arms and legs

188
 Management

 Sedate the baby by giving IV or rectal:

Phenobarbitone 20 mg/kg stat; or

Diazepam 0.2mg/kg over 3 minutes.
Repeat every 30 minutes up to 3
doses
Do not exceed 2mg/kg/24 hrs
 While baby is sedated:

Clean the cord thoroughly

189
 Management

Note: Watch respiration during sedation

Subsequent Care:
Counsel the mother
Keep baby in a quiet dark room
Frequent monitoring of vital signs – watch
respiration
Avoid too much handling
 190
 Management

Paint cord with providine iodine or spirit

Feed Expressed Breast Milk through
nasogastric tube.
Maintain sedation with:
- Phenobarbitone 5mg/kg/day in 2 doses
- Chlorpromazine 2mg/kg/day
(These can also be given as continuous
infusion). 191
 Management

Give antibiotics – IV Crystalline Penicillin

50,000 units/kg 12 hourly
Refer to ICU if facility is available
Immunize the mother and ask her to complete
immunization as per the National schedule
If baby recovers refer to MCH for
immunization
192
 Prevention

 Ensure that all pregnant mothers

are given Tetanus Toxoid according
to the National Immunization
schedule
Provide education on the
importance of cord care.
Appropriate cord care

193
BIRTH INJURIES

Definition:
 This refers to direct injuries to the baby during the birth process. (labour
and delivery)
 Labour and delivery are very stressful and strenuous process both to the
mother and the baby.
 Birth injuries are either avoidable or unavoidable.

194
 Predisposing factors to
birth injuries

 Prematurity
 Large for dates babies
 Cephalopelvic disproportion
 Malpresentation eg brow, breecch,face etc
 Congenital malformations eg hydrocephalus

195
Birth injuries cont’d
 They are divided into two categories
Minor injuries – cause little damage or result to complete recovery
Major injuries – cause serious complications in future or death at birth.
 It occurs anywhere in the body of the baby.

196
 Classification of Birth Injuries

 Are based on either anatomical site or their related cause.

1. Intracranial injury – intracranial hemorrhage, cerebral anoxia or
hypoxia
2. Extracranial injury –

 caput succedaneum
 cephalohaematoma
 subconjuctival hemorrhage
 retinal hemorrhage

197
 Injury to the skull (Extra-
cranium).
a) Caput succedaneum
 This is an edematous swelling under the scalp and above the periosteum
which forms on the presenting part.
 It does not need treatment as is resolves spontaneously.

198
Caput Succedaneum
Common after
prolonged labor
Accumulation of
blood/serum above
periosteum
Soft tissue swelling /
edema / petechiae /
ecchymoses
Crosses suture lines
 Caput succedaneum cont’d

Causes
 Pressure of the dilating cervix
particularly during prolonged
labour. The swelling occurs in the
presenting part.
 Venous Congestion and lymphatic
drainage retarded causing edema
200
 Caput succedaneum cont’d

Signs and symptoms

 Usually present at birth. It crosses the suture ( sargittal suture).
 When applying pressure a depression is left (pits on pressure)
 It grows less with time and can disappear within 36 hours.
 Whenever double, caput is unilateral
 Rx. Left alone and disappears within 36 hours

201
b) Cephalohaematoma
 This is an effusion of blood below the periosteum that covers the
skull bones.
Or
 Is a collection of blood between periosteum and skull bones.
 It usually resolves after 2-3 weeks.
 No treatment is necessary but the baby should be observed for jaundice
and the mother reassured.

202
 b) Cephalohaematoma

Signs and symptoms

 Fine capillaries are damaged and bleeding occurs under the periosteum

203
 b) Cephalohaematoma con’t
 Signs and symptoms
 Fine capillaries are damaged and bleeding occurs under the periosteum.
 Signs hardly appears at birth. Swelling appears after 24 hours
 Swelling never crosses the suture
 The swelling tends to grow larger with time
 It persists for weeks, Does not pit on pressure
 Can be either unilateral or bilateral.

