Fragile X syndrome is an X-linked disorder that causes mental retardation. It is caused by a repeat in the
3. Spontaneous breathing and crying 4. Good muscle tone
In an effort to predict which newborns will require more intensive resuscitation, the gestational age should be esti-mated as accurately as possible prior to delivery. This allows the appropriate neonatal team to be present and prepared for resuscitation. It is also possible to assess the infant after delivery using the Ballard scoring system, which evaluates neuromuscular and physical maturity (Fig. 10.1).
The Apgar Scoring system is commonly used as an objective means to assess the newborn’s condition (Table 10.1). Five signs are given scores of 0, 1, or 2, for a total of up to 10. Scores are assigned at 1 and 5 minutes, and at every 5 minutes until 20 minutes thereafter, if the 5-minute Apgar score is less than 7. Although these continued
assess-Likewise, the Apgar score cannot be used to identify the causes of the newborn illness. In general, a low 1-minute Apgar score identifies the newborn who requires particu-lar attention. The 5-minute Apgar score can be used to evaluate the effectiveness of any resuscitative efforts that have been undertaken, or to identify an infant who needs more evaluation and management. It should not be used to predict neurologic outcome in term infants.
Routine Care
Basic routine care is necessary for all newborn infants, regardless of the need for resuscitative efforts. For infants who do not require resuscitation at birth, routine care is performed immediately following delivery.
First, the newborn infant is thoroughly dried to main-tain appropriate body temperature. Warm blankets, skin-to-skin contact with the mother, or a radiant warmer can all accomplish this task.
For healthy, vigorous, term neonates, skin-to-skin contact promotes maternal–infant bonding and initiation of breast-feeding in the first hour or life.
(A)
(B) Square
window (wrist) Posture
Neuromuscular maturity
Maturity rating
Physical maturity
-1 0 1 2 3 4 5
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
Skin
Sticky friable, transparent
>90°
180°
180° 140°-180° 110°-140° 90°-110° <90°
160° 140° 120° 100° 90° <90°
90° 60° 45° 30° 0°
Lanugo None Sparse
Gelatinous red, translucent
<50 mm, no crease
Impercep-tible Barely perceptible
Lids open, pinna flat, stays folded Lids fused
loosely (-1) tightly (-2)
Scrotum flat, smooth
Scrotum empty, faint rugae
Prominent clitoris, small labia
minora
Prominent clitoris, enlarged
minora Testes in
upper canal rare rugae
Slightly curved pinna, soft, slow recoil Flat areola-no bud Faint red
marks Abundant
Smooth pink, visible
veins
Majora
& minora equally prominent
Testes descending,
few rugae Well curved
pinna, soft but ready
recoil Stripped
areola, 1 -2 mm
bud Anterior transverse
crease only Thinning Superficial peeling or rash or both,
few veins
Majora large, minora
small Testes down, good rugae Formed and firm,
instant recoil Raised areola, 3 - 4 mm
bud Creases
on anterior
2/3 Bald areas Cracking
pale areas, rare veins
Parchment deep cracking, no vessels
Leathery, cracked, wrinkled
Score Weeks
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
Mostly bald
Creases over entire sole
Full areola, 5 - 10 mm
bud Thick
carti-lage, ear stiff Testes pendulous
deep rugae Majora
cover clitoris
& minora Clitoris
prominent, labia flat Heel-toe
40-50 mm:-1
<40 mm:-2 Plantar
surface
Breast
Eye/ear
Genitals male
Genitals female
FIGURE 10.1. The Ballard score. The Ballard Scoring System uses points assigned to observations about neuromuscular maturity and physical maturity. (B) The points are summed yielding a score used to arrive at an estimated age in weeks. (Guidelines for Perinatal Care. 6th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007:216–217. Original source: Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score expanded to include extremely premature infants. J Pediatr.
1991;119(3):417–423.)
Premature infants have more difficulty maintaining their body temperature and are more susceptible to cold stress.
These infants require warming pads, heated towels, and a preheated radiant warmer to stay warm.
