HIGH RISK NEW BORN- LOW BIRTH

WEIGHT BABIES, PRETERM BABY AND

INTRA UTERINE GROWTH RETARDATION

INTRODUCTION:
The term ‘ high risk new born’ identifies a group of new born
who very will develop a severe acute or an adverse outcome.
A new born, regardless of gestational age or birth weight ,
who has a greater than average chance of morbidity or
mortality because of condition or circumstances super imposed
on the normal course of events associated with birth and the
adjustments to extra uterine existence.
CONCEPT
 To predict a in fund is at high risk allows for
advanced preparation so that specialized skilled
healthcare personal can be present at the time of
childbirth to perform intervention.
 It helps to save the newborn's life and also
prevent future problem such as neurological
disorders.
 Mother should be council regarding the mode of
feeding before delivery.
National health goals on high risk
newborn :
 Reduction of IMR and MMR by 50% from existing level in
next 7 years
 Universal access to public health services
1. Women HEALTH
2. Child Health
3. Water Sanitation And Hygiene
4. Immunization
5. Nutrition
Principles of HIGH RISK newborn care:
 Promoting Warmth
 Normal Breathing ( RESUSCITATION)
 Mother's Milk
 Protection From Infection

Prevention
 Female LITERACY And Formal Education
 Maternal Health State
 Antenatal Care
 Maternal Infection
Goals
 Perinatal Prevention
 Resuscitation And Stabilization
 Evaluate And Manage
 Monitoring
 Family Centered Care
Factors- to define high risk newborn
 Democratic Social Factors
 Past Medical History
 Previous Medical History
 Present Pregnancy
 Labour And Delivery
 Neonate
Demographic social factors
 Maternal Age < 16 Or > 40 Years
 Poverty
 Unmarried
 Emotional Or Physical Stress
 Illicit Drug, Alcohol, Cigarette Use.

Past Medical History

 Genetic Disorder
 Diabetes Mellitus
 Hypertension
 Asymptomatic Bacteriuria
 Rheumatologic Illness
 Immune Mediated Disease
 Long Term Medication
Previous pregnancy
 Intrauterine Fetal Demise
 Neonatal Death
 Pre Maturity
 Intrauterine Growth Restriction
 Congenital Malformation
 Incompetence Cervix
 Blood Group Sensitization
 Neonatal Thrombocytopenia
 Hydrops Fetalis
PRESENT PREGNANCY
 Vaginal Bleeding
 Sexually Transmitted Infections
 Multiple Gestation
 Preeclampsia
 Premature Rupture Of Membrane
 Poly/Oligohydramnios
 Acute Medical Or Surgical Illness
 Inadequate Prenatal Care
 Abnormal Fetal USD Findings
 Treatment Of Infertility
Labour And Delivery :
 Exposed Pregnancy
 Post Dated Pregnancy
 Fetal Distress
 Breech Presentation
 Meconium Stained Fluid
 Nuchal Cord
 Cesarean Section
 Forceps Delivery
 Apgar score < 4 At 1 Minute
NEONATE:
 Birth Weight < Or Equal To 2500gm Or < Or Is Equal To 4000
Gms ( LBW)
 Birth < 37 Weeks Or >Or Equal To 42 Weeks Of Gestation
(Prematurity Or Post Maturity)
 Small Or Large Gestational Age
 Respiratory Distress
 Cyanosis
 Congenital Malformation
 Pallor, Plethora ,Petechiae
 Neonatal Infection
IDENTIFICATION OF HIGH RISK
NEWBORN
Assessment :
The assessment helps to identify infants that are
preterm and post term, smaller or large for gestational age.
Purpose
 To compare a given infant against standardize to norms of
neonatal growth based on gestational age
 It also includes evaluation of physical characteristic of the
infant for the degree of maturity.
 It helps in medical treatment and intervene nursing
management
1.Initial Assessment
2 Transitional Assessment
3 Assessment Of Clinical Gestational Age And Birth Weight
4.Systematic Assessment
I.INITIAL ASSESSMENT
using APGAR SCORING system
II.TRANSITIONAL ASSESSMENT
assessment during the period of reactivity (assessment of
normal newborn
care)
III. ASSESSMENT OF GESTATIONAL AGE
definition : the course of time from day of menstrual cycle in
Method used in determination of
gestational age :
 Physical And Neurological Examination
 Last Menstrual Period Lmp
 Obstetric History
 Laboratory Test
 Fetal Ultrasonic Scanning
A . Skin :
Progressive Jaundice Especially In First 24 Hours,
Generalized Cyanosis, Pallor, Mottling, Grayness, Plethora,
Hemorrhage, Ecchymosed Or Petechiae , Poor Skin Turgor,
Rashes, Pustules Or Blisters, Café-au-lait Spot(Light Brown
Spots), Nerves Flammeus (port-Wine Stain).
B. Head
Fused Sutures, Bulging Or Depressed Fontanels,
Widened Sutures And Fontanels, Craniotabes- Snapping
Sensation Along Lambdoid Sutures That Resembles Ping Pong
Ball
EYE:
 Pink Colour Of Iris
 Purulent Discharge
 Upward Slant In Non Asians
 Hypertelorism/ Hypotelorism
 Congenital Cataracts
 Constricted Or Dilated Fixed Pupil
 Abscess Of Red Reflex
 Abscess Of Pupillary Corneal Reflex
 Inability To Follow Object Or Bright Light To A Midline
 Yellow Sclera
EARS:
 Low Placement Of Ears
 Absence Of Startle Reflex Response To Loud
Noise
 Minor Abnormalities

