NEONATOLOGY
 Neonatal birth injuries
Shoulder dystocia
Delivery requiring additional OB manoeuvre to release
shoulder, after gentle downward traction failed. 1 in
200 (0.5%).
Path: head stuck at coccyx and pubic symphysis; cord
squashed in between.
RF: large (postdates) babies, maternal BMI > 30,
induction/ augmentation, prolonged stage 1 or 2,
assisted delivery (forceps), previous shoulder dystocia,
GDM (independent RF).
Associated: PPH, perineal tear, OBPI.
Management: as soon as it is identified, McRobert’s
manoeuvre should be performed (flexion and
abduction of maternal hips, bringing her thighs to her
abdomen), this rotation increases the relative AP angle
of pelvis. Suprapubic pressure is also applied.
Episiotomy won’t relieve bony obstruction but helps
with internal manoeuvres.
2nd-line: internal manoeuvre after McRobert’s and
suprapubic pressure fails. This includes Wood’s screw
manoeuvre (pressure behind posterior shoulder to
rotate it by 180o so it now lies anterior) or delivery of
posterior arm (grasp by flexion at elbow, baby’s hand is
brought down – so narrowing the diameter).
Last-line: lateral replacement of urethra by metal
catheter, symphysiotomy, Zavanelli (replace fetal head
by firm pressure of arm – reversing labour and
returning head to OA, then CS… irreversible fetal
acidosis at this stage).
Oxytocin is not indicated.
If baby died: cleidotomy (cut both clavicles) to deliver.
Suggest planned CS if previous macrosomic baby.
Erb’s palsy
Can result from shoulder dystocia (10X increased risk).
Pt: Baby arm is “waiter’s tip” posture.
DDx: clavicular #
Management: PT (if do not improve after 6m, unlikely
improve).
Moulding
Normal during VB. Skull bone overrides at suture.
Caput (succedaneum)
Normal from venous congestion 2o to pressure
during VB. Oedematous swelling of scalp, superficial
to cranial periosteum. Disappears in first days of
birth. A Ventouse form a chignon.
Cephalhaematoma
Fluctuant, subperiosteal swelling on fetal head.
Boundaries limited by individual bone margins (MC
over parietal bones). Spontaneous absorption (over
weeks) – may cause jaundice.
Subaponeurotic haematoma
Blood between aponeurosis and haematoma (not
confined to one bone margin so can cause anaemia
or jaundice). Associated with Ventouse.
Skull #
Associated with forceps or difficult 2nd-stage CS
where head impacted. Commonest over parietal or
frontal bones. Depressed # associated with CNS signs
e.g. CN VII palsy (neurosurgery consult).
Intracranial injuries
Associated with difficult or precipitate labour,
instrument, and breech. Esp. in premature babies.
Excessive moulding and sudden pressure changes
reduce cushioning effect of CSF.
Anoxia can cause intraventricular haemorrhage;
asphyxia causes intracerebral haemorrhage (often
petechial), resulting in cerebral palsy. EDH, SDH, SAH
all can occur.
Pt: convulsions, cyanosis, apnoea, bradycardia,
hypotonia, abnormal neurology.
Management: check fetal platelets (if low, check
mum platelet allo-antibodies, PLA1 system).
Subsequent babies at risk (PPx maternal IVIg). For
this baby, support + expectant management in NICU.
Fetal laceration
1-2% CS deliveries. More common with breech CS
delivery and CS after membrane rupture (as baby
skin lies flush against uterus). Most are superficial
and heal without scarring.
  Apgar score = assess newborn immediately after birth (10 points score at 1 and 5 minutes). Each
criteria have a score of 0 / 1 / 2 (max score =10). Score of 0-3 is very low (1-min score may be
transient, and is re-assessed at 5 mins. However, 5-min score remaining 0-3 suggests likely
permanent neurological damage e.g. CP). A score > 7 is normal.

