Birth Flashcards
still birth
an infant born after the 24th week of pregnancy who does not, at any time show any other sign of life.
perinatal mortality
still births plus deaths in first week of life.
infant mortality
deaths from birth to 1yr.
post natal mortality
deaths from 4wks of age to 1yr.
gestational age
Age measured from the first day of the last menstrual period before conception and expressed in complete weeks or days.
chronological / postnatal age
Time elapsed from birth
Corrected age
Chronological age minus the number of weeks born before 40wks gestation.
Spontaneous abortion (miscarriage)
A conceptus born after spontaneous labour without any signs of life before 24 completed weeks gestation.
Live birth
A baby that displays any sign of life (i.e. breathing, heart beat, cord pulsation, or voluntary movement) after complete delivery from the mother, irrespective of gestation.
Stillbirth (late foetal death)
Foetal death prior to complete delivery from the mother after 24 completed weeks gestation.
Perinatal mortality
Includes all stillbirths and neonatal deaths in the first week.
Neonatal mortality
Death amongst live births before 28 days of age (whatever the gestation at birth).
Neonatal period
from birth to 28 postnatal days in term infants.
Preterm Birth
before 37 completed weeks gestation. 78% of births.
term birth
Between 37 and 42 completed weeks gestation.
Post-term (post-mature)
Birth after 42 completed weeks gestation. <5% of births.
Low birth weight (LBW)
Birth weight <2500g. 7% of births.
Very low birth weight (VLBW)
Birth weight <1500g. 1.2% of births.
Small for gestational age (SGA)
Birth weight <10th centile for gestational age.
what are the key differences between children and adults?
size
anatomy - short, soft neck, obstruct in overextenstion during resuscitation
physiology - pulse, resp rate, bp change with age
describe how the weight of an infant changes in the first year?
average birth weight = 3kg which increases to 10kg by 1 year
how can weight be predicted in children between the ages of 1-10?
weight (kg) = 2 (age in yrs + 4)
perinatal mortality risk factors?
- birth weight
- Cesarean delivery
- multiple delivery
- fetal distress
- meconium aspiration
- patent ductus arteriosus (PDA)
- maternal chorioamnionitis
- hypertension (pregestational and gestational, including preeclampsia)
- diabetes (pregestational and gestational)
REDUCING PERINATAL MORTALITY
preconception
early screening and intervention of risk factors/optimisation of patient for conception
REDUCING PERINATAL MORTALITY
antenatal care
early booking and screening
REDUCING PERINATAL MORTALITY
intrapartum
active management of 3rd stage of labour / magnesium sulphate
REDUCING PERINATAL MORTALITY
postpartum
effective review and follow up of child and mother after delivery
PRETERM LABOUR
- what is it
- what percentage of deliveries are preterm
- what percentage occur <34 weeks
- Labour occurring at <37 completed weeks gestation
- 6%
- 2%
PRETERM LABOUR
what factors impact on prognosis
- Availability of neonatal intensive care unit
- Gestational age and birh weight
- Baby condition at birth (aasphyxited infants more likely to die from respiratory distress syndrome)
- Immediate neonatal management
- Antenatal steroids
causes of preterm labour
- Previous pre term labour
- Premature rupture of the membranes
- Multiple pregnancy
- Polyhydranios
- Antepartum haemorrhage
- Fetal death
- Bacterial vaginosis
- Maternal pyrexia (UTI, infections)
- Uterine abnormalities
- Cervical incompetence
PRETERM LABOUR
what are the important aspects of examination
maternal pulse, temp, resp rate, uterine tenderness, foetal presentation, speculum, gentle VE
PRETERM LABOUR
what investigations are important
FBC, CRP, swabs, MSU, USS for foetal presentation and estimated weight, foetal fibronectin/transvaginal USS
management of preterm labour
- Is there threatened or real preterm labour (transvaginal cervical length scan (>15mm unlikely to be labour / fibronectin assay – if -ve unlikely to be labour)
- Admit if high risk
- Inform neonatal unit
- Check foetal presentation with USS
- Steroids (12mg betamethasone IM – 2 doses 24h apart) – reduce rate of respiratory distress, intraventricular haemorrhage and neontal death
- Consider tocolysis (nifedipine and atosiban iv)– drug treatment to prevent labour and delivery
- Aim to improve perinatal morbidity and morality
preventing preterm labour
- Treat bacterial vaginosis with clindamycin to reduce preterm prelabour rupture of membranes and low birth weight in women with previous preterm birth
- Progesterone – in high risk women reduces recurrence / in low risk womn with short cervix reduces preterm birth by 50% / cream or pessaries used
- Cervical sutures (cerclage) – elective in women with previous loss from cervical weakness / ultrasound indicated for those with short cervix / rescue in response to cervical dilatation
- Cervical pessary
- Reduction of pregnancy number – selective reduction of triplet or higher pregnancies to 2 reduces risk of preterm labour but also slightly increases risk of early miscarriage
- Methods for prediction of preterm labour – transvaginal USS of cervix, fetal fibronectin
describe preterm prelabour rupture of membranes?