204
 Difference btn caput &
cephalohematoma

Caput cephalohematoma

1.Always present at birth

1.Appears 24 hours after
2.Caput crosses the suture
birth
3.Tends to grow less for a
2.Never crosses the suture
period of about 3 days
3.Tends to grow larger
and disappears
4.Persists for weeks
4.May disappear within
5.Does not pit on pressure
36 hours
6.Can either be unilateral
5.Pits on pressure
or bilateral
6.Always unilateral
206
 Subgaleal hematoma
Subgaleal hematoma is bleeding in the
potential space between the skull
periosteum and the scalp galea
aponeurosis.
(і) Shock and pallor: tachycardia, a low
blood pressure, within 30 minutes of the
haemorrhage the haemoglobin and
packed cell volume start to fall rapidly.
 Subgaleal hematoma
(ii) Diffuse swelling of the head.
 Sutures usually are not palpable.
 The amount of blood under the scalp is far more than is estimated.
 Within 48 hours the blood tracks between the fibres of the occipital and frontal
muscles causing bruising behind the ears, along the posterior hair line and around
the eyes.
Subgaleal Hemorrhage

Occurs between periosteum and epicranial

aponeurosis
Most often with difficult vacuum or forceps
extraction
1 in 2,000 deliveries (1/200 vacuum)
Boggy fluid collections with a fluid wave
beneath the scalp
Hemorrhage extending from above the eyes to
the neck, frequently displacing ears anteriorly
Subgaleal Hemorrhage

Presents with pallor, tachycardia,

tachypnea, mottling, hypotension,
hypotonia -- hemorrhagic shock
Can cause consumptive coagulopathy
Prognosis correlates with the degree of
brain ischemia following delayed or
incomplete correction of blood loss and
hypotension
Subgaleal hemorrhage
 Nursing care

 Serial head circumference may detect any increase

due to haemorrhage.
 The infant must be observed for signs of
hyperbilirubinaemia and anaemia.
 If the haemorrhage is severe , blood transfusion
may be necessary.
 Monitor the bleeding time and coagulation time.
 Assess the level of consciousness.
 Assess Haemoglobin and haematocrit
213
 Classification of Birth Injuries

3. Sternomastoid injuries – muscles of the neck

It is usually caused by excessive rotation of the shoulder and also gross
lateral extension of the shoulder.
These are usually procedures performed during delivery of a complicated
breech. Many are caused by birth attendants.
Diagnosis -: Swelling of the affected neck soon after birth or days or weeks
after birth

214
Muscle
 The most commonly damaged is a neck muscle called sternomastoid.
 It results in twisting of the neck to the affected side referred to
as torticollis.
 It is managed by laying baby on the unaffected side and
physiotherapy.
 It usually resolves after several weeks

215
 B)

 The most common are the facial nerve and branchial plexus injuries.
1. Facial Nerve Injury:

216
NERVE TRAUMA/ INJURIES

 Facial nerve palsy;

 This results from damage to the facial nerve. The eyelid on the
affected side remains open and the mouth is drawn to the normal side.
This might cause some feeding difficulties.
 No treatment is required
 Spontaneous improvement should be seen in 7 -10 days

 Due to the feeding difficulty, help mother to attach well; and if this fails;
give expressed breast milk

217
2. Branchial Plexus Injuries:
 Branchial plexus nerves injury are caused by stretching or disruption of
the nerve at the apex of the axilla, lying under the clavicle.
 Injuries can be cause by excessive lateral flexion of the head and neck
in cases of shoulder dystocia or breech presentation.
 There are three main types of injury
a) Erb’s palsy
b) Klumpke’s palsy
c) Total branchial plexus palsy
a) Erb’s palsy:
 This involves damage to the upper roots of the branchial plexus
involving the 5th and 6th cervical nerve roots.
 The affect arm is inwardly rotated, lies limply by his side and he can
not flex his elbow or lift his arm, the half-closed hand is turned outwards
(waiter’s tip position), but there is movement of arm and218fingers.
3. Phrenic nerve injury:
 Commonly occurs in association with brachial plexus and less
commonly as an isolated lesion.
 It may affect one or both sides of the diaphragm.
Treatment : varies from simple oxygen therapy to intermittent
positive pressure ventilation
Complication: Hypostatic pneumonia
4. Horner’s syndrome:
This is caused by damage to the cervical sympathetic nerves and
is often associated with klumpke’s paralysis
The syndrome occurs infrequently, presenting with ptosis
(drooping or falling of the upper eyelid), enophthalmos (posterior
displacement of the eyeball within the orbit) due to loss of function
of the orbitalis muscle, constriction of the pupil and absence
219

of sweating from the affected side of the head and face

Classification of Birth Injuries

5. Injury to the spinal cord – usually the cervical region caused by

manipulation during delivery of complicated breech.
6. Injury to the organs.
 Rupture of the spleen, liver and kidneys. Common during manipulation of
complicated breech.
7. Injury to the soft tissues. – genitalia and fatty tissues.

