Chapter 10: THE NEWBORN Perinatology - From 20th week of gestation to birth and until 28th day after

- It also involved genetic, social, obstetrical and medical problems of mother, and abnormalities of placenta and the fetus - Most common cause of death: Prematurity and sepsis - Most common factor for asphyxia: maternal hypertension and vaginal bleeding - Mortality rate 1992 = 35/1000 live birth - Non preventable variables o Socio-economic o Geographycal o Cultural o Congenital anomalies - Preventable variables o Social support o Health education o Risk identification o Prenatalc care o Obstetric care o Nutrition The Fetus - Assesment of fetal growth and maturity - Fetal organogenesis completed by 12 weeks of life (in utero) - First trimester genetic expression is affected by the environment factor - Ultrasound may be done on 18th and 29th week of gestation - UTZ assessment serially measures o Biparietal diameter o Fetal size o Implantation o Head to abdomen circumference ratio o Femoral length o Amount of amniotic fluid o Estimation of gestational age - 2 kinds of fetal growth retardation o First, growth below 2 SD from normal values for the estimated age of gestation from beginning of pregnancy to time of assessment o Second, normal growth initially which slows down as the pregnancy advances in gestation - Amniocentesis to estimate fetal lung maturity and surfactant - -Surfactant surface active substance that prevent alveolar collapse of premature lung - 16th to 18th week fetal heart tones are first appreciated - 18 to 20th week fetal movement - . - Assessment of well-being or fetal distress - Most common cause of intrauterine distress placental insufficiency which may restrict blood flow to fetus - Intrauterine growth retardation and hypoxia due chronic insufficiency - Hypoxia > increased vascular resistance in fetal circulation - >acidosis - Manifestations of fetal distress o Initial tachycardia then bradycardia if not corrected immediately (N=120-160 beats/min) measured by FHT o Hypoxia and acidosis measured by Percutaneous umbilical blood sampling

Reduction, absence, or reversal of diastolic blood flow, of wave-form in fetal aorta or mbilical artery assessed by UTZ Tests used to monitor fetal well-being o Non-stress test  Reactive or normal FHR acceleration with fetal movements of at least 15 beats/min and lasting for 15 secs  Non-reactive suggest fetal compromise o Contraction stress tests (CST)  Oxytocin stimulated uterine contractions (3 contractions in 3 mins) followed by decelerations.  Contraindicated in: preterm labor, multiple gestation, incompetent cervical oss, polyhydramnios, placenta previa o Biophysical profile (BPP)  Scoring based on breathing, fetal movement, FHR, and amount of AF o Fetal heart rate patterns  Early deceleration (type I dip) due to head compression  Variable deceleration cord compression  Late deceleration (type II dip) fetal hypoxia  Reflex late deceleration chronic, compensated fetal hypoxia  Non-reflex late deceleration severe hypoxic depression of myocardial muscle o Fetal scalp blood sampling  Normal pH varies from 7.33 (early phase of labor) to 7.25 (during labor)  7.20 hypoxia . Maternal medical problem Rubella syndrome most documented infx Most common maternal illness which are non-infectious o Diabetes o Toxemia of pregnancy and other HPN conditions o Thyroid hormone abn o Immunologic dse o Placenta previa o Maternal PKU . Intrauterine diagnosis of fetal disease Diagnosed by intrauterine UTZ o Hydrocephalus o Anencephalus o Spina bifida o Duodenal atresia o Diaphragmatic hernia o Renal agenesis o Bladder outlet o Limb abnormalities o Sacrococcygeal teratoma o Cytic hygroma o Omphalocele o

o Gastroschisis Immunization greatly reduce congenital rubella Rh(D) immunoglobulin for Rh incompatible Steroid prevent respiratory distress

Circulatory System - Characterized by three shunts: o Patent foramen ovale bw the two auricles o Patent ductus arteriosus bw pulmonary artery and aorta o Patent ductus venosus in the liver - Placenta act as clearing house - Oxygenated blood from mother o Umbilical vein o Ductus venosus in liver o Hepatic veins o Inferior vena cava (IVC) o Right auricle (Oxygenated from IVC and oxygenated from SVC) o Shunted to Patent foramen ovale o Left auricle o Ascending aorta o Brain and upper half of body - Unoxygenated blood o Right ventricle o Pulmonary artery (high resistance due to unexpanded lungs) o Shunted to Patent ductus arteriosus o Descending aorta o Lower half of the body o Umbilical arteries o Placenta

o Closure of PDA o Increased oxygen content causes muscular constriction and functional closure of PDA Closure of foramen ovale o Left atrial pressure from the blood from lungs

