Neonatology for Obstetricians: Initial Steps

Neonatology for
Obstetricians
Col Karthik Ram Mohan
Neonatologist
CH(SC)

Why this Class ….
• Zonal/peripheral hospitals usually have
only one Pediatrician
• Some hospitals don’t have Pediatricians
• Obstetrician can manage most common
neonatal problems
• “The Final diagnosis” (1959)

Maternal Data
• Diabetes, Htn, TB
• Bld Gp, VDRL/HBsAg/Anti-HCV/HIV/TORCH, ROM, Sepsis Risk factors
• MSL, FHR Problems, Fetal Movements, Liquor Status, Antenatal USG
• Problems in previous pregnancies
• Antenatal Steroids, Antenatal MgSO4, Maternal Antibiotics/
Medication, Any Maternal Concerns.

Ensuring
immediate access
to supplies & eqpt

DCC (Delayed Cord clamping)
• for >30 secs
• Benefits in Preterm: higher BP & bld volume, ↓ IVH, NEC, Bld Txn
• Benefits in Term: may ↓ IDA and may improve neurodev outcomes

Cord Milking
• ‘Intact cord milking’: 3-5 times→ After milking → cord is clamped &
cut → infant can be taken to the resuscitation area.
• ‘Cut cord milking’: Cord clamped & cut (length ~25 cm) → infant is
taken to the resuscitation area immediately → milking occurs during
resuscitation or stabilisation.
• Where DCC is not possible cord milking should be considered
in infants >28 wks gest.
• For infants born at <28 wk of gest, cord milking is not
recommended

2 Vital
characteristics
(After initial
steps)

INITIAL STEPS
• Warm,
• Dry the infant (unless preterm and covered in
plastic wrap),
• Stimulate the infant to breathe
• Position the infant in a “sniffing” position to open
the airway
• Suction if needed

INITIAL STEPS
•Warm,
plastic wrap),
the airway

Temperature in the Delivery Room
• Admission temp of newly born non-asphyxiated infants: strong
predictor of mortality at all gest ages. Preterm infants are especially
vulnerable.
• Hypothermia assoc with: ↑IVH, resp issues, hypoglycemia, and LOS.
• Recommended temperature of baby: 36.5 - 37.5°C
PLEASE SWITCH OFF THE AC!!

Interventions to Maintain Newborn Temperature
• Increased room temperature
• skin-to skin contact or KMC
• Radiant warmers
• clean food-grade plastic bag
• Cap
• thermal mattresses,
• Use of warmed humidified resuscitation gases
• Hyperthermia (>38°C) should be
avoided

Thermal regulation: Stabilizing preterm neonates in
sterile plastic bags

INITIAL STEPS
• Warm,
•Dry the infant (unless preterm and covered in
plastic wrap),
the airway

INITIAL STEPS
• Warm,
plastic wrap),
•Stimulate the infant to breathe
the airway

Acceptable
methods of
stimulating
a baby to
breath

INITIAL STEPS
• Warm,
plastic wrap),
•Position the infant in a “sniffing” position to
open the airway

INITIAL STEPS
• Warm,
plastic wrap),
the airway
•Suction if needed

Clearing the Airway: (A) Amniotic Fluid Is Clear
• Suctioning immediately after birth: considered only if the airway
appears obstructed or if PPV is reqd.
• Avoiding unnecessary suctioning: Risk of induced bradycardia

Clearing the Airway: (B) MSAF
• If vigorous with good respiratory effort and muscle tone → baby
stays with mother → Routine care
• If poor muscle tone and inadequate breathing efforts → initial steps
of resuscitation under the radiant warmer → Further steps as reqd
• For nonvigorous newborns (presenting with apnea or ineffective
breathing effort) delivered through MSAF, routine laryngoscopy with
or without tracheal suctioning is not recommended …
• but can be beneficial in babies who have evidence of airway
obstruction while receiving PPV

To Remember- INITIAL STEPS
• Warm,
plastic wrap),
the airway

Preterm- Initial Steps
• Preterm babies should have the initial steps of
newborn care performed under a radiant warmer.
• Late-preterm gest (34-36 wks) with stable vitals &
good respiratory effort → baby can be brought to the
mother within several mins to continue transition.

Indications for PPV
1. Apnea (not breathing)
2. Gasping
3. Heart rate <100 bpm
4. Oxygen saturation below the target range despite free-flow
O2 or CPAP
• Assisted ventilation should be delivered at rate of 40-60/min
to promptly achieve or maintain a HR>100/min
• VENTILATION OF THE LUNGS IS THE SINGLE MOST
IMPORTANT & EFFECTIVE STEP, REGARDLESS OF THE
CONCENTRATION OF OXYGEN BEING USED!