Appearance = skin colour (blue all over / pink body + blue limbs / all pink)
Pulse = HR (0 / <100 / >100)
Grimace = reflex irritability on suction (none / grimace / cries, sneezes, or coughs)
Activity = muscle tone (absent or floppy + frog-like / limb flexion or some / active)
Respiratory effort (absent / irregular and slow / strong and crying)

 Neonatal resuscitation

Term gestation; amniotic fluid clear; breathing or Transient tachypnoea of newborn

crying; good muscle tone  routine care (warmth,
dry, A if necessary, assess colour + O2 if cyanosis
persist). Delay cord clamping by 1 minute.
If don’t meet above criteria:
A – Warmth + dry, clear airway (jaw thrust;
meconium + unresponsive  suction of
oropharynx under direct vision), stimulate,
reposition (head on back, head in neutral).
If vigorous – do nothing. Assess Apgar.
If apnoeic or HR < 100/min
B – Not breathing adequately by 90s = 5
inflation breath with Neopuff BVM or
consider tracheal intubation. Either method,
PPV = 30 cmH2O for 2-3 seconds. Then
reassess
 If HR increase = success.
 If increase but not breathing on
own = regular 30-40/min
breaths.
 HR remains slow (< 60) = fail.
If HR < 60/min despite good passive chest
movements
C – ensure A + B, start compressions (both
hands encircle chests, finger over spine,
thumb at lower sternum). Rate = 100/min,
compress AP diameter by 1/3. The
compression: inflation ratio = 3:1.
If still HR < 60/min
D – Drugs e.g. adrenaline (1 in 10000),
bicarb (4.2%), and dextrose (10%; check
BM). Volume replacement if acute blood
loss. Umbilical venous catheter for
emergent central assess.
Excess lung fluids, resolve by 24h. Associated w CS.
Hyaline membrane disease
Deficient alveolar surfactant production in premature
babies, causing atelectasis. Respiratory failure due to
exhaustion from re-inflating lungs. Prevention: maternal
IM steroids 2 doses (23-35/40). Management: NICU,
ventilation, inositol.
Clinical Rhesus
At worst, hydrops fetalis. Tx anaemia-associated CCF with
transfusions, vitamin K, furosemide, limit IVF.
Vitamin K deficiency bleeding
Occurs 2-7 days post-partum. As baby do not have
enteric bacteria to make VK. Pt: baby is well but
bleeding/bruising. Dx: PT/APTT elevated. High risk
infants: asphyxia, bleeding, cholestasis, maternal liver
disease, maternal usage of carbamezapine,
phenobarbital, phenytoin, rifampicin, or warfarin.
Prevention: VK 1 mg (0.4mg/kg if prem) IM to all.
Meconium aspiration syndrome
Term or near-term infants when meconium passed in
utero. It is respiratory distress which otherwise cannot be
explained. Tx: endotracheal suctioning (if not vigorous at
birth). Surfactant, ventilation, NO, Abx may be needed.
Necrotising enterocolitis
Inflammatory necrotic bowel. RF: prematurity associated
+ LBW, enteral feeding, mucosal injury, bacterial
colonisation. Pt: distension, mucus/ blood PR. If severe –
sudden distension, peritonism, shock. XR = pneumatosis
intestinalis (pathognomonic).
Tx: stop PO feed (except probiotics), culture faeces, X-
match, ceftotaxime + vanco. Surgery if perf.
Sepsis (early and late)
Early-onset = Prolonged ROM > 18h, maternal
infection, GBS carrier, pre-term labour, fetal distress,
breaks in skin or mucosa. Tends to be acquired
organisms from mum = GBS, E. coli, Listeria,
anaerobes, H. flu, HSV, Chlamydia.
Late-onset = lines, CM, severe illness, malnutrition,
immunodeficiency. Tends to be environmental bugs
e.g. coagulase negative staph, SA, E. coli, GBS.
DIC
Pt: sick as shit, petechiae, venepuncture oozing, GI bleed.
Ix: low platelets and fibrinogen, high INR/PTT/D-dimer,
schistiocytes on film.
Tx: underlying cause e.g. NEC, sepsis. Slow vitamin K +
platelet transfusion. Cryo + FFP + heparin + protein C.
Exchange transfusion is last resort.

