HIGH RISK NEWBORN

Dr. H. Usha Rani

 HIGH RISK NEWBORN
Maternal characteristics

• 1. Age at delivery
a. Over 40 years. - chromosomal abnormalities, SGA
b. Under 16 years – Preeclampsia, prematurity

• 2. Personal factors
a. Poverty – prematurity, SGA
b. Smoking – SGA, ↑ perinatal mortality
c. Drug/alcohol use – SGA, fetal alcohol syndrome, withdrawal
d. Poor diet - SGA
e. Trauma (acute, chronic) – fetal demise, prematurity
•3. Medical conditions

a. Diabetes mellitus – congenital anomalies, still birth, RDS,

hypoglycemia, hypocalcemia
b. Thyroid disease – Goitre, hypothyroidism, hyperthyroidism
c. Renal disease – SGA, still birth, prematurity
d. Urinary tract infection – Prematurity, sepsis
e. Heart and/or lung disease – SGA, prematurity
f. Hypertension. - – Still birth, SGA, prematurity, asphyxia
g. Anemia – still birth, SGA, prematurity, Asphyxia, hydrops
h. Isoimmunization – still birth, anemia, jaundice, hydrops
j. Thrombocytopenia
4. Obstetric history

a. Past history of prematurity, jaundice, RDS, anomalies –

recurrence.
b. Maternal medications
c. Bleeding in early pregnancy – prematurity
d. Hyperthermia - NTD
e. Bleeding in third trimester – still birth, anaemia
f. Premature rupture of membranes - sepsis
g. TORCH infections - infection
h. Trauma – fetal demise, prematurity
B. Fetal characteristics and associated risk for fetus
or neonate
• Multiple gestation – Prematurity, TTTS, birth trauma,
asphyxia
• IUGR – fetal demise, still birth, asphyxia, hypoglycemia, polycythemia
• Macrosomia – Congenital anomalies, birth trauma, hypoglycemia
• Abnormal fetal position/presentation – birth trauma, hemorrhage
• Abnormality of fetal heart rate or rhythm – Hydrops, asphyxia,
CHF, heart block
• Decreased activity – Fetal demise, still birth, asphyxia
• Polyhydramnios – CNS disorders, neuromuscular disorders, swalowing
problems, CDH,omphalocele, gastroschisis,hydrops, maternal
diabetes
• Oligohydramnios – IUGR, placental insufficiency, postmaturity, fetal
demise, renal agenesis, pulmonary hypoplasia,deformations.
 C. Conditions of labor and delivery
• Preterm delivery : RDS, BPD. ROP, IVH-PVL,NEC, PDA, anemia,
hyperbilirubinemia, hypothermia,
• Postterm delivery - Still birth, asphyxia, MAS
• Maternal fever- infection
• Maternal hypotension- still birth,asphyxia
• Rapid labor – Birth trauma, intracranial hemorrhage
• Prolonged labor – still birth, asphyxia, birth trauma
• Meconium-stained amniotic fluid – still birth, asphyxia, MAS, PPHN
• Prolapsed cord – Asphyxia, ICH
• Cesarean section – TTNB, blood loss
• Obstetric analgesia and anesthesia – respiratory depression, hypothermia,
hyperthermia
• Placental anomalies
a. Small placenta. - SGA
b. Large placenta – hydrops, maternal diabetes
c. Torn placenta and/or umbilical vessels. – blood loss
d. Abnormal attachment of vessels to placenta- blood loss
 POST PARTUM CAUSES
D. Immediately evident neonatal conditions

• Prematurity.
• Low 5-minute Apgar score.
• Low 15-minute Apgar score.
• Pallor or shock.
• Foul smell of amniotic fluid or membranes.
• Small for gestational age
• Postmaturity syndrome.
 TRIAGE
• Concept of Triage:
Triage is a process of rapidly examining all sick
newborn when they arrive in hospital in order to place them
in one of the following categories with the help of TABC
concept.

• The basic purpose of triage is to ensure that sickest newborn

gets earliest treatment
categories Action
Emergency Need emergency treatment
Priority Need assessment & rapid action
Non-Urgent Need assessment
 TABC
• Concept of TABC:
When sick newborn arrives in Emergency
dept. of a hospital the assessment is done based on
TABC concept where:
T stands for Temperature
A stands for Airways
B stands for Breathing and
C stands for Circulation, Consciousness/ Coma
and/or presence of Convulsion.
• Based on the TABC, newborns are classified as
having –
1) emergency signs
2) Priority signs
3) Non urgency signs
 EMERGENCY SIGNS
If any of the following are present (alone or in
combination)
• T: Moderate or Severe hypothermia (Temp < 35.9 C)
• A: No chest movement
no air entry in lungs/obstructed airways
central cyanosis
• B: Not breathing
Severe respiratory distress with increased work of breathing as evidenced
by respiratory rate>60/min with nasal flaring , chest retractions and/or baby
grunting/gasping/head bobbing
• C: Capillary refill time > 3 sec ,poor pulse ,decreased urine output
Colour of baby mottled or pale with or without cyanosis
Presence of unconsciousness
Presence of Convulsion
 Emergency signs
• The neonates with emergency signs are at high risk
and require urgent intervention and emergency
measures. These neonates with emergency signs
after stabilization are to be admitted SCNU (Special
Care Newborn Unit).
 PRIORITY SIGNS
If any of the following are present (alone or in combination)