Second, after the umbilical cord is clamped and cut, it is left exposed to air to facilitate drying and separation.
Local application of antimicrobial agents (e.g., triple-dye, iodophor ointment, hexachlorophene powder) is com-mon. The umbilical cord loses its bluish-white appearance within the first 24 hours after delivery. After a few days, the blackened, dried stump sloughs, leaving a granulating wound. If cord blood banking has been requested, the sample should be obtained and stored at this time.
Another essential component of routine care is the assessment of vital signs. An infant’s temperature, heart and respiratory rate, core and peripheral color, level of alertness, tone, and activity should be monitored at deliv-ery and evdeliv-ery 30 minutes thereafter until these measures are stable for at least 2 hours.
If the mother plans to breastfeed, the newborn should be placed at the breast in the delivery room within the first hour after delivery. In general, healthy neonates should remain with their mothers.
TRANSITIONAL CARE
Following the initial assessment and routine care of a healthy neonate, continued close observation is necessary for the subsequent stabilization-transition period (the first 6 to 12 hours after birth) to identify any problems that may arise. The following findings should raise concern and result in closer observation: temperature instability; change in activity, including refusal of feeding; unusual skin coloration; abnormal cardiac or respiratory activity; abdominal distention; bilious vom-iting; excessive lethargy or sleeping; delayed or abnormal stools;
and delayed voiding.
Following delivery, all newborns should receive pro-phylactic application of antibiotic ointment (containing erythromycin [0.5%] or tetracycline [1%]) to both eyes to prevent the development of gonococcal ophthalmia
neonatorum. This is recommended regardless of the mode of delivery. This prophylactic measure can be delayed up to 1 hour to allow for breastfeeding.
Every newborn should also receive a parenteral dose of natural vitamin K1 oxide (phytonadione, 0.5 to 1 mg) fol-lowing delivery to prevent vitamin K-dependent hemor-rhagic disease of the newborn. This form of administration is efficacious, and no commercial oral vitamin K prepara-tion is approved for use in the United States at this time.
This measure also can be delayed for up to 1 hour to allow breastfeeding in the first hour of life.
A newborn infant’s voiding pattern and bowel move-ments should be closely observed within the first 24 hours following birth. Concern about an obstruction or congen-ital defect of the urinary tract is appropriate if voiding has not occurred within the first day of life. Ninety percent of newborns pass stool within the first 24 hours. A congenital abnormality such as imperforate anus should be consid-ered if this does not occur. For the first 2 or 3 days of life, the stool is greenish-brown and tar-like in consistency.
With the ingestion of milk, the stool becomes yellow in color and semisolid.
Circumcision
Circumcision is the surgical removal of a distal portion of the foreskin. It is usually performed within the first 2 days of life on healthy term infants. Circumcision is an elective procedure; therefore, parents should be given accurate and impartial information to allow them to make an informed deci-sion. Circumcision should always involve the administra-tion of an anesthetic; both ring blocks and dorsal penile blocks have proved effective. Complications from circum-cision are rare and include local infection and bleeding.
Jaundice
Jaundice, which occurs in most newborns, is usually benign, but because of the potential toxicity of bilirubin, all newborns should be assessed prior to hospital discharge to Apgar Scoring System
Sign 0 1 2
Color Heart rate
Reflex activity response to stimulation
Muscle tone Respirations
Bpm = beats per minute.
10.1
T A B L E
Blue or pale Absent No response
Limp Absent
Acrocyanotic
<100 bpm Grimace
Some flexion Weak cry;
hypoventilation
Completely pink
>100 bpm
Cry or active withdrawal
Active motion Good, crying
A
B
C
D
Birth
Yes
30 secApproximate time
No
Breathing HR >100 and pink
Effective ventilation,
HR > 100 and pink
Pink Breathing
HR >100 but cyanosis
HR > 60 HR < 60
HR < 60
Persistent cyanosis Apneic
HR < 100
Term gestation?
Amniotic fluid clear?
Breathing or crying?
Good muscle tone?