NB has all equipment lungs, chmoreceptors, baroreceptor Occassional gasp seen during first trimester and become less as mature Hypoxia stimulus to gasp even term fetus Alveolar aeration o Fetus passes through birth canal o Chest wall compressed and elimination of respiratory fluid o Elastic chest recoils back o Negative intrathoracic pressure (10-70 cmH2O) + loud cry - Initiation of respiration o Change in environmental temperature from warm to cold o Stimulation of chemoreceptors by increasing concentration of H ions and fall of PO2 o Rise in PCO2 in the circulation - Lecithin a phospholipid in surfactant - Lecithin production increased as fetus nears term , sphingomyelin remains the same - High L/S ratio lung maturity. Gastrointestinal System - Swallowing movement 12th week of gestation - Meconium greenish-black composed viscid substance of mucopolysaccharide, epithelial cells, and conjugated bilirubin - Meconium normally expelled in first 24 hrs after birth - Pancreatic amylase inadequate at birth Renal system - Urine production 4th month (16th week) - Metabolic acidosis at birth may last for few hours o Temporary overproduction of lactic acid o Inadequate removal of acid ions ( Chloride and phosphate) o Limited ammonia formation - Diluted urine of NB still unable to concentrate urine - Weight loss (6%-10%) o Loss of water in dieresis o Expulsion of meconium Endocrine System - Witch s milk from hypertrophied mammary tissue of NB, effect of maternal estrogen - Hymenal tags, vaginal discharge, actual vaginal bleeding of NB maybe present - Diabetic mother NB has hyperplastic Islet of Langerhans excessive insulin production hypoglycemia in 1st 24 hrs Usually fat and cushingoid facies Central Nervous System - Rapid growth at last half of fetal life, peak at near or at birth, then decrease in first year of life - Posture of NB late fetal flexion attitutude all limbs are in flexion, hands are closed, thumbs are adducted - Waking state manifest generalized muscular activity - Normal and important reflex of NB

Respiratory system -

o Moro reflex o Grasp reaction o Swimming reflex o Tonic and righting reflexes o Reflexes ass with feeding: sucking, rooting, tongue protrusion - Can regard moving objects in his line of vision - Perceive changing light intensity - Can hear as shown by startle rxn Hematologic system - At birth, high hemoglobin, 15-20 mg/dL relative hypoxia in utero - Blood volume 80-90 ml/kg depending whether umbilical cord clumped early (less than 10 secs) or late (after 10 secs) - WBC- unpredictably from 10K to 30K/mm3, segmenters predominance - Lymphocyte predominance attain as infant grows - Hemoglobin start to drop on 3rd day of life and cont until 10 12 mg/dl on 2nd or 3rd mo of life (Physiologic anemia) - Several factors for physiologic anemia o Relative decrease in bone marrow erythropoeitic activity o Relative increase rate of hemolysis o Hemodilution due to expansion of blood volume Immunologic system - NB has a completely developed immunologic system - Antibodies present are maternal origin (7s or IgG) - Equal or higher than in maternal blood o Tetanus antitoxin o Diptheria antitoxin o Smallpox agglutinins o Astistreptolysins o Toxoplasma antibodies o Salmonella H antibodies o Rh blocking antibodies - Less than in maternal or absent (19S) against gram (-) and some (+) o Strep agglutinins o H influenza antibodies o Blood group isoagglutinins o Shigella antibodies o Salmonella somatic (O) antibodies o E coli H and O antibodies - Infant is susceptible to gram neg infx Thermoregulation - 32 -34C and 50 % humidity to be maintained in full term NB - Thermoregulators: Chemical, physical, thermal insulation - Chemical thermoregulator o Two kinds:  Shivering heat production acc by electrical activity of skeletal muscle  Nonshivering without visible or electrical muscular activity, more effective in NB  As infant grows, he shifts more toward shivering