220
Fractures

 Fractures are rare and are usually caused by difficult birth. The most commonly affected
bones are the clavicle, humerus, femur and those of the skull.
 Features
 Displacement of bone from its normal position
 Pain (crying) when a limb or shoulder is moved
 Lack of movement or asymmetrical movement of a limb
 Swelling over bone ,Crepitus

221
General management for fractures

 Confirm the diagnosis with X-ray

 Handle the baby gently when moving or turning, and
teach the mother how to do so.
 Avoid movement of the affected limb as much as possible
 Immobilize the limb to reduce pain when the baby is
handled
 Ifthe mother is able to care for the baby and there are no
other problems requiring hospitalization, discharge the
baby
222
 FRACTURES
 A fracture can occur during delivery most common are : fractured of
the skull , clavicle, humerus and femur bones.
1. SKULL FRACTURES:
 These are rare and majority are linear and asymptomatic.
 An overlying cephalohaematoma or skull deformation may be
the only feature
 They may be associated with intracranial haemorrhage,
seizures, and death as contusion of the underlying brain may
have occurred
Treatment :
 symptomatic e.g. ant seizure drugs for seizure
 Antibiotics cover for patients with leak of Cerebral Spinal Fluid
(CSF ) from the nasal and auditory canal 223
2. CLAVICLE FRACTURE:
 this occurs due to shoulder dystocia and in breech
delivery
 It is often asymptomatic and may go undiagnosed
Signs and symptoms:
A crack is heard during delivery
 Feeling of distortion at the break
 Presence of crepitus
 In late phase by callus formation
Treatment :
 Figureof eight bandage if the infant shows signs of
discomfort
A stable union of the break usually occurs within 7-10
224

days
 3. Fractured Humerus
 This may occur in shoulder dystocia or in extended arms in
breech presentation
Signs and symptoms
A crack may be heard at delivery or
 The infant may present with deformity or
 Pseudo paresis of the upper arm secondary to pain
 Confirm diagnosis by an x-ray
Treatment:
 by splinting the upper arm or bandaging the arm to the
chest
 Stable union occurs 3-4 weeks 225
 4. Fracture femur
 Fracture of the femur may occur during delivery of extended legs in
breech presentation.
Signs and symptoms:
A crack may be heard or felt at the time
 Fractures are usually in the mid shaft presenting with deformity
 Or pseudo paresis due to pain
 diagnosis confirmed by x-ray
Treatment :
 simple splinting and application of a firm a crepe bandage to
the upper leg for 2-3 weeks.
5. Fracture spine: very rare but may also occur in breech deliver
with extended head
226
 Head Injury
 This involves injury to bones of the skull and
intracranial tissues. It is rare, but can occur
during difficult deliveries
 Features include:
 No sign of overlying cephalohaematoma
 Intracranial haemorrhage
 Raised intracranial pressure
 CSF leakage
227

 Diagnosis is by: X-ray and Ultrasound of the head
 Management
 Linear fractures usually need no treatment
 Depressed fractures may require surgery
 Antibiotic cover for those with CSF leakage
 Treat associated problems like haemorrhage

228
 Subconjuctival hemorrhages

 These are hemorrhages seen below the conjunctiva and above the
sclera. There is no need for treatment except to reassure the mother.
 Abrasions and swellings on presenting
parts: (e.g. on face, genitalia etc).
 Abrasions and lacerations should be kept clean and dry. If infected,
antibiotics may be needed. Deep lacerations may require suturing.

229
Prevention
Prevention
 i. Good ANC care
 ii. Anticipation of problem and early management or referral
 iii. Early recognition of injury and management

230
 soft tissue injuries in the newborn.
 Soft tissue injuries usually occurs when there is some degree of disproportion between
the presenting part and the maternal pelvis (cephalopelvic disproportion).
Causes of soft tissue injuries
Dystocia
Cephalopelvic disproportion
Forceps delivery
Enlarged fetus
Vacuum delivery
Improper episiotomy technique
Caesarean section (rare)
231
signs , symptoms and feature of soft tissue injuries