Management: ABCDE + sepsis-6 (including LP).

Early  empirical: benzylpenicllin + gentamicin
Late  empirical: flucloxacillin + gentamicin
Pre-term + CVP line (coag –ve staph)  source
removal + vancomycin
If meningitis suspected  ceftriaxone
If Listeria suspected (purulent conjunctivitis, maternal
infection)  ampicillin or amoxicillin.
If conventional Tx fail  ?fungal
 PUERPERIUM
 Perinatal psych
Large cause of postnatal maternal death. AN
problems no more risky, but predisposes PN
problems. RF: vulnerability, hyperemesis, pre-existing
mental illness. Lower SES = more PND; older primip =
more suicide.
Normal mood changes
Baby blues – transient, self-limiting condition (75%
primips). It is not hormonal. Pt: 3-5 d postpartum as
tearfulness, anxiety, insomnia, fatigue, or irritability.
This persists for up to 2 weeks. RF: anxiety and low
mood in T3. Tx: reassurance + support (health visitor).
Post-partum thyroiditis – test TSH, fT4 as well.
Post-natal depression
Depression occuring 4-6 weeks postnatally. Peaks 3m.
Affects 10-15% women (10% mild/moderate, 3%
severe)
Risk greater if Hx postpartum abnormal mood
changes (50%), or pre-existing unipolar or BPD (25%).
Natural Hx: most resolve in < 6 m.
Pt: core depression Sx (low mood, anhedonia) +
biological Sx (lose sleep + appetite + concentration) +
cognitive Sx (worthless, helpless, suicidal).
Ix: Edinburgh PN depression scale (EPDS): 10-item
test – how mum felt over previous week, with an
item on self-harm. Max score = 30. Score > 10 =
possible depression. Score > 13 = depressive illness of
varying severity.
Tx: reassurance + support. CBT 1st (= SSRI). If Sx
severe – try certain SSRIs (sertraline, paroxetine – has
low milk/plasma ratio). Avoid fluoxetine (long half-
life). S/Es: probably safe, but can cause PHTN and
withdrawals.
Recur: 35% in future pregnancies. 60% relapse.
Anxiety
Not a Dx (many anxiety disorders including tokophobia =
fear of pregnancy and birth, needle phobia, OCD, and
PTSD). Co-exist with depression.
Ix: GAD-7. Reassurance. Don’t give BZDs (dependency +
sedation; if use AN – cleft lips and palate).
Puerperal psychosis
Psychiatric emergency. Affects 0.2% (1 in 500). Peaks
at 2 weeks to 1 month.
Pt: sudden, severe psychotic episode with affective
Sx (severe mood swings like BPD) and disordered
perception (auditory hallucinations). There can be
confusion (unlike most psychosis), low self-esteem,
delusions of guilt, and abnormal beliefs. Infanticide is
very rare.
Tx: admit to hospital (+ maternal-baby unit). Meds
(mood stabilisers + anti-psychotics e.g. lamotrigine
and long-acting BZDs). Support. Upon discharge,
refer to local mental health services (crisis plan) +
health visits.
Recur: 20%.
Couvade syndrome
Pregnancy Sx in father. Neurotic/somatoform
phenomenon. Resolves PN.
Pseudocyesis
Pregnancy Sx in absence of true pregnancy (swollen
abdo, amen, breast enlargement). RF: pregnancy
loss, infertility, and social isolation.
Substance abuse
1%. Worsens all risk (suicide, mental + physical).
RF: social vulnerabilities (pregnancy = window)
EtOH: FAS, opiates: withdrawal implications (switch
to methadone, buprenorphine) as baby cannot
handle sympathetic overdrive from withdrawal.
Consequences
Maternal: mortality (high-functioning, previous
attempts, rapid onset, late pregnancy + early PP);
morbidity (relapse and future pregnancies).
Child: Psych (IQ, cognition, emotional regulation.
Risk doubled in severe maternal anxiety. Teenage