Positive Pressure Ventilation Devices

Oxygen Administration
1 min: 60-65 %
2 min: 65-70 %
3 min: 70-75 %
4 min: 75-80 %
5 min: 80-85 %
10min: 85- 95%
• Term Infants: initiate resuscitation with
air (21% O2). Suppl O2 may as reqd.
• Preterm (<35 wks gest): initiate
resuscitation with low O2 (21-30%).
Suppl O2 may as reqd.
• Oxygen saturation value in the
interquartile range of preductal
saturations

Birth Weight
• In a well baby born by NVD, check wt when mother is being shifted
from labor table.
• Put a sterile sheet on the weighing scale before checking wt
Birth wt classification
1) Normal birth wt (NBW): From 2,500 to 4,000 g.
2) LBW: < 2,500 g.
• VLBW: < 1,500 g.
• ELBW: < 1,000 g.

Examination of Baby
• History, Case Sheet, Antenatal
Reports
• General Exam: Vitals,
Anthropometry, Gestation, Wt, PI,
CAN Score
• Head, Eye, Mouth, ENT
• Genitals, Extremities, Spine, Skin
• Systemic Exam: Resp, CVS, CNS,
Abdo
• Placenta
Don’t Miss!
• Dysmorphisms
• Cleft palate
• MMC
• ARM
• Hypospadias
• Micropenis
• Undescended testes
• Birth injuries

Rapid confirmation of Term status
1. True plantar creases over at least 2/3rds of foot
2. Stiff ear cartilage
3. Full areola with breast buds of 5-10mm
4. Resting posture of full flexion

Patency of esophagus
Should be ascertained at birth in:
1. Presence of polyhydramnios.
2. Antenatally suspected esophageal atresia or diaphragmatic hernia.
3. Excessive frothing
4. Presence of vertebral or anorectal anomalies (VACTERL association)
• Performing routine stomach wash in babies to prevent gastritis
(amniotic fluid or meconium) should not be done.

Vit K Administration
• Birth Wt < 1000 gms: 0.5 mg
• Birth Wt ≥ 1000 grams: 1 mg
• IM injection using the 26G (1/2 inch) needle and a 1 mL syringe on
the anterolateral aspect of the thigh.
• Preferable to administer K1, however if not available, Vit K3 may be
administered

Hypothyroidism Screening (ISPAE)
• Screening should be done for every newborn using cord bld (Preferable),
or postnatal bld, ideally at 48-72 h of age.
• Sick babies should be screened at least by Day 7 of life.
• Preterm and LBW infants should undergo screening at 48–72 h postnatal
age.
• CHSC Practice: In well babies, send cord blood TSH. In preterms & Sick
babies, do TSH prior to discharge
• Neonates to be recalled for confirmation:
• Cord TSH >20 mIU/L or
• >34 mIU/L for samples taken b/w 24-48 h of age

NICU Admission policy
(1) Wt < 1,800 gm,
(2) Gestation <35 wks
(3) Neonate who is not able to take
feeds from the breast or by
katori- spoon (irrespective of
birth wt and gest)
(4) A sick neonate (irrespective of
birth wt and gest)
(5) Birth Asphyxia with:
i. APGAR ≤3 at 1 min or <7 at 5
min,
ii. Bag & Mask vent for > 1min,
iii. Use of intubation/ chest
compression/ medication

Labour Room points
• High Risk Pregnancies: Check Mother’s case-sheet and antenatal reports in
all cases
• Resuscitation Eqpt (Labour Room & OT) to be kept ready at all times.
• Collect Cord Blood TSH for all babies, except Sick/Preterm/LBW in whom it
will be done prior to discharge.
• All Rh Negative Pregnancies: Send Cord Bld CBC, Bili, Bld Gp, DCT
• If baby is well, place baby on mother’s abdomen immediately after delivery.
Let baby attempt breast crawl.

Labour Room Points (Contd)
• Baby to be taken to radiant warmer only if resuscitation reqd. In all
other cases, baby will remain with mother, even when episiotomy is
being stitched (Unless mother is non-cooperative)
• Weigh baby only after the mother is being shifted to postnatal room
(Put autoclaved newspaper on the weighing scale)
• Especially monitor feedings of: (1) LBW, Preterm & IUGR babies,
(2) IDM, (3) LGA Baby
• If Mother shifted to ICU/OT and baby is well: Arrange for relatives to
look after baby
• Very Premature: resuscitate & manage accordingly

Labour Room- Radiant warmer
• AFTER RESUSCITATION, DO NOT LEAVE BABY UNDER RADIANT
WARMER WITHOUT SKIN/AIR PROBE FIXED AND SETTING MADE.
BABY MAY GET BURN INJURY.
• Make sure that probes have not slipped off. Can fix probe to limbs.
• Skin Mode: Use in unstable baby and initial mgmt of preterm
(<1.8kg). Set at 36.5C and adjust accord to axillary temp.
• Birth Asphyxia: Avoid hyperthermia