Provide warmth Position; clear airwaya (as necessary) Dry, stimulate, reposition
Provide positive-pressure ventilationa
Administer chest compressions
Administer epinephrine and/or volumea
aEndotracheal intubation may be considered at several steps.
Give supplementary oxygen Evaluate respirations,
HR, and color
Observational care
Postresuscitation care Provide positive-pressure
ventilationa
Provide warmth Clear airway if needed Dry
Assess color Routine care
30 sec30 sec
identify those at high risk for severe hyperbilirubinemia.
Two methods of assessment can be used: (1) predischarge measurement of total serum bilirubin or transcutaneous bilirubin levels in infants who are jaundiced in the first 24 hours, and (2) application of clinical risk factors for pre-dicting severe hyperbilirubinemia. Late preterm (35 to 37 weeks gestation) infants are at higher risk for hyperbiliru-binemia than are term infants. Acute bilirubin encephalopa-thy or kernicterus is associated with total serum bilirubin levels greater than 30 mg/dL.
If possible, the cause of the hyperbilirubinemia should be determined. Breastfeeding has a significant effect on unconjugated hyperbilirubinemia (breast milk jaundice and
“breast-non-feeding jaundice”). Jaundice that persists for 2 weeks requires further investigation, including measure-ment of both total and direct serum bilirubin concentra-tions. Elevation of the direct serum bilirubin concentration always requires further investigation and possible interven-tion, which include phototherapy or exchange transfusion.
INITIAL CARE OF THE ILL NEWBORN
Although most deliveries are uncomplicated, requiring only basic neonatal care, resuscitation may be necessary in up to 10% of all deliveries; 1% of these require major resuscitative efforts. The need for these efforts increases in circumstances such as premature birth, low–birth-weight infants, prolonged labor, and non-reassuring measures of fetal well-being. Not all deliveries occur in a setting with intensive pediatric care immediately available. In the absence of such staff and facilities, maternal transport to a facility with a greater capacity to provide appropriate care should be attempted before delivery. Alternatively, the transport of a neonatal team from a tertiary care center to the primary care site is an option.
Neonatal Resuscitation
The normal newborn breathes within seconds of delivery and usually has established regular respirations within 1 minute of delivery. If the neonate is having difficulty breathing, ventilation, chest compression, and epineph-rine should be instituted, as shown in the protocol in Figure 10-2. If an infant does not respond to epinephrine, hypovolemic shock should be considered, especially if there is evidence of blood loss. In this case, intravenous normal saline at 10 mL/kg should be given.
The same principles of adult resuscitation (airway, breath-ing, and circulation) apply to neonatal resuscitation (Figure 10.3). First, the newborn is transported to a radiant warm-ing unit to be thoroughly dried. When drywarm-ing the infant, it is important to remove wet towels to minimize the effect of evaporation that would otherwise lead to a rapid drop in core body temperature. The nose and oropharynx are suc-tioned to ensure an open airway as the infant is placed in the
supine position. The head should be positioned with the neck slightly extended—the “sniffing position”—to allow for maximal air entry. Drying and suctioning, along with providing mild stimulation by rubbing the back or soles of the feet—or flicking the soles of the feet—help to stimulate the infant to breathe and cry.
FIGURE 10.2. Algorithm for neonatal resuscitation. (Source:
2005 American Heart Association Guidelines for Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care, © 2005, American Heart Association.)
Respiratory distress may occur as a consequence of maternal narcotic administration during labor. A narcotic antagonist can be considered only if severe respiratory pres-sure ventilation has improved the heart rate and color, and the mother received narcotics within 4 hours of delivery.
partum fever, and multifetal gestations. A segment of umbilical cord is double-clamped and cut and placed on the delivery table pending assessment of the 5-minute Apgar score, so that it may be taken for assessment of pH, PO2, PCO2, HCO3, and base deficit. It should be remem-bered that, in the fetus, freshly oxygenated blood from the placenta travels to the fetus through the umbilical vein, and blood metabolized by the fetus travels back to the placenta through two umbilical arteries. The most meaningful assess-ment of metabolic status of the infant at the time of delivery is through analysis of umbilical artery blood gases. Analysis of paired arterial and venous specimens should prevent debate over whether a true arterial specimen was obtained. There-fore, where possible, obtaining both venous and arterial samples (paired specimen) is recommended. Normal val-ues for umbilical arterial and venous samples are given in Table 10.2.