- how often it occurs and what is it often associated with
- investigations
- management
- risks to fetus
- 1/3 of preterm deliveries. 1/3 associated with overt infection
- Ask about vaginal loss
Investigations: FBC, CRP, swabs, MSU, USS - If chorioamnionitis – betamethasone 12mg IM, deliver, broad spectrum antibiotics
If no chorioamnionitis – manage conservatively – admit, SCBU, 12mg betamethasone IM, antibiotics (erythromycin) - Risks to fetus: prematurity, infection, pulmonary hypoplasia, limb contractures
LOW BIRTH WEIGHT
- how common is it
- weight
- why is it useful?
- very low birth weight
- extremely low birth weight
- 42% stillbirths and 25% neonatal deaths were <10th birth weight centile
- <2500g
- Useful on a worldwide basis where gestational age at delivery is often unknown
- 1500g
- <1000g
what is intrauterine growth restriction
presence of pathology that is slowing foetal growth which if it could be removed would allow resumption of normal foetal growth. No tests available
IUGR is failure of growth in utero that may or may not result in SGA
LOW BIRTH WEIGHT
what is symmetric SGA?
all growth parameters symmetrically small- suggest foetus affected from early pregnancy
LOW BIRTH WEIGHT
what is asymmetric SGA?
weight centile < length and head circumference. Usually due to IUGR due to insult in late pregnancy eg pre-eclampsia
LOW BIRTH WEIGHT
causes of SGA
small parents restricted foetal oxygen, glucose supply placental dysfunction maternal hypertension multiple pregnancy, maternal illness foetal abnormality maternal substance exposure
LOW BIRTH WEIGHT
complications
increased risk of death and asphyxia, congenital infection, hypoglycaemia, polycythaemia, necrotising enterocolitis, thrombocytopenia, meconium aspiration syndrome
LOW BIRTH WEIGHT
management
routine postnantal care, clinical evaluation for underlying cause, thermal care and blood glucose monitoring, temp, pulse, resp monitor, admit to neonatal unit if birth weight <1800g
LOW BIRTH WEIGHT
small for gestational age
statistical definition used if birth weight below standard for gestational age.(<10th centile) Used antenatally when growth or size of fetus falls below statistically determined limits
LOW BIRTH WEIGHT
SGA risk factors
1. minor
2. major
- maternal age >35, smoker 1-10 day, nulliparity, BMI <20 or 25-34.9, IVF singleton, previous pre-eclampsia, pregnancy interval <6 or >60 months, low fruit intake pre-pregnancy
- maternal age >40, smoker >11 day, previous SGA, maternal/paternal SGA, previous stillbirth, cocaine use, daily vigorous exercise, maternal disease, heavy bleeding, low PAPP-A
LOW BIRTH WEIGHT
SGA neonatal complications
birth asphyxia meconium aspiration hypothermia hypo-hyperglycaemia polycytheamia retinopathy of prematurity persistent pulmonary hypertension pulmonary haemorrhage necrotising enterocloitis
LOW BIRTH WEIGHT
SGA long term complications
cerebral palsy T2DM obesity hypertension precocious puberty behavioural problems depression alzheimers disease cancer (breast, ovarian, colon, lung, blood)
POST NATAL TRANSITION
describe infant size and growth
Average infant = 3500g
Boys weight 250g more
During first 3-5 days upto 10% birth weight is lost which is regained by 7-10 days
First month average weight gain per week = 200g
POST NATAL TRANSITION
skin
Thin epithelial layer, incompletely developed sweat ad sebaceous glands
Prone to heat and water losses
Skin covered with greasy protective layer- vernix caseosa
POST NATAL TRANSITION
head
Average occipitofrontal head circumference is 35cm
Anterior fontanelle closes between 9 and 18 months
Posterior fontanelle closes by 6-8 weeks
POST NATAL TRANSITION
respiratory system
Changes at birth to convert from dependence on placenta to breathing air
In utero – airways filled with fluid containing surfactant in later stages of pregnancy. Oligohydramnios can lead to pulmonary hypoplasia
Lung fluid removed by squeezing of thorax during vaginal delivery, reduced secretion, increased absorption mediated by fetal catecholamines during labour and after birth
Surfactant lines the air – fluid interface of alveoli and reduce surface tension lung expansion and fall in pulmonary vascular resistance
Newborns mainly breath with diaphragm – 30-50 breaths/min
Brief self limiting apnoeic spells might occur during sleep
Respiratory distress syndrome more common in premature babies <32 weeks gestation (surfactant deficiency)
POST NATAL TRANSITION
cardiovascular system
in fetal circulation
- right sided (pulmonary) pressure exceeds left sided (systemic)pressure
- Blood flows from right to left through foramen ovale and ductus arteriosis.