Main source: adipose tissue  Brown addipose more effective supplier of heat o Cold stimulus > hypothalamus > norepinephrine > adipose tissue > triglyceride hydrolysis > free fatty acids > to suitable site for oxydation -> heat - Physical thermoregulation mechanism of heat loss from the body surface area to environment - Thermal isolation refers to heat exchange between body and its environment o Internal insulators: subq fat layer, skin blood flow o External insulators: clothings, incubator temp - When environment is cold, more energy is utilized for heat production and O2 consumption increases Physical Examination Skin - Vernix caseosa o Protects the skin of fetus from maceration in utero o Stained yellow in fetal distress o Meconium stain from amniotic fluid o Disappear after few days. Vigorous removal should be avoided - Lanugo hair - Back, shoulder, upper arm - Skin o Term - Smooth, elastic with fair amount of subq tissues o Preterm less subq tissue, almost transparent, gelatinous, visible veins o Post term and in NB with placental dysfunction syndrome paler, dry, desquamating skin - Pallor anemia - Plethora venous hct >65% - Jaundice not present at birth o Developed in 24 hours hemolytic process - Acrocyanosis cyanosis of finger tips and does. Due to cold stress or poor perfusion. Normal for 24 -48 hrs - Transient harlequin color change sharp demarcation in the midline of the whole body separating red from pale half - Mottling when exposed to cold. Due to instability of circulation of NB. - Mongolian spot blush grey pigmented areas, back, buttock extremities - Milia small whitish papules covering the nose, distended subaceus glands - Erythema toxicum small papules topped by vesicles at the tip and surrounded by a patch of erythema o Should be differentiated from pustular dermatitis - Generalized petechiae systemic disease - Localized petechiae pressure effect Head - Head circumference at widest diameter. From occiput to glabella - Small fontanelle small head, microcephaly, craniosynostosis - Tense fontanelle increased ICP - Rounded head CS or breech extraction - Caput succedaneum edema from pressure on the scalp as the head passes through the cervical ring - Cephalhematoma subperiostal bleeding. Limited by periosteal attachment o

Neck Chest -

o Does not cross the suture o Outer border is raised with sensation of depressed fracture Craniotabes o Soft areas on parietal bones, sensation of pingpong ball o If persist beyond infancy, sign of bone pathology (rickets and osteogensis imperfecta) Down syndrome can be recognized at birth Facial paralysis due to pressure on nerve Suconjunctival hemorrhages sometimes seen Congenital cataracts look for other anomalies (Rubella syndrome, galactosemia) Fundoscopic exam babies in high concentration of O2, retinopathy of prematurity Low set ears chromosomal disorder and renal anomalies Amniotic fluid in ear canal 3 txo 5 wbc in gram stain suggestive of infxn Cleft palate whitish shiny cyst seen in the palate and gum margins ( Epstein or epithelial pearls) High palatine arch ass with small head and mental retardation Large tongue hypothyroidism and whose mandible is hypoplastic (Pierre-Robin syndrome) Short lingual frenulum restrict to tongue protrusion Laxity and webbing ass with Down and Turner syndromes Cystic hygromas appear as fluctuant masses with indifinite boreders usually on the lateral side and reach axilla and scapular region Assymetry in movement lung or diaphragmatic pathology Difficulty in respiration o Retraction of chest and sternum o Retraction of intercostal and subcostal space RR of 40 mins/min at rest diaphragmatic respiration RR of sustained at 60 mis/min at rest for 5 mins respiratory distress Bowel sounds in the chest diaphragmatic hernia HR of 120-140/min not uncommon in preterm Rapid HR indicate respiratory distress syndrome or cardiac failure Slowing of HR congenital heart block, hypoxia, intracranial hemorrhage Globular but not distended normally Distention intestinal obstruction, especially with vomiting and no meconium stool Diastases recti separation of recti muscle, common in NB Small umbilical hernia maybe normal, close on 3rd year Large umbilical hernia omphalocoele o Defect is large with intestinal contents protruding covered only by amnion o Infection is likely o Surgical treatment Liver - usually palpable edg at about 2-3cm below the right costal arch Spleen not easily palpable Spinal cord lesion meningocoele and spina bifida Pilonidal dimple tiny pore surrounded by hair and exude a whitish secretion

Abdomen -

Genitalia

Musculo-skeletal -

Female o May show mucoid non purulent or sometimes bloody vaginal discharge o Hymen may have prominent tag o Clitoris may be large and confused for a penis o Labia minora are relatively prominent Male o Hydroceles may be present with or without accompanying hernia Hemimelia distal portion of extremities are absent, ends in stump Phocomelia proximal portion is absent, hand and foot seems arise from Hip dislocation dx by Ortalini s maneuver o Abducting the thigh and hearing a click Simean crease Down s syndrome, some normal individual Weak or paralyzed both lower ext spinal injury Femoral pulse detection of coarctation of aorta Blood pressure in all ext when cardiac anomaly is suspected Muscle tone and reflexes CNS function and evaluate the age of gestation Ballard scoring system