depression). Physio (LBW, asthma, reduced
immunity, soft neuro signs, decreased telomere l).
Child abuse.
  Breastfeeding
Breast and milk production
HPL and bHCG fall rapidly and becomes undetectable
by day 10. Progesterone falls with delivery of
placenta.
Colostrum produced from ½ way through pregnancy
but the high progesterone inhibit milk secretion and
keep volume down. Colostrum is secreted in 2-3 days
after delivery (rich in WBC and Ab esp. sIgA and fat-
soluble vitamins). The milk “comes in” (mum feels it)
after 2-3 days (transitional then matured milk at week
2).
Breast engorged between 2-4 days, increased
vascularity, increased areolar pigmentation, increase
in # and size of alveoli (enlarged lobules).
Milk production is a use it or lose it process.
Milk composition
 70 kcal/ 100 mL
 7% lactose and oligosaccharide
 4% milk fat (via reverse pinocytosis)
 1% proteins including sIgA, lysozyme (via
transcytosis).
 0.2% minerals (via exocytosis and apical
transport).
 Cells e.g. WBC, epithelial cells (via extravasation).
Encourage feeding as soon as baby needs it. Lower
lip of baby below nipple so that it is drawn into
mouth. This prevents insufficient milk, engorgement,
mastitis, and nipple trauma.
Benefits to baby
Less GI illness (D+V, constipation); fewer chest, ear,
urinary infections; reduction risk of leukaemia,
Hodgkin’s, neuroblastoma; reduced adult obesity
and TIIDM; less chance atopy.
Benefits to mum
Reduces PPH (uterine involution); exclusive
breastfeeding is natural contraceptive (99% at 6m);
uses 500 cal/day; lower risk of pre-menopausal
breast and ovarian CA, and osteoporosis.
Other benefits
Cost-saving, on-demand feed (= cannot overfeed),
bonding.
Contraindications
HIV+ mum in developed countries (use bottle
feeding).
 After delivery:
1. Mum and baby should not be separated. Ensure privacy.
2. Breastfeed.
3. Early mobilisation.
4. Check daily: lochia (sloughed off necrotic decidual layer + blood, 3-6 weeks), involution,
BP, To, pulse, perineal wound (heals by 4 weeks), and fluid balance.
5. Analgesia and pelvic floor exercises.
6. FBC before discharge (Fe + laxatives if needed).
7. MW/doctor who delivered should visit. GP alerted to any complications.
8. Contraception advice.
9. Psych.

 6-week postnatal check

1. Check how mum and baby relate.
2. BP and weight (BMI).
3. FBC if anaemic postnatally.
4. Arrange smear if due.
5. Check contraception.
6. Ask about depression, backache, bowel or urinary incontinence, retention, constipation.
7. Ask if resume intercourse. Recommend abstinence or gentle intercourse for 1st 6 weeks
PP to prevent air embolism.
8. PVE to check healing – not needed unless women concerned or incontinent.

 Post-partum changes
1. Genital – uterus contraction (involution) to occlude blood vessels. Size decrease over 6
weeks (no longer palpable over by 10 days). Internal os close by day 3. Contractions and
after pain up to day 4. Lochia: blood-stained 4 weeks  yellow-white. Menstruation is
delayed by lactation. If not lactating, return by 6 weeks.
2. Cardio – CO and plasma volume decreases within 1 week. Oedema resolution takes up to
6 weeks. BP back to normal in 6 weeks if elevated transiently).
3. Urinary – physiological dilation returns to normal over 3 months. GFR falls so urea +
electrolyte back to normal.
4. Haem – Hb + HCT increases with haemo-concentration. WCC fall. Platelet and clotting
factors increase (thrombosis risk).