POST NATAL TRANSITION
cardiovascular system
at birth
- Left sided pressure rises when umbilical vessels clamped
- Right sided pressure falls as lungs expand and rising PO2 triggers prostaglandin mediated vasodilatation
- Foramen ovale and ductus arteriosus close functionally shortly after birth. Ductus closes due to muscular contraction in response to rising oxygen tension
- Some congenital heart disease are ‘duct dependent’ ie flow through duct necessary for oxygen delivery and closure of duct precipitates deterioration
POST NATAL TRANSITION
ductus arteriosis
PGE1 and PGE2 keep the ductus arteriosus open via involvement of specific PGE-sensitive receptors (such as EP4 and EP2). … Immediately after birth, the levels of both PGE2 and the EP4 receptors reduce significantly, allowing for closure of the DA and establishment of normal postnatal circulation.
POST NATAL TRANSITION
GI system
Most infants over 35 weeks have coordination to latch on to feed
At term – secretory and absorbing surfaces are well developed, and digestive enzymes (except pancreatic amylase)
Meconium within 6 hours (abnormal ifmore than 24 hours)
With normal feeding meconium replaced by yellow stool by day 3 or 4
Immaturity of liver enzymes responsible for conjugation of bilirubin responsible for physiological jaundice
POST NATAL TRANSITION
genitourinary system
Urine production during second half of gestation and makes up much of amniotic fluid
Infant may micturate during delivery and should void within 24 hours of life
Renal concentrating ability diminished in neonates
POST NATAL TRANSITION
haematopoietic and immune system
Newborn red cell contain fetal haemaglobin with a higher affinity for oxygen
Hb conc of cord blood range from 15-20g/dL, A large volume of blood is present in placenta and late clamping causes this blood to enter baby and can lead to polycythaemia
Impaired neutrophil reserves
Diminished phagocytosis and intracellular killing capacity
Decreased complement components
Low IgG2, leading to infections with encapsulated organisms
POST NATAL TRANSITION
thermal and metabolic
Core temp of fetus abou 0.5 degrees above mother (uses no energy staying warm)
After birth the ability to maintain temp comtrol is determined by environment and internal physiological processes
Newborns attempt to stay warm by increasing muscle activity and burning brown fat increasing metabolic rate. Newborns don’t shiver. Peripheral vasoconstricton also decreases heat loss to skin surface
Heat production requires oxygen and glucose and produces lactic acid, so persistent hypothermia may result in metabolic acidosis, hypoglucaemia, decreased surfactant production and poor growth
Maternal glucose readily crosses placenta and supplies fetus with energy for growth and to store glycogen inliver for use after birth
Release of catecholamines during labour and birth mobilises glycogen yet blood glucose levels decline after birth and lowest at 1 hour of age
NEWBORN BABY ASSESSMENT (NIPE)
- when should it be done
- why
- Must be perfomed within 72 hours. Second examination at 6-8 weeks (usually GP)
- screen for congenital abnormalities, make referrals for tests, provide reassurance for parents
NEWBORN BABY ASSESSMENT (NIPE)
introduction
Confirm infant name and DOB Explain ‘examine head to toe’ Consent Wash hands Expose child Ask questions during the check
NEWBORN BABY ASSESSMENT (NIPE)
questions
Pregnancy details (time, date, type, complications, screening results)
Breech presentation – if yes after 36 weeks USS of hips for dysplasia
Risk factors for infection
Family history
Feeding pattern, urination, passing meconium, parental concerns
NEWBORN BABY ASSESSMENT (NIPE)
what are the components?