Nose :
 Non Patent Canals
 Thick, Blood Nasal Discharge, Flaring Of
Nares (Alae Nasi)
 Copious Nasal Secretions Or Stuffness.
MOUTH AND THROAT :
 CleftLip , Cleft Palate, Large Protruding Tongue
Or Posterior Displacement Of Tongue
 Profuse Salivation Or Drooling,
 Candidiasis (Thrush )
 White Adherent Patches On Tongue Palate And
Buccal Surfaces
 In Ability To Pass Naso Gastric Tube
 Hoarse High Pitched Weak Absent
Neck:
 excessive skin folds
 resistance to flexion
 absence of tonic neck reflex
 Fractured clavicle
Chest:
 depressed sternum
 marked retractions of chest
 asymmetric chest expansion readiness and
firmness around nipples
 wide spaced nipples
Lungs :
 Inspiratory Stridor Expiratory Grunt
 Retractions Persistent
 Irregular Breathing
 Periodic Breathing With Repeated Apneic Spells
 See Saw Respiration
 Paradoxical
 Wheezing
 Diminished Breath Sound
 Peristaltic Bowel Sounds On One Side
Heart:
 Dextrocardia( heart on right side
displacement of Apex )
 muffled cardiomegaly
 abdominal shunts
 Murmur
 Thrill
 persistence Central cyanosis
 hyperactive pericardium.
Abdomen:
 Abdominal Distension
 Localized Bulging
 Descended Veins
 Absent Bowel Sounds
 Enlarged Liver And Spleen.
 Ascites
 Scaphoid Or Concave Abdomen
 Moist Umbilical Cord
 Presence Of Only Pus Leaking From Cord Or Cord Insertion
Site.
FEMALE GENITALIA:
 Enlarged Clitoris With Urethral Meatus At Tip
 Fuse Labia
 Absence Of Vaginal Opening
 Meconium From Vaginal Opening
 No Urination Within 24 Hours
 Masses In Labia
 Ambiguous Genitalia
MALE GENITALIA :
 Hypospadias's
 Urethral Opening On Ventral Surface Of Penis
 Ventral Curvature Of Penis
 Testis Not Palpable In Scrotum Or Inguinal Canal
 No Urination With 24 Hours
 Inguinal Hernia
EXTREMITIES:
 Polydactyly( Extra Digit)
 Syndactyly (Fused Or Webbed Digit)
 Phocomelia
 Hemimelia
 Hyper Flexibility Of Joints
 Sole Covered With Creases
 Decreased Or Absent Range Of Motion
 Unequal Knee Height Or Abduction
 Audible Clunk On Abduction
 A Symmetry Of Extremities
NEUROMUSCULAR SYSTEM:
 hypotonic floppy, poor head control
 extremities limp
 hypertonia jittery
 arms and hands tightly flexed
 legs stiffly extended
a symmetric posturing
 opisthotonics postering
CLASSIFICATION OF HIGH
RISK NEWBORN:
 LOW BIRTH WEIGHT (LBW) INFANT
An infant whose birth weight is less than
2500 grams regardless of gestational age
1. VERY LOW BIRTH WEIGHT: < 1500 GRAM
2. VERY VERY LOW BIRTH WEIGHT:
extremely low birth weight < 1000 gram
3. MODERATELY LOW BIRTH WEIGHT:
birth weight is 1500 to 2500g
4. APPROPRIATE GESTATIONAL AGE( AGA) INFANT:
An infant whose weight falls between the 10th- 90th percentile on intra
uterine growth curves