Acidemia is generally accepted as an increase in hydrogen ion concentration in an umbilical arterial sam-ple resulting in a pH of <7.20. Fetal asphyxia is defined as a condition of impaired blood gas exchange leading to progressive hypoxemia and hypercapnia with a significant metabolic acidosis (base deficit ≥12 mmol/L).
Normal Umbilical Cord Blood Gas Values
Arterial Venous
pH 7.25–7.30 7.30–7.40
PCO2(mm Hg) 50 40
PO2(mm Hg) 20 30
HCO3(mEq/hr) 25 20
10.2
T A B L E Tongue
Epiglottis Glottis
Trachea
Esophagus (a)
(b)
FIGURE 10.3. Airway management in newborn resuscita-tion. (A) Management with mask and Ambu bag. Most new-borns can be safely and effectively managed with a face mask, elevating the chin [1] so that the airway is pulled up and opened [2] into the “sniffing position.” (B) Management with endotracheal intubation. Intubation should only be per-formed by trained personnel to avoid iatrogenic injury.
In infants born to a narcotic-addicted mother, naloxone is contraindicated because the immediate withdrawal symp-tom that ensues can be life-threatening.
The base deficit can be used to predict metabolic acidosis sig-nificant enough to cause newborn complications.
Umbilical Cord Blood Gases
During the resuscitation process, the metabolic well-being of an ill newborn is most accurately assessed using umbil-ical cord blood gases. Cord blood gases should be obtained in cases of cesarean delivery for fetal compromise, a low 5-minute Apgar score, severe growth restriction, abnormal fetal heart rate tracing, maternal thyroid disease,
intra-Ten percent of newborns with a base deficit of 12 to 16 mmol/L and 40% of newborns with a base deficit of
>16 mmol/L will have moderate to severe complications, such as newborn encephalopathy and cardiovascular and respiratory complications. The terms acidemia, acidosis, and asphyxia should be used carefully when applied to the newborn condition, because each term defines a series of changes that may or may not represent true metabolic compromise.
Umbilical Cord Blood Banking
Umbilical cord blood is now known to contain potentially life-saving hematopoietic stem cells for possible adult trans-plant for the correction of inborn errors of metabolism, hematopoietic malignancies, and genetic disorders of the blood and immune system. If a patient requests information
on umbilical cord banking, balanced and accurate informa-tion regarding the advantages and disadvantages of public or private banking should be provided. The remote chance of an autologous unit of umbilical cord blood being used for a child or a family member (approximately 1 in 2700 individuals) should also be disclosed.
NEWBORN SCREENING
Newborn screening programs, which should be available to all newborns, include tests designed to detect infants with specific conditions who may benefit from early diag-nosis and treatment. These conditions include disorders of metabolism, endocrinopathies, hemoglobinopathies, hear-ing loss, and cystic fibrosis. The tests may also identify par-ents who are carriers of inherited conditions.
To obtain a sample for testing, heel stick-derived blood is collected and placed onto filter paper. If the initial sample is collected before 12 to 24 hours after delivery, a second sample should be collected at 1 to 2 weeks of age to decrease the probability that phenylketonuria and other disorders with metabolite accumulation are missed as a result of early testing. Premature infants, neonates
receiv-ing parenteral feedreceiv-ing, or those treated for illness should have a newborn screening test performed at or near 7 days of age, regardless of feeding status.
Each state must have a system in place for notification, timely follow-up, and evaluation of any infant with a posi-tive screening result. Posiposi-tive results are usually reported to the newborn’s primary care provider and the parents.
