Approach to the Newborn

Table Of Contents
  1. History
  2. Assessment of gestational age and size
  3. Growth abnormalities
  4. Birth examination
  5. Essential Newborn care

History

Maternal and paternal medical and genetic History

  • Genetic History
    • History of congenital anomalies in the family
    • Anything else with genetic implications from both the mother and father
  • Medications during pregnancy (particularly teratogens)
    • Antiseizure meds which are continued during pregnancy since risk of harm to baby during seizure>teratogenic effect)
  • Dietary habit
    • Did she get appropriate nutrition? Any unique dietary habits? On a calorie restricted diet?
  • Smoking or alcohol during pregnancy
    • Smoking can lead to clots and placental problems.
    • EtOH can lead to Fetal alcohol syndrome.
  • Occupational- or environmental-related risks
    • Medical personnel, radioactive exposure, certain industrial occupations, strenuous labor, farming, exposure to cats, veterinary exposure
  • Chronic medical conditions
    • DM (leads to macrosomia)
    • Hypothyroidism (cretinism)
    • Hypertension
    • Autoimmune disorders
    • Infections (TORCHES including HIV)

Maternal Obstetric History

  • Gravida/Para status
    • Gravida (Total pregnancies)
    • Parity: pregnancies carried to viability (20 weeks)
  • Blood type, especially Rh status
    • Incompatible Rh status
    • Whether or not the mother received prophylactic Rhogam
  • Past pregnancy outcomes, and details if there were problems
  • History of current pregnancy
    • Abnormal Sonographic findings
    • Results from routine screening tests (hCG, nuchal translucency, TORCH titres, Pap smears, Quad screens, OGTT, GBS, Rh status)
    • Results from any amniocenteses (if mother underwent procedure)
  • Documentations of any OB related complications during the pregnancy
    • Pre-eclampsia/eclampsia
    • Gestational HTN
    • GDM
    • UTI
    • pre-term labour (stopped with tocolytics)

Anteparturm/Intrapartum hx

  • Duration of rupture of membranes (ROM)
    • How long has it been since membranes broke?
  • Appearance of show (bloody? meconium stained?)
    • Meconium stained show = post-term infant/feta distress = increased risk of meconium aspiration syndrome
  • Presence of maternal fever? Fetal distress?
    • Distress picked up by Fetal HR
  • Fetal presentation
    • Breech persentation = aggressive maneuvers (traction etc.) which can injure the baby
  • Mode of delivery (vaginal, CS) including use of instruments such as vaccum or forceps
    • Vacuum: increases risk of subgaleal hemorrhage
    • Forceps: can cause injury
  • Use of anesthesia
    • Anesthesia can reduce fetal respiration
  • APGAR score at 1 and 5 minutes at birth

Assessment of gestational age and size

The most reliable method of estimating gestation age is the LNMP. Other methods include sonography or Ballard method (among other criteria) post-partum. SGA is NOT synonymous with LBW. SGA implies a problem with growth, whereas LBW implies a baby who is small at the time of birth (even though they may not be SGA) LBW is defined simply as weight alone, while SGA is defined as weight relative to gestational age.

  • Low birth weight (LBW)
    • <2500g
  • High birth weight (HBW)
    • 4000g
  • Baby’s size relative to gestational age
    • Plotted on a growth chart to show the percentile.

Growth abnormalities

Small for Gestational Age (SGA)

  • What is SGA associated with an increased risk of?
    • Fetal distress
    • Hypoglycemia
    • Polycythemia
    • Hypocalcemia
  • Symmetric defects are associated w/early pregnancy problems
    • Intrauterine viral infection (CMV)
    • Chromosomal anomalies
    • Maternal drug abuse
  • Asymmetrical defects are associated w/late birth problems
    • Placental insufficiency (gestational HTn, maternal vascular disorders)
    • Maternal age ≥ 35y
    • Poor weight gain during pregnancy
    • Multiple gestation

APGAR score

Virginia Apgar (1909-1974) is credited for coming up with the scoring system to determine whether the baby is responding to resuscitative efforts and the baby’’s current status. It is NOT a predictor for long-term outcome; but is a likely predictor of NEC risk

Taken at 1 and 5 minutes after birth.

0-4 = poor

5-7 = fair

8-10 = good

012
Appearance (Skin colour)CyanoticBody pink, limbs cyanoticPink
PulseAbsentslow (<100)Normal (>100)
Grimace (Response to catheter in nares)NoneGrimaceCough or Sneeze
Activity (Muscle tone)LimpFlexionSpontaneous movement
Respiratory effortNoneSlow; irregularGood, crying

Birth examination

  • APGAR scoring (1 and 5 minutes)
    • Skin color is good indicator of Cardiac output
  • Skeletal examination (looking for birth trauma)
    • Palpate clavicle, humerus, other bones: Clacivle and humerus are common fractures
    • Look for lacerations from instruments (esp. in the case of CS)
  • Examination of the Umbilical cord and placenta (done by the OB)
    • 2 arteries and one vein (abberation = defect)
    • Small placenta (roughly correlated with baby’s size)
    • Infarcts or clots in the placenta (associated with insufficiency)

Essential Newborn care

  • Attend to resuscitation and/or other emergencies first
  • Keep the newborn warm (Body Temp 36.5 – 37.5 C)
  • Cleanse skin and umbilical cord w/warm, soft, soap solution
  • Disinfect the umbilical cord w/Chlorhexidine digluconate 7.1%
    • Term babies: immediately after cord cutting the q1d for 7 days
    • Preterm babies: apply only once after cord cutting
  • Treat eyes with Tetracycline eye ointment (TEO) or Erythromycin ointment or silver nitrate drops
  • Administer 1mg Vitamin K intramuscular (0.5mg if VLBW)
  • Vitamin and Mineral supplementation for preterm infants and Low Birth weight infants from 2 weeks to 6mos/1year of life
    • Multivitamin syrup
    • Folate
    • Iron supplementation
    • Vitamin D
    • Calcium supplementation
    • Daily phosphorus
  • Kangaroo Mother Care