 Bruising with excoriation can occur in breech and face

presentation
 Inface presentation the face is congested and bruised
and the eyelids and lips edematous.
 In breech presentation there is bruising and edema of
the vulva area in female child and scrotum in male.
Nursing care for soft tissue injury.
Assess the newborn for bleeding from the injury site.
The soft tissue injury usually fade (disappear)
spontaneously within few days, without treatment.
Explain,reassure and provide health information to the
parents about these injuries. 232
General management of birth injuries
 Intrapartally ,predisposing factors should be diagnosed and managed early
eg.preterm labour,malpresentation,prolonged labour.
 Obseve the baby closely for skin colour, twitching, rolling of eyes,
convulsions
 Keep the baby warm
 Administer vitamin K 0.5 – 1mg i.m for they are predisposed to haemorrhage
 Maintain 2hrly turning of the baby
 Provide intermitent oxygen therapy when neccessary (PRN)
 Give fluids eg.10% dextrose for the first 24 hours then introduce oral feeds
if the condition improves.
 Give symptomatic management.
 Have resuscitative equipment ready incase of emergency
 Administer anticonvulsants eg. Phenobarbital prophylactically
233
Complications
 Musculoskeletal deformities
 Brain damage
 Respiratory distress
 Hyperbilirubinaemia (jaundice)
 Hypogycaemia

234
CONGENITAL ABNORMALITIES

Definition:
 A congenital abnormality is any defect in form, structure, or function a
baby is born with.
 They are varied and may be major or minor.
Diagnosis
 All babies should be examined soon after birth to rule out congenital
abnormalities.

235
Terminology

 Congenital means exist since birth, whether clinical evidences are

obvious or not obvious.

 Anomaly means a deviation from the normal.

 Malformation means faulty development of a structure

236
Causes

Chromosomal abnormalities
Single gene defects
Mitochondrial DNA disorders
Teratogenic causes
Multifactorial causes
Unknown causes
237
Congenital abnormalities

These include:
Gastro intestinal obstruction
(GIT) e.g. tracheoesophageal
fistula, upper GIT obstruction,
imperforate anus.
Gross cardiac defects.

238
Prevention

Avoid unnecessary drugs and X-

rays in pregnancy
To prevent spina bifida encourage
use of folate 400μg daily before
pregnancy, encourage adequate
diet at all times

239
Oesophageal Atresia and
Tracheoesophageal Fistula:
 This
is when there is atresia of oesophagus with
connection of the oesophagus to the trachea
 Features
 Suspectthis in a baby with copious amounts of
mucus from the mouth
 Baby gets blue when feeding is attempted
 When recognized:
 Do not feed baby, but have IV fluid maintenance
 Attempt to pass NG tube and suction gently
 Refer urgently 240
Imperforate anus:
 This is when there is no anal opening.
 Itcan be diagnosed by inspection and subsequent failure to
insert a thermometer.
 Management:
 Provide emotional support and reassurance to the mother
 Establishan IV line, and give only IV fluid at maintenance
volume according to the baby’s age
 Ensure that the baby does not receive anything by mouth
 Insert a nasogastric tube and ensure free drainage
 Urgently refer the baby to a tertiary hospital or specialized
241
Omphalocele OR Exomphalus

Definition
Is a defect in which the bowel or other
viscera protrude through the umbilicus.
Is a congenital herniation of the
abdominal contents (small gut) through
the defect in the abdominal wall at the
umbilicus.
242
Embryology of Omphalocele

Normally, midgut returns to the

abdomen by 10th week of gestation
Somatic layers of cephalic, caudal,
and lateral folds join to close
abdominal wall
With omphalocele, folds fail to close
In Omphalocele there is a thin
layer covering the bowel.
Management of Omphalocele:

 The baby can be fed with breast milk and needs to be reviewed by a
surgeon.
 Management
 If the defect is not covered by skin:
 Cover with warm sterile saline gauze to reduce fluid and heat loss and to
give a degree of protection
 Keep gauze moist at all times, and ensure that the baby is kept warm

247
Gastroschisis:

Definition
Is a paramedian defect of the abdominal
with extrusion of bowel that is not
covered by peritoneum.