5. SMALL FOR DATE (SFD) OR SMALL FOR GESTATIONAL

AGE:
birth weight falls below the 10th percentile on intra uterine growth
curves.

6. INTRA UTERINE GROWTH RETARDATION(IUGR)

Found in infants who intra uterine growth is retarded

7. LARGE FOR GESTATIONAL AGE (LGA) INFANT :

an infant whose birth weight falls above the 90% intra uterine growth
charts
CONTD…..
 HYPOTHERMIA
 HYPERTHERMIA
 HYPOGLYCEMIA
 INFANT OF DIABETIC MOTHER
 NEONATAL SEPSIS
 HYPERBILIRUBINEMIA
 RESPIRATORY DISTRESS SYNDROME
 PROBLEMS ASSOCIATED WITH LOW BIRTH
WEIGHT, PRETERM, IUGR:
 Low birth weight baby:
A baby’s weight at birth is 2500 g or less was taken as
index of Prematurity without taking any consideration of the
gestational period or any other factor
Incidence
1. In India, about 30 to 40%,neonates are born in LBW
approximately 80% of all neonatal death 50% of infants
with related to lbw
2. About 10% of LBW baby require admission to the special
care nursery.
RISK FACTORS AND CAUSES OF LOW BIRTH WEIGHT
 Poor socio economic condition
 illiteracy
 maternal malnutrition and anaemia
 maternal illness like diabetes mellitus,
hypertension
 low maternal weight
 teenage pregnancy
 two frequent childbirth
 maintenance smoking and drug addiction
Contd….
 multiple pregnancy
 Placental dysfunction
 Antepartum haemorrhage
 pregnancy induced hypertension
 acute emotional stress
 premature onset of labour
 Intra uterine infection
 congenital malformation
Clinical features of low birth weight baby
 weight <2500 gram
 length <47 CM
 Head circumference <33 CM
 chest circumference < HC >3 cm
 general activity poor and weak cry
 attitude relaxed and limbs extended with poor tone
 sucking following cough and moro reflexes
 skin shiny, loose thin, delicate, pink with scanty vernix
and plenty Lanugo
 ear are soft and flat, cartilages not fully developed
Contd….
 Eyes remains closed and protruding
 hairs are scanty wooly and fuzzy
 face is small with small chin and less buckle
fat
 breast nodules are absent or < 4 mm
 abdomen full , soft and not grown up to finger
tips
 nails are short and not grown up to finger tips
 Deep creases over palms and soles due absent
CLINICAL FEATURES SYSTEM WISE:
1. ALTERED RESPIRATORY FUNCTION
 Respiration Is Rapid Shallow And Irregular
 Apneoa And Cyanosis
 Cough And Gag Reflex Is Weak Or Absent
 Primary Atelectasis And Hyaline Membrane Disease May
Develop
 Respiratory Muscles Weak
 Poor Expansion Of Lungs
 Inefficient Respiratory Centre
 Deficiency Of Surfactant In The Alveoli
2. IMPAIRED THERMO REGULATION:
 Variations of body temperature
 hypothermia
 poor insulating subcutaneous fat
 poor muscular activity and less brown fat
3. DISTURBANCE IN FOOD AND NUTRITION
 Poor sucking and swallowing reflex
 capacity of stomach less
 Cardio esophageal sphincter is incompetent leading to regurgitation and
respiration
 Inadequate digestion and absorption of essential nutrients resulting
malnutrition
 prone to develop iron deficiency anemia and deficiency of vitamin A,D,E & K
4.Lack of immunity:
 cellular immunity and antibody level low
 infections during incubator care, resuscitation and
invasive procedures
5. Metabolic disturbance:
 hypoglycemia
 hypocalcemia
 hypoxia
 acidosis
 poor metabolic function
 poor glycogen Store
6. Inefficient Hepatic Function:
 Hyper Bilirubinaemia
 Kernicterus
 Physiological Jaundice
 Haemorrhagic Disease
7. Impaired Renal Function:
 Acidosis
 Dehydration
 Decreases Urination
 Drug Toxicity
8. INEFFICIENT NEUROLOGICAL FUNCTION:
 More Reflex( Absence Or Incomplete)
 Cough Reflex Poor
 Sucking Reflex Poor
 Swallowing Reflex Poor
 Lethargy
 Inactivity
PREVENTIVE MEASURES OF LOW BIRTH
WEIGHT BABY:
 Detection of high risk antenatal mother and management