SUGGESTED READINGS
American College of Obstetricians and Gynecologists. The Apgar score. ACOG Committee Opinion No. 333. Obstet Gynecol. 2005;
106(5):1141–1142.
American College of Obstetricians and Gynecologists. Circumcision.
ACOG Committee Opinion No. 260. Obstet Gynecol 2001;98(4):
707–708.
American College of Obstetricians and Gynecologists. Newborn screening. ACOG Committee Opinion no. 393. Obstet Gynecol.
2007;110(6):1497–500.
American College of Obstetricians and Gynecologists. Umbilical cord blood banking. ACOG Committee Opinion No. 399. Obstet Gynecol. 2008;111(2):475–477.
Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American College of Obstetricians and Gynecologists; 2007:205–302.
11 Postpartum Care
This chapter deals primarily with APGO Educational Topics:
Postpartum Care Lactation
Anxiety and Depression
The student should be familiar with normal postpartum events to provide optimal clinical care as well as be able to identify abnormal events.
Topic 29:
Topic 14:
Topic 13:
125 ficial layer, which becomes necrotic and sloughs, and a basal layer adjacent to the myometrium, which had con-tained the fundi of the endometrial glands. This basal layer is the source of the new endometrium.
The subsequent discharge, called lochia, is fairly heavy at first and rapidly decreases in amount over the first 2 to 3 days postpartum, although it may last for several weeks. Lochia is classically described as: (1) lochia rubra, menses-like bleed-ing in the first several days, consistbleed-ing mainly of blood and necrotic decidual tissue; (2) lochia serosa, a lighter dis-charge with considerably less blood in the next few days;
and (3) lochia alba, a whitish discharge which may persist for several weeks and which may be misunderstood as ill-ness by some women, requiring explanation and reassur-ance. In women who breastfeed, the lochia seems to resolve more rapidly, possibly because of a more rapid involution of the uterus caused by uterine contractions associated with breastfeeding. In some patients, there is an increased amount of lochia 1 to 2 weeks after delivery, because the eschar that developed over the site of placental attachment has been sloughed. By the end of the third week post-partum, the endometrium is reestablished in most patients.
Cervix and Vagina
Within several hours of delivery, the cervix has reformed, and by 1 week, it usually admits only one finger (i.e., it is approximately 1 cm in diameter). The round shape of the nulliparous cervix is usually permanently replaced by a transverse, fish–mouth-shaped external os, the result of laceration during delivery. Vulvar and vaginal tissues return to normal over the first several days, although the vaginal mu-cosa reflects a hypoestrogenic state if the woman breastfeeds, be-cause ovarian function is suppressed during breastfeeding. The muscles of the pelvic floor gradually regain their tone.
he puerperium is the 6- to 8-week-period following birth during which the reproductive tract, as well as the rest of the body, returns to the nonpregnant state. Some of the physiologic changes of pregnancy have returned to normal within 1 to 2 weeks postpartum. The initial post-partum examination should be scheduled at 4–6 weeks after delivery.
PHYSIOLOGY OF THE PUERPERIUM Involution of the Uterus
The uterus weighs approximately 1000 g and has a volume of 5000 mL immediately after delivery, compared with its nonpregnant weight of approximately 70 g and capacity of 5 mL. Immediately after delivery, the fundus of the uterus is easily palpable halfway between the pubic symphysis and the umbilicus. The immediate reduction in uterine size is a result of delivery of the fetus, placenta, and amniotic fluid, as well as the loss of hormonal stimulation. Further uterine involution is caused by autolysis of intracellular myometrial protein, resulting in a decrease in cell size but not in cell number. As a result of these changes, the uterus returns to the pelvis by 2 weeks postpartum and is at its normal size by 6 weeks postpartum. Immediately after birth, uterine hemostasis is maintained by contraction of the smooth muscle of the arterial walls and compression of the vascu-lature by the uterine muscuvascu-lature.
Lochia
As the myometrial fibers contract, the blood clots from the uterus are expelled and the thrombi in the large vessels of the placental bed undergo organization. Within the first 3 days, the remaining decidua differentiates into a