Care of the Normal Newborn - Wrapped in clean blanket to avoid unnecessary exposure to prevent chilling and infx - Vitamin K to peven prothrombin deficiency o Hemolysis and hyperbilirubinemia in high dose and synthetic vit K in G6PD def o Oral vit K prevent hemorrhage - Opthalmic ointmnt o Erythromycin is preferred but not available in Philippines o Protect against ophthalmia neonatorum - Cleaning o Skin - water, mild soap o Umbilical cord - Povidone-iodine - Temperature o Rectum initially, axilla subsequently o Every 4 hours until stable, then every 8 hrs o Normal = 36.6 to 37.2 C - Breastfeeding o Early feeding at 3-6 hrs of age is advocated in SGA, LGA, prematures, infants of diabetic mother High risk infants Premature before 37th week of gestation SGA below 2500 grams, high risk Premature infant is considered SGA when o Weight less than ten percentile for gestational age o 25% or more underweight for gestation o Below 2 SD from the mean for gestational age Evaluating maternal and fetal wellbeing o Intrapartum evaluation: FHR and fetal scalp pH o Antepartum surveilance of the fetus:

Biophysical profile: y Non stress test (NST) y Presence of 3 fetal body movements in 30 mins y Presence of chest movements or breathing y Good fetal tone (one cycle of extension-flexion) movement of fetal limb within 30 mins y Presence of normal amount of amniotic fluid (amniotic fluid index of more than 5 cm)  Biochemical testing: y Estriol y Human placental lactogen RIA Assessment of gestational age o Extreme premature within 12 hours of life o Term even upt to 72 hrs For physical maturity: skin, lanugo, plantar surface, breast, eye/ear, genitals (see Ballard) For neuromuscular maturity: square window (wrist), arm recoil, popliteal angle, scarf sign, heel to ear. 

Post term infants and placental dysfunction syndrome - Post term after 42 weeks AOG, irrespective of birth weight - Little vernix if at all, no lanugo hair, pale skin usually dry and desquamating, fingernails longer than term - Usually born to mother with: toxemia, chronic renal disease, chronic illness or addiction, elderly primigravidas, placental abnormalities - Dysfunction of placenta: o First stage: alert, loose hairless skin, abundant scalp hair and long nails o Second stage: first stage + meconium stained. Meconium stain suggest intrauterine distress o Third stage: deeper staining of nail beds and skin are bright yellow with umbilical cord yellow-green. Leaner, drier skin and parchment-like and peels off easily Other high risk infants - Multiple pregnancy malformation is common - Twins with diff sexes dizygotic twin - Twins with same sex dizygotic or monozygotic - Monozygotic twinning possibility of fetal transfusion syndrome (parabiotic syndrome) one twin gets more of blood supply and is relatively bigger than the other. Feeding and Fluid therapy - Infants less than 1250 grams and sick not fed orally but given parenteral feeding of 5-10% glucose without saline on first day - Na and K added on 2nd day - . - Infant who appear well fed 4 to 6 hrs after birth - Premature less than 34 weeks may able to suck and swallow but not coordinated, risk for aspiration - Feeding given by OGT

Resuscitation -

120-140 cal/kg/day Protein is less than 3 gm/kg/day ( > 5mg/kg/day overtax the immature kidney and will cause metabolic acidosis) Cannot tolerate oral feeding for long time intravenous hyperalimentation o o

Main goal to establish an adequate spontaneous respiration and cardiac output at the soonest possible time Needs resuscitation born limp, cyanotic, apneic, pulseless A airway suction meconium before positive breathing can be applied or before infant makes gasping attempt B breathing bag or mask or ET tube with 100% O2 o Ambubag 60-80/min when there is poor response to ventilation C circulation external chest massage o D drug o Naloxone 0.1 mg/kg IV or intratracheally if mother received narcotic drugs for analgesia o Bradycardia despite 100% O2 - NaHCO3 3mEq/kg  Bradycaria severely and metabolically acidotic  10 % dextrose maybe started through umbilical vein  HR below 80/ min after 30 secs chest compression by placing the 2 thumbs on the middle of the sternum, below an imaginary line between 2 nipples with the rest of the fingers encircling the chest  Depth of compression - 2/3 of an inch  Rate 120/ min  Compression to ventilation 3:1 o Asystole  Epinephrine (0.1-0.3 ml/kg of a 1:10,000 solution, IV or intratracheal  If no response use 5 10 times the standard dose of epi o Hypovolemic shock, hypotension, or weak pulses  Give volume expander: PNSS, blood, 5% albumin, Ringer s lactate at 10 mL/Kg o Cadiogenic shock 2dary to severe asphyxia  Dopamine or dobutamine as a continuous infusion (5-20 ug/kg/min)