of risk mother
 Recommended dietary intake in pregnancy for the
expected fetal weight gain
 Efficient management of premature labour and the
prevention of complications
 Delivery of lbw baby attended by expert neonatologist for
prompt management
MANAGEMENT OF LOW BIRTH WEIGHT
BABIES:
 IMMEDIATE CARE OF LOW BIRTH WEIGHT AT BIRTH
1. Air passage to be cleared
2. Adequate of warmth by drying and wrapping the baby and
rooming in with mother
3. Administration of vitamin k to prevent heamorrhagic
problems
4. Initiating breast feeding as early as possible.
5. Body can be caused in prone position
6. Gentle handling and care in special neonatal care unit
NURSING CARE OF LOW BIRTH WEIGHT BABY
1. Maintenance Of Respiratory Function
2. Maintenance Of Thermoregulation
3. Maintenance Of Nutrition And Fluid
4. Prevention Of Infection
5. Provides Stimulation
6. Informing The Parent About Infant Progress
COMPLICATIONS OF LOW BIRTH WEIGHT :
1. Birth Asphyxia
2. Respiratory Distress Syndrome
3. Intraventricular Haemorrhage
4. Intraventricular Haemorrhage
5. Patent Ductus Arteriosus
6. Necrotizing Enterocolitis
7. Anaemia
8. Kernicterus
9. Cardiac Failure
10. Renal Failure
11. Retinopathy Of Prematurity
12.Infections
Preterm baby
DEFINITION
Baby born with a gestational age of less than 37
completed weeks
INCIDENCE
 it consistutes 2/3 of low birth weight baby
 20% to 25% in the developing countries
 10% in developed countries
CAUSES OF PRETERM
 Constitutional
1. acute emotional stress
2. trauma
 low maternal weight gain
 poor socio economic condition
 Young primi
 unmarried mothers
 frequent childbirth
 history of previous preterm baby
 maternal nutrition (anaemia) maternal Mal nutrition
 Maternal disease
1. Antepartum Haemorrhage
2. Cervical Incompetence
3.Threatened Abortion
4. Bicornuate Uterus
5.Infections
6. Chronic And Systemic Disease
 Spontaneous Cause
1. Toxins (Cigarette ,Smoking And Drug Abuse)
2. Fetal Causes Multiple Pregnancy
Congenital Malformation
 Induced causes
1. Maternal Diabetes Mellitus
2. Severe Heart Disease
3. Placental Dysfunction
4. Eclampsia , Severe Eclampsia And
Hypertension
5. Fetal Hypoxia And Fetal Distress
6. Severe Rh ( Rhesus) Incompatibility
7. Improper Diagnosis Of Maturity In Elective
Deliveries
 Types of preterm baby
1. Late Preterm:
born between 34 and 36 weeks of pregnancy
2. Moderately Preterm :
born between 32 weeks to 34 weeks of pregnancy
3. Very Preterm:
born less than 32 weeks of pregnancy
4. Extremely Preterm:
born at or before 25 weeks of pregnancy
RISK FACTORS
 Having A Previous Premature Birth
 Pregnancy With Twins , Triplets Or Other Multiples
 Interval Of < 6 Month Between Pregnancy
 Conceiving Through In Vitro Fertilization
 Problems With The Uterus , Cervix Or Placenta
 Smoking Cigarette Or Using Illicit Drugs
 Poor Nutrition
 Not Gaining Weight During Pregnancy
 Infections Chronic Conditions( High BP And Diabetes)
 Multiple Miscarriage Or Abortions
 Physical Injury Or Trauma
CLINICAL FEATURES
 Length < 44 CM
 Weight 2500 Gram Or < 2500 Gram
 HC Disproportionately Exceeds That Of The Chest
 Skin Is Thin, Red Or Shiny
 Pinnae Of The Ear Are Soft
 Eyes Are Kept Closed
 Muscle Tone Is Poor
 Planter Creases Not Visible Before 32 Weeks
 Testis Is Undescended
 Labia Majora Is Exposed And There Is Tendency Of Herniation
 The Nail Is Not Grown Up To The Fingertips
 Reflex Or Poor
MANAGEMENT
1. Supportive care
 Being Placed In An Incubator
 Monitoring Of Baby's Vital Signs
 Having A Feeding Tube
 Replenishing Fluids
 Spending Time Under Bilirubin Lights
 Receiving A Blood Transfusion
2. MEDICATIONS:
 SURFACTANT ( to treat RDS)
 find mist (aerosolised ) or iv medication
 antibiotics
 Diuretics( increase urine output )