248
In gastroschisis there may be
exposed bowel.
Gastroschisis

 No membrane covering
 Abdominal wall defect typically 2-4cm diameter
 Lateral to the right side of the umbilical cord
 Usually contains midgut and stomach
 Thickened, atretic, and possibly ischemic bowel
 Associated with malrotation
Gastroschisis
Embryology of Gastroschisis

 Failure of vascularization of the abdominal wall due to abnormal

involution of the right umbilical vein or a vascular accident of
omphalomesenteric artery causes abdominal wall weakness and
subsequent rupture
 Rupture of a small omphalocele with absorption of the sac and growth of
a skin bridge between the abdominal wall defect and umbilical cord
Management of gastroschisis

 This is when the abdominal wall does not

close fully and remains open.
 InOmphalocele there is a thin layer covering
the bowel and in gastroschisis there may be
exposed bowel.
 General Management
 Provideemotional support and reassurance to
the mother
 Establish
an IV line and give only IV fluid at
maintenance volume according to the baby’s
254
Management of Gastroschisis:

 Establish an IV line and give only IV fluid at maintenance volume

according to the baby’s age.
 Insert a nasogastric tube, and ensure free drainage
 Refer the baby urgently to a tertiary hospital or specialized centre for
surgery
 Note that the baby is susceptible to infections and antibiotic cover is
required.

255
CLEFT LIP AND PALATE:

 There is a defect in the upper lip that may be accompanied by a defect in the palate.
 Management
 Provide emotional support and reassurance to parents
 Mother needs to be told that feeding is important to ensure adequate growth until surgery can
be performed
 Show mother how to feed the baby with breast milk

256
Cleft lip and palate:

Note that babies with minor clefts can

breastfeed
However those with bilateral clefts must
be fed by cup and spoon
Take care to prevent aspiration
Refer to surgeon for repair

257
Cleft lip and palate:

258
Talipes equinovarus:

 This is a deformity of the foot where the ankle

is turned downwards and the front part of foot
is turned inwards.
 Management
 Apply plaster of Paris
 Revise every 1-2 weeks
 Refer if no response after 3 months

260
Hydrocephaly:

 Thisoccurs when there is an unusually large

head arising from blockage in the free flow of
CSF in the ventricular system.
 Management
 Monitor head circumference
 Refer early for surgical CSF drainage

261
 Hydrocephalus

 Hydrocephalus is an excess of cerebrospinal fluid within the

ventricles, and the subarachnoid space.

Congenital cerebral
malformations: e.g. Arnold-Chiari
malformation.
Congenital fetal infections e.g.
toxoplasmosis, cytomegalovirus.

262
 Hydrocephalus

Intrauterine intracranial hemorrhage.

Certain forms are multifactorial origin.

Obstruction of the aqueduct of Sylvius

which may be due to genetic
disorders as trisomy 21, infection as
toxoplasmosis and cytomegalovirus,
intracranial tumors, and intracerebral
hemorrhage.
263
Antenatal diagnosis of
hydrocephalus:
Clinical:
 Polyhydramnios.
Large size head.
 Breech presentation is
common
 During labor, vaginal
examination: Wide sutures,
large fontanelles and thin, soft
identable cranial bones. 264
 Management Options

 Termination of pregnancy could be offered, if diagnosis is definite in the

early second trimester.
 Search for associated anomalies.
 Establishment of the etiology if possible.
 Amniocentesis to determine fetal karyotype.
 Intrauterine therapy (under ultrasound guide): Attempts at intrauterine
ventriculo-amniotic shunts (with a one way valve may be done to drain
CSF from cerebral ventricles into the amniotic sac to prevent compression
and atrophy of brain tissues) are being tested.

265
Management Options

 Effects of hydrocephaly on vaginal delivery:

 Breech presentation is common.
 Feto-pelvic disproportion: Non-engagement of the presenting large head and
obstructed labor. Some infants cannot be delivered without destructive
procedure or cesarean section.
 Conduct of delivery:
 Destructive procedures to facilitate vaginal delivery.
 The head is perforated and cerebrospinal fluid is drawn off.
 In breech presentation, the aftercoming head is either perforated or spinal tapping is
carried out. A metal canula is introduced through the spinal canal (or through spina
bifida is present).

266
 Management Options

 Delivery of a live newborn, with possible cesarean section, when there are
favorable signs.
 Absence of associated anomalies.
 Stable hydrocephalus.
 Cerebral mantel remains more than 10 mm (thickness of cerebral cortex) and
the newborn will have surgical procedures after delivery i.e. shunting operations
(ventriculo-peritoneal shunt).