Defns of Gestational Age Periods
<28 wks: Extremely preterm, 34 - 366/7wks: Late preterm
28 - 316/7 wks: Very preterm, 37 - 416/7 wks: Term
32 - 336/7wks: Moderate preterm, >42 wk: Post-term
[Early term (37 – 386/7wk), full term (39 – 406/7wk), and late term (41 – 416/7wk)]

Age
Terminology
During the
Perinatal
Period
Term Definition Units of Time
Gestational age Time elapsed b/w the 1st day of the LMP and the day of delivery Completed wks
Chronological age Time elapsed since birth Days, wks, mths, yrs
Postmenstrual age Gestational age + chronological age Wks
Corrected age Chronological age reduced by the no of wks born before 40 wks of gest Wks, mths

Extreme Prematurity- Viability
(ADC)

Extreme Prematurity- Guidelines for Decision
making (ADC)
• For fetus/babies at extremely
high risk, palliative (comfort
focused care) would be the usual
mgmt.
• For fetus/babies at high risk of
poor outcome, the decision to
provide either active (survival
focused) mgmt or palliative care
would be based primarily on the
wishes of the parents.
• For fetus/babies at moderate
risk, active mgmt should be
planned.

Extreme Prematurity-
Indian Guidelines

Extreme Prematurity- Indian Guidelines
• AIIMS Protocol:
• Offer comfort care for neonates with gestation ≤23 wks and
• Individualise decision at 24 wks gest and
• Routinely provide care to infants of ≥25 wks gest.
• CMC, Vellore: Active neonatal intervention is offered to infants >25 wks
gest age (GA).

Indications
for routine
Blood
glucose
monitoring

Blood glucose monitoring schedule
Category of infants Time schedule
1 At risk neonates 2, 6, 12, 24, 48, and 72
hrs
2 Sick infants (Infants with sepsis, asphyxia,
shock during active phase of illness)
Every 6-8 hrs
(individualize as needed)
3. Stable Neonates on parenteral nutrition Initial 72 h: every 6-8 hrs
After 72 hr: once a day
4. Infants exhibiting signs compatible with hypoglycemia should be
investigated SOS

Neonatal Transport
• Warm Chain

Breastfeeding
• “Ideal food” for Babies
• Normative practice for infant feeding
and nutrition.
• Exclusive breastfeeding for 1st 6 mths
of life, with continued Breastfeeding
till minimum 2 yrs age
• ↓ U-5 mortality by 13%
• Breastfed baby is 14 times less likely
to die of diarrhea and 4 times less
likely to die of Respiratory infection
• “Anewbornbabyhasonly3demands.Theyare
warmthinthearmsofitsmother,foodfromher
breasts,andsecurityintheknowledgeofher
presence.Breastfeedingsatisfiesall3.(Grantly
Dick-Read)

Signs of Good Attachment
1) The baby's mouth is wide
open
2) Most of the nipple and areola
in the mouth, only upper
areola visible, not the lower
one
3) The baby's chin touches the
breast
4) The baby's lower lip is everted

Breastfeeding positions after cesarean delivery

Ten Hospital Practices to Encourage and Support
Breastfeeding (UNICEF-WHO)
1. Have a written breastfeeding policy that is routinely communicated to all health care
staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help women initiate breastfeeding within 1 hour of birth.
5. Show women how to breastfeed and how to maintain lactation, even if they are
separated from their newborns.
6. Give newborns no food or drink other than breast milk unless medically indicated.
7. Practice rooming-in; allow mothers and newborns to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer to them on
discharge from the hospital or birth center.

Components Of Safe Positioning For The
Newborn While Skin-to-skin
1. Infant's face can be seen.
2. Infant's head is in “sniffing” position
3. Infant's nose & mouth are not
covered
4. Infant's head is turned to one side
5. Infant's neck is straight, not bent.
6. Infant's shoulders & chest face
mother.
7. Infant's legs are flexed.
8. Infant's back is covered with blankets
9. Mother-infant dyad is monitored
continuously by staff
10. When mother wants to sleep, infant is placed in
bassinet or with another support person who is awake
and alert.

Practices that improve breastfeeding initiation
(Labour Room)
• Immediate postpartum mother–infant skin-to-skin contact with
suckling,
• Start Breastfeeding within 30 min of birth.
• Delay in routine procedures (weighing, measuring, bld tests,
vaccines, and Vit K) until after the 1st feeding is completed

Practices that encourage successful
breastfeeding (Postnatal Ward)
• Rooming-in arrangements,
• Demand feeding,
• Inclusion of fathers in breastfeeding education
• Support from experienced women
• Back massage for stimulating lactation
• Domperidone (Not Metaclopramide)

Management of Inverted Nipple
Manual method Syringe Technique

Adequacy of feeds
• Passage of urine: 6-8 times in 24 hrs
• Baby sleeping well: for 2-3 hrs after feeds
• There is no excessive wt loss

Breastfeeding Points …
Consultant Permission Reqd for:
• Nipple Shield Purchase
• Breast-pump Purchase
• RCM Administration: Has to be a written order
• Avoid RCM in large ward-room. Preferably keep patient in separate
room.