3. parental education:
The baby can
 breathe without support
 can maintain a stable body temperature
 can breast or bottle feed
 is gaining weight steadily
 is free of infection
INTRA UTERINE GROWTH RETARDATION
DEFINITION:
Babies with a birth weight less than 10 th percentile for
their gestational age.
Incidence:
 comprise about 1/3 of low birth weight
 2-8% in developed countries
 5 % among term baby
 15% among post term baby
CLASSIFICATION:
Depending upon the relative size of their head, abdomen and femur,
the fetuses are subdivided into
1. symmetrical or type – 1
2. asymmetrical or type- 2

SYMMETRICAL TYPE:
ONSET - early in utero
Etiology –congenital, infections, genetic disorder.
pathophysiology- impaired cell division, decrease cell number irreversible
clinical features – inadequate growth of head and body
head:abdomen ratio may be normal
prognosis- poor prognosis
ASYMMETRICAL TYPE 2
ONSET - later onset
ETIOLOGY - Uteroplacental insufficiency, maternal malnutrition,
hypertension
PATHOPHYSIOLOGY: Impaired cellular hypertrophy , decreased cell s
size reversible
CLINICAL FEATURES: Brain is Spared, head to abdomen ratio is
increased
PROGNOSIS : most favorable prognosis
CAUSES
causes of fetal growth restriction divided into four
groups
1. maternal condition
 Constitutional
 small women
 maternal genetic and racial background
 maternal nutrition before and during pregnancy
2. MATERNAL DISEASE
 Anaemia
 hypertension
 thrombophilia
 Heart disease
 chronic renal disease
 collagen vascular disease
 toxins

3.FETAL
 structural anomalies
 chromosomal abnormality
 infection torch agent
 multiple pregnancies
4.PLACENTAL
 poor uterine blood flow
 chronic placental insufficiency
 placenta previa
 circumvallates placenta
 infarction and mosaicism
CLINICAL FEATURES
 Length is unaffected
 weight is about 600 gram below at birth
 dry and wrinkled skin
 Thin meconium stained vernix caseosa
 scaphoid abdomen
 planter creases are well defined
 thin umbilical cord
 all these give a old man appearance
 the baby is alert, active
 has normal crying
 reflexes or normal
DIAGNOSTIC EVALUATION :
 Bio physical examination
 Sonography predictive values (HC/ AC)
 Amniotic fluid volume
 Doppler velocimetry
CARE OF HIGH RISK NEWBORN:
 Care At Neonatal Intensive Care Unit
 Maintenance Of Breathing
 Maintenance Of Stable Body Temperature
 Gentle Early Stimulation
 Prevention, Early Deduction And Prompt Management
Of Complication
 Vaccination
 Transport Of Sick Baby
 Family Support Discharge
 Follow And Home Care
COMPLICATIONS

1. FETAL
 Antenatal - chronic fetal distress
- fetal death
 intranatal - hypoxia
- acidosis
2. IMMEDIATE
 Asphyxia
 Micro Coagulation Leading To DIC During First Day Of
Life
 Hypothermia
 Pulmonary Haemorrhage
 Polycythaemia
 Hyper Viscosity Syndrome
 Necrotising Enterocolitis
 Intra Ventricular Haemorrhage
 Hypoglycaemia
 Meconium Stained Syndrome