• T: Mild hypothermia (Temperature ~ 36.0 to 37.4 degree

centigrade) or Fever (Temperature of more than 37.5 degree
centigrade)

• A: Decreased air entry in either lungs ± chest signs by

auscultation e.g. crackles/ wheezing

• B: Fast breathing respiratory rate > 60/min ± retractions

• C: Capillary refill time < 3 sec but decreased urine output

 PRIORITY SIGNS
• Other features which classify a newborn as having priority
signs :
1. Low birth weight ( wt < 1800 gms)
2. Irritability/restlessness/jitteriness
3. Refusal to feed
4. Abdominal distension
5. Severe jaundice
6. Severe pallor
7. Bleeding from any sites (apart from physiological
vaginal bleed in female)
8. Major congenital anomaly
9. Large baby( wt > 4 kgs)
10. Redness around umbilical area with or without pus
discharge
 Priority signs
• The neonates with priority signs are sick and would
need immediate assessment. They should be
attended to on a priority basis. These need to be
admitted to SCNU.
 NON URGENT SIGNS
• Newborns with non urgent signs are mostly well and
can wait for their turn to be addressed.
• TABC assessment in newborn with non urgent sign is
normal and usually newborns present with following
features:
1. Physiological jaundice
2. Transitional stools
3. Developmental peculiarity
4. Minor malformations
5. Rashes
6. Superficial infections
 Triaging Neonates: where and how?
• The reception and resuscitation (RR) area or the casualty of
the hospital managing sick neonates should be the triaging
area.
• The site at the facility where a neonate is first brought should
be the triaging area.
• All the staff involved in the initial management of a child
should be trained in the triaging process.
• The most experienced doctor present who is trained in
neonatal care should undertake the responsibility of
emergency treatment and management of the neonate.
 HOW TO TRIAGE
Temperature assessment: Feel the
newborn’s soles and abdomen
• If abdomen and soles both are warm
the newborn has normal
temperature.
• If soles are cold and abdomen warm
the newborn is suffering from mild
hypothermia/cold stress.
• If the soles and abdomen are cold the
newborn has moderate/severe
hypothermia.
Axillary thermometer should be used to
record the newborn temperature.
 Airway and breathing assessment
• Is the newborn not breathing/
gasping/grunting/having head
bobbing or nasal flaring?
• Is the airway obstructed?
• Is the newborn blue? (Centrally
cyanosed)
• Does newborn has severe
respiratory distress with or without
retractions?

Any positive finding should be

addressed on urgent basis and
airways should be made patent.
Oxygen is usually started before a
definite diagnosis is made
 Circulation assessment
To assess if the newborn has
Circulatory problems one
should:
• Look for cold and clammy skin
• Look for Capillary refill time
(CRT) .
• Look for weak and fast pulse
rate.

• Colour of skin - Pallor, mottling

and cyanosis are key visual
indicators of reduced
circulation to skin.
 Assessment of consciousness
• AVPU scale can be used to
rapidly assess the newborn.
• A: Is the newborn alert?
• V: Is the newborn responds to
Voice?
• P: Is the newborn responding
to pain?
• U: Is the newborn not
responding? (Unresponsive)
Any unresponsive newborn or
newborn with convulsion
needs immediate attention
 FOLLOW UP
PRE DISCHARGE
• Medical examination
• Neurobehavioral and Neurological examination
• Neuroimaging
• ROP screening
• Hearing screening
• Screening for congenital hypothyroidism
• Screening for metabolic disorders
HIGH RISK
• Babies with <1000g birth weight , gestation <28 weeks
• Major morbidities such as chronic lung disease, intraventricular
hemorrhage and periventricular leucomalacia
• Perinatal asphyxia
• Surgical conditions like Diaphragmatic hernia, TEF
•SGA and LGA
• Mechanical ventilation for more than 24 hours
• Persistent prolonged hypoglycemia and hypocalcemia
• Seizures, meningitis
• Shock requiring inotropic/vasopressor support
• Infants born to HIV‐positive mothers
• Twin to twin transfusion
• Neonatal bilirubin encephalopathy
• Inborn errors of metabolism / other genetic disorders
• Abnormal neurological examination at discharge
Neurodevelopmental delay:
supervise & screen for developmental delay with Neonatologist and
– Radiologist, Audiologist, Ophthalmologist
– Social worker, Dietician, Physiotherapist
– Pediatric neurologist
– Geneticist
– Occupational therapist
– Speech therapist
– Endocrinologist
– Pediatric surgeon
MODERATE RISK:
– Babies with weight – 1000 g‐ 1500g or gestation < 32 wks
– Twins/triplets
– Moderate Neonatal HIE
– Hypoglycemia, Blood sugar<25 mg/dl
– Neonatal sepsis
– Hyperbilirubinemia > 20mg/dL or requirement of
exchange transfusion
– IVH grade 2
– Suboptimal home environment

Follow up with neonatologist and developmental pediatrician:

screen for developmental delay, manage intercurrent illnesses
with
– Developmental pediatrician ,
– Radiologist, Audiologist, Ophthalmologist
– Social worker, Dietician, Physiotherapist
MILD RISK
– Preterm,
– Weight 1500 g ‐ 2500g
– HIE grade I
– Transient hypoglycemia
– Suspect sepsis
– Neonatal jaundice needing PT
– IVH grade 1

Follow up with pediatrician / primary care provider with objective to

screen for deviation in growth and development
Thank you