introduction questions weight inspection tone head skin face eyes ears mouth and palate neck and clavicles upper limbs chest abdomen genitalia lower limbs back and spine anus reflexes
NEWBORN BABY ASSESSMENT
weight
Check against weight chart
If small – head circumference and length to determine symmetrical growth restriction (fetal factors) or asymmetrical growth restriction (placental insufficiency)
NEWBORN BABY ASSESSMENT
inspection
Pallor – anaemia, haemorrhage, congestive cardiac failure
Cyanosis – peripheral vasoconstriction secondary to hypovolaemia / right to left cardiac shunting
Jaundice – high bilirubin
Posture – hemiparesis / erb’s palsy
NEWBORN BABY ASSESSMNENT
tone
Gently move limbs passively
Hypotonic infants – feel like a rag doll, difficulty feeding (common in downs syndrome)
NEWBORN BABY ASSESSMENT
head
Circumference (microcephaly/macrocephaly)
Shape – cranial sutures (closely applied, widely separated, normal
fontanelle – flat? Sunken? Bulging? (bulging – raised ICP eg hydrocephalus / sunken – dehydration)
NEWBORN BABY ASSESSMENT
skin
Birthmarks, bruising, lacerations
Body maps in red book
Colour- pallor, cyanosis, erythema, jaundice
Bruising/lacerations – location and size
Facial birthmarks – salmon patch, haemangiomas, port wine stain
Vernix – waxy white substance coating skin – normal
NEWBORN BABY ASSESSMENT
face
Dysmorphic features
Asymmetry
Trauma
Nose – patency of nasal passage
NEWBORN BABY ASSESSMENT
eyes
Erythema or discharge
Sclera
Position and shape of eyes
Red reflex (absence – congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma
NEWBORN BABY ASSESSMENT
ears
Pinna – asymmetry, skin tage, accessory auricles
Hearing screening test prior to discharge
NEWBORN BABY ASSESSMENT
mouth and palate
Clefts of the hard or soft palate- tongue depressor and torch
Tongue and gums – tongue tie
NEWBORN BABY ASSESSMENT
neck and clavicles
Length of neck, webbing
Neck lumps
Clavicular fracture
Cystic hygroma
NEWBORN BABY ASSESSMENT
upper limbs
Symmetry
Fingers – count/abnormal morphology
Palms – check for 2 palmar creases
Brachial pulse – asymmetry suggest vascular abnormality (coarctation of aorta
NEWBORN BABY ASSESSMENT
chest
Inspect Resp rate (40-60) Assess for increased work of breathing Pectus excavatum / pectus carinatum/ asymmetrical chest wall expansion Auscultate Heart – auscultate (120-150bpm) Pulse oximetry
NEWBORN BABY ASSESSMENT
abdomen
Inspect – distension, umbilicus, inguinal hernia in groin
Palpation – liver (No more than 2cm below costal margin), spleen (may be palpable at costal margin), kidneys (if easily palpable – polycystic kidney disease), bladder (dhouldnt be palpable)
NEWBORN BABY ASSESSMENT
genitalia
Male – position of urethral meatus, size (2cm at least), testicular swelling, palpate scrotum
Female – inspect labia (ensure not fused), clitoris (normal size), vaginal discharge (white discharge normal due to maternal oestrogens
NEWBORN BABY ASSESSMENT
lower limbs
Asymmetry, Oedema Ankle deformities Missing digits Tone Movement Range of knee joint movement Palpate femoral pulses
Hips – barlowsand ortolanis tests-hip joint instability and dislocation
- Barlows – adduct hip and apply pressure on knee, if dislocate – positive
- Ortolani – flex hips and knees of supine infant to 90 degrees, pressure on trochanters and adduct, positive if clunk can be heard
NEWBORN BABY ASSESSMENT
back and spine
Inspect for scoliosis, hair tufts, naevi, brithmarks, sacral pits
NEWBORN BABY ASSESSMENT
anus
Patency
Meconium should be passed in first 24 hours
NEWBORN BABY ASSESSMENT
reflexes
Palmar grasp
Sucking
Rooting reflex
Stepping reflex
NEWBORN BABY ASSESSMENT
blood spot screening
Tests for 9 congenital conditions taken on day 5, heel prick test which requires 4 separate drops, results take 6-8 weeks to come back • Sickle cell disease •Cystic fibrosis • Congenital hypothyroidism • Phenylketonuria • Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) • Maple syrup urine disease (MSUD) • Isovaleric acidaemia (IVA) • Glutaric aciduria type 1 (GA1) • Homocystin
NEWBORN BABY ASSESSMENT
hearing screening
Otoacoustic emission-OAE within first 4 weeks of life, automatic auditory brainstem response testing is carried out if any uncertainty in OAE response
what is developmental hip dysplasia?
Structural abnormality in hips due to abnormal development of fetal bones during pregnancy which leads to instability in the hips and a tendancy or potential for subluxation or dislocation. These can persist into adulthood. It is either be picked up during newborn examinations or later when child present with hip asymmetry and reduced range of movement
what are the risk factors for developmental hip dysplasia?
first degree family history, breech presentation, multiple pregnancy
describe the screening for developmental hip dysplasia?
• Newborn examination and at 6-8 weeks
Findings suggestive of DDH
• Different leg lengths
• Restricted hip abduction on one side
• Significant bilateral restriction in abduction
• Difference in the knee level when the hips are flexed
• Clunking of the hips on special test
- Ortolani test
- Barlow test
- Clicking on examination Is common
describe how a diagnosis of developmental hip dysplasia is made?
ultrasound of hips if child is suspected of having DDH, X-ray can be helpful
describe the management of developmental hip dysplasia?
Pavlik harness (if less than 6 months) – keeps hips flexed and abducted / surgery if harness fails of older than 6 months
