Neonatal medicine

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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16 Neonatal medicine

Care of the normal baby following delivery

Umbilical cord

The umbilical cord should be clamped once the baby has been delivered by replacing the forceps that may have been used at delivery with a sterile clamp.

Temperature control

The newborn infant is at significant risk of hypothermia because of its impaired ability to increase metabolic rate after delivery. There is a natural heat loss, which is exacerbated by a baby’s high surface area to volume ratio. Hypothermia will also worsen hypoxia and acidosis and induce respiratory distress.

Vitamin K

Vitamin K is essential for the coagulation pathways so a deficiency, as may occur in breastfed babies, may result in haemorrhagic disease of the newborn. Vitamin K deficiency may also occur in premature infants, small babies or babies who are unable to feed sufficiently. Maternal liver disease, drug abuse, or mothers on anticonvulsant or antituberculous medication are more likely to lead to babies with this problem.

Vitamin K as a single intramuscular administration at birth will prevent this disease.

Care on the postnatal ward

General care takes place on the postnatal ward. The cord stump should be cleaned daily with soap and water. Vernix, dried blood and meconium can be cleaned soon after birth, but the first bath can be delayed until the following day. Routine observations on the postnatal ward include temperature, heart rate, respiratory rate, bladder and bowel activity, and weight.

Temperature and heart rate

Abnormal temperature (>38 °C or <35.5 °C) or a tachycardia (>160 bpm) that lasts longer than 1 hour is cause for concern and could indicate sepsis.

Respiratory rate

A normal rate is ≤60 breaths per minute. Other than sepsis, the common cause of tachypnoea is transient tachypnoea of the newborn. This is attributed to a build-up of fetal lung fluid, particularly following caesarean section in the absence of labour, and has characteristic chest X-ray appearances. It is diagnosed only after other causes of respiratory distress have been excluded, especially infection. The common causes of respiratory distress in the term baby include:

• Infection – this commonly includes group B β-haemolytic streptococcus, Escherichia coli, Staphylococcus aureus, Listeria monocytogenes, Klebsiella, Enterobacter and Streptococcus pneumoniae

• Meconium aspiration

• Spontaneous pneumothorax

• Severe anaemia

• Central nervous system depression, especially after birth asphyxia

• Cardiac failure

• Metabolic disease with acidosis

• Transient tachypnoea of the newborn

• Congenital anomalies, including causes of upper airway obstruction like goitre, tracheo-oesophageal fistula, diaphragmatic hernia and pulmonary agenesis.

Respiratory distress should be treated as neonatal sepsis until proven otherwise – usually group B streptococcal infection.

Other signs of respiratory distress include grunting; central cyanosis; subcostal, intercostal and sternal recession.

Blood sugar levels

Small and premature babies have different nutritional needs from larger babies and are more prone to hypoglycaemia. If feeding poorly, 3-hourly assessment of blood glucose (before a feed) should be performed. Signs of impending hypoglycaemia include lethargy, irritability, apnoea and fitting. Healthy term babies do not routinely need blood glucose assessment.

Bladder and bowel activity

Failure to pass urine is rare and is associated with palpable kidneys or bladder. Poor stream or dribbling in male infants may be associated with posterior urethral valves.

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