Lecture three
Gestational age assessment :Estimation of gestational age can be based on :
Menstrual period .
Date of conception .
Fetal ultrasonography .
Physical and neuromuscular criteria after birth ( ballard score ).
The ballard score is based on the neonate physical and neuromuscular maturity and can be used up to 4 days after birth .the neuromuscular component are more consistent over time because the physical component mature quickly after birth . however , the neuromuscular component can be affected by illness and drugs.
The physical and neuromuscular score are added to calculate gestational age .
Physical criteria include ( increasing firmness of the pina of the ear ,size of the breast tissue , lanugo hair , creases of planter surface and genitalia ) .
Neurological criteria include ( posture , squire window , arm recoil ,popliteal angle , scarf signs and heal to ear ) .
Birth trauma
Birth injury refers to avoidable and unavoidable injury to the fetus during the birth .Caput succedaneum is a diffuse edematous often dark swelling of the soft tissue of the scalp that extended across the midline and suture line ,and seen after prolong labor in full term and premature infants .
Cephalhematoma is a subperiosteal hemorrhage that does not cross the suture lines and may associated with skull fractures . with time may organized and calcified , also may cause jaundice , both caput and cephalhematoma not need treatment .
Retinal and subconjuctiveal hemorrhage are common and not need treatment .
Brachial plexus may result from excessive traction on the neck producing paresis or complete paralysis .the simplest one Erb- duchenne paralysis involve the fifth and sixth cervical nerves .the usual picture is is painless adduction , internal rotation of the arm and moro reflex absent on affected side and the hand grasp is intact . Klumpke paralysis is caused by injury to the seventh and eight cervical nerve and the first thoracic nerve , if the sympathetic nerve are injured an epsilateral Horner syndrome ( ptosis ,miosis ) treatment of brachial injury is supportive and include positioning to avoid contracture , active and passive exercise may be needed and nerve graft in persist defect .
Facial nerve injury may be the result of compression of the seventh between the facial bone and the mother pelvic bone or the physician forceps .this peripheral injury is characterized by asymmetric crying face and the affected side is flaccid , the eye does not close , the nasolabial fold is absent and the side of the mouth is dropped at rest . if there is a central injury to the facial nerve , only the lower two third of the face ( not the forehead ) are involved .
skull fractures are rare are usually linear and require no treatment other than observation for very rare delayed complications like leptomeningeal cyst .depressed fractures may need elevation .
clavicle fracture is the most common fractures and usually is unilateral of course in macrosomic infants after shoulder dystocia .decreased the movement and moro reflex on the affected side . the prognosis is excellent and many infants require no treatment.
Extremity fractures are less commonly than clavicle and involve humerus more than the femur .the treatment involve immobilization and triangular splint pandage for the humerus and traction suspension for the legs for femoral fractures .
Visceral trauma to the liver and spleen or adrenal gland occurs in macrosomoc infants and in extremely premature infants with or without breech or vaginal delivery.rupture of the liver with subcapsular hematoma formation may lead to anemia and shock and DIC . infants with anemia and shock who are suspected to have intraventricular hemorrhage but with normal head ultrasound examination should be evaluated for hepatic or splenic rupture .infants with severe adrenal gland hemorrhage may exhibit a flank mass , jaundice and hematuria with or without shock .
Certain procedures that can be done to the newborn :
Metabolic screen . before discharge a blood sample should be obtained from every neonate for presence of congenital hypothyroidism and phenylketonuria. In certain states screening also performed for other inborn error of metabolism like ( galactosemia , cystic fibrosis . sickle cell anemia , maple syrup urine disease homocystinuria , histidinemia ) .
Every newborn should receive a single dose of 0.5 -1 mg of natural vitamin K within one hour of birth .
Prophylaxis of gonococcal ophthalmia either a 1% silver nitrate or 0,5 erythromycin .
Newborn circumcision has potential medical benefits and advantage with disadvantage . benefit and risk should be carefully explained to the parents
Benefits :
Prevent inflammation of glans and prepuce .
Decrease the incidence of penile cancer at adult .
Reduce urinary tract infection .
Risk :
Local infection .
Bleeding .
Pain .
All newborn should be vaccinated with first dose of hepatitis vaccine .and if the mother is hepatitis B surface antigen –positive should also receive a dose of hepatitis B immunoglobulin as soon as possible after birth .