267
 Anencephaly

Is absence of the forebrain and vault

of the skull.
Anencephaly is a lethal anomaly due
to the absence of
The membrane-ossifying bones of the
cranial vault and consequently the skull
and scalp.
The cerebral hemispheres, underlying
the above structures 268
269
 Anencephaly
 Antenatal diagnosis:
Clinicalfeatures: Polyhydramnios and
abdominal palpation (absence of head).
Investigations:
Raised plasma and amniotic fluid -
fetoprotein levels and
ultrasound features.
 Management of anencephalic pregnancy:
 Elective abortion.
 Vaginal delivery :there is an increased incidence of face presentation and
shoulder dystocia

270
 Microcephaly

 Microcephaly is an
abnormally small head.
 Diagnosis depends on
biometry: Occipto-frontal
diameter (OFD) and BPD are
reduced.
 Complications of
microcephalus:
 Mental retardation: the
smaller the head the
worse the prognosis.
 The presence of 271
 Spina bifida

 Spina bifida is a defect in the spine resulting from failure of the

two halves of the vertebral arch to fuse.

 There is no skin covering the defect which

allows protrusion of the meninges.
 The meningeal membrane may be flat or
appear as a membranous sac, with or
without cerebrospinal fluid but it does not
contain neurotube.

272
 Types of spina bifida
1. Spina bifida cystica ‘ overta’which includes:

 Meningocele.
 Meningomyelocele:
 Myelocele:
 Encephalocele

274
 a)
Meningomyelocele/myelomeningocel
e
 Is a protrusion of both the meninges and spinal cord.

rupture and
The lesion may be enclosed or the meningocele

expose the neural tissue.

 The defect is in the midline and
affects the skin of the back, muscles,
bones of the vertebral arches and
neural tube.
The membrane is easily ruptured

275
276
 b) Encephalocele

 This is a tumour covered with meninges.

 It protrudes through the lambdoidal suture on the foetal skull.
 It contains brain tissue
 It pulsates, is opaque, does not fluctuate and usually has a pedicle.

277
 c) Meningocele.

It is protrusion and herniation of the

meninges, and cerebrospinal fluid
through a bony deficit to the skin.
It is fluctuant, does not pulsate and
becomes tense when baby cries.
Large meningoceles may rupture
during delivery.
The baby should be nursed prone with
the sac covered with a sterile dressing.
278
 2. Spina bifida occulta:
Is the most common minor type of
defect where the vertebra is bifid.
The bone only is affected, while the
spinal cord and the membranes are
intact (no spinal cord involvement).
A tuft of hair or sinus at the base of
spine may be noted on the first
examination of baby.
It has a good prognosis.
No treatment is required. 279
Ultrasound features of spina bifida:

The features appear by 18-20 weeks

gestation in about 90 per cent of cases.
The posterior ossification centers of the
spine, at the level of the defect are
widely spaced. The vertebral segment
appears in U-shape. The defect may be
visualized on longitudinal scanning.
There is restricted motility of the lower
limbs 280
Spina bifida management

 This occurs when there is a defect in the vertebral column

 Management
 Provide emotional support and reassurance to parent
 If the defect is not covered by skin:
 – Cover with sterile gauze soaked in sterile normal saline
 – Keep gauze moist at all times and ensure that the baby is kept warm

281
Spina bifida

– If ruptured give Benzyl Penicillin

50,000units/kg 12hrly and Gentamicin 5mg/kg
daily for 5 days
Organize transfer, and refer the baby to a
tertiary hospital or specialized centre for
further evaluation or surgical care, if possible

282
 The prognosis is related to the following:

 Presence and severity of neurological involvement

 The presence of associated abnormalities: e.g.
 Arnold-Chiari malformation (coexisting hydrocephalus due
to prolapse of the cerebellar hemispheres (obstructing the
flow of CSF). It is to be noted that 90 per cent of cases of
spina bifida have or develops hydrocephalus later on.
 Orthopedic malformations: congenital dislocation of hips,
foot deformity e.g. talipes, and kyphoscoliosis.
 Chromosomal defects: e.g. trisomy 18.
283
 Management of common genetic birth defects

 Provide emotional support and reassurance to the mother

 Ifthe baby has Down syndrome or unusual facial features,
advise the parents about the long-term prognosis, and refer
the family to a specialized centre for developmental
evaluation and follow-up
 Refer to paediatrician for further care
 Ifthe mother is not going to breastfeed and the mother
requests for a contraceptive method, provide family
planning services
284
Counselling:

In all cases of birth defects:

 Counsel parents in all cases.
 Counsel both parents at the same time wherever possible
 Have the most qualified health worker talk to parents
 Ensure honesty, sensitivity and empathy by all staff
 Parents should be shown any obvious defect on the baby and
told the implications
 Current and future management to be discussed
 Link with any community support groups should be made
285