What are the Risks of
artificial feeding?
“Nipple Confusion”

Hypo/Hyperthermia- Clinical Assessment
Situation Abdomen Feet Impression
Hypothermia Warm Cold Cold Stress/ Mild/
Moderate
Hypothermia
Hypothermia Cold Cold Severe Hypothermia
Hyperthermia Warm Warm ? Overheating
Hyperthermia Warm Cold ? Sepsis

Neonatal GI Bleed
• If sick, shift immediately to NICU.
• If well, do APT test immediately. If APT
positive (for Baby blood), shift to NICU.

Bilious Vomiting
• First check colour of Mother’s milk.
• If bilious vomiting confirmed → Xray Abdo Erect View →
USG Abdomen (Also consider SMV & SMA Doppler) →
Paed Surg Opinion →
If Inv WNL, Observe in KMC Room →
If Rpt Bilious Vomiting →
Shift to Surgical NICU

Postnatal ward- discharge criteria
• Not until Fully breastfeeding
• Primigravida: 72 hrs
• Multigravida: 48 hrs
• IUGR/SGA/IDM: At least 72 hrs
• Late-Preterm: 1 week (Personal Practice)
• Final Decision for discharge to be made during morning round. Tell
parents to arrange for vehicle only after morning round

Interim Discharge policy for Civil maternity
ward (14.11.22)
• Primi, LGA, SGA, IDM and any baby requiring blood sugar
monitoring: 72 hrs
• Late preterm: shift to the mother's room of pediatrics wd after 72hrs.
• Multigravida well baby: discharge whenever the OBG are discharging
the mother. Call back to civil OPD at 48hrs for review.

Immunisation Advice
• Document Birth Hepatitis B
in the Case-sheet and Child
health Record
Book/Immunisation Card
• Immunisation in Wards on
Tuesday & Fridays
• Paed Service OPD:
Immunisation Daily (BCG &
MR on Tue & Fri)
• Paed Civil OPD:
Immunisation on Saturdays

Child health Record Book, Immunisation Card
• Fill Child health Record Books for
Service patients
• Ensure Immunisation Cards for Civil
Patients

Discharge Advice: MCP CARD (2018)
• Keep the baby warm.
• Start breastfeeding within 1 hr of birth
• Feed the baby only mother’s milk
• Do not bathe the baby for the 1st 48 hrs
• Keep the cord dry
• Keep the baby away from sick people
• Special care if baby < 2.5 kg at birth

Discharge Advice: Contd
• Exclusive Breast-feeding for 6 mths. Start semisolid foods at
completion of 6 mths age. Breastfeeding for Minimum 2 yrs. Never
Bottle-feed the baby.
• The umbilical stump: should be kept dry and devoid of any
application.
• Bath: If Wt >2.5kg, else sponge the baby daily.
• Oil Massage: Recommended with coconut/olive oil. Avoid Mustard
oil.
• Talcum powder application: should be avoided
• Disposable Diaper: Only for “social” purposes

Discharge Advise: Contd
• Immunisation as per schedule: Info
patient about CH(SC) Immunisation days.
• Review in CHSC POPD at 2 days
• Review SOS in CHSC in case of Danger
signs
• No “screen time”: Till 2yrs age!
• Civilian Emergencies: Admission
Preferably during Working Hours

Danger Signs: MCP CARD (2018)
Contact your Health Worker immediately if
baby:
• Not able to feed
• Convulsion
• Fast breathing >60 breaths per min
• Severe chest indrawing
• Axillary temp ≥37.5º C (feels hot to touch)
• Axillary temp <35.5º C (feels cold to touch)
• Movement only when stimulation or no
movement at all.

Danger Signs: Contd
• Apnea
• Cyanosis
• Bleeding from any site
• Persistent vomiting
• Yellow vomiting & Abdo distension
• Excessive Crying
• Severe Jaundice (Yellow staining of palms
& soles)
• <4 urinations per day after day 3, Not
passing urine for >12hrs

Ensure before routine discharge
• Birth Wt, Length, HC, Gestation, PI (If
indicated), CANS Score, Discharge Wt
• Critical CHD check (SpO2 screen)
• Discharge: Notes/ Slip/ Summary/
Neonatal follow-up book/ CHSC Follow-
up Book
• Immunisation: Child health Record book/
Immunisation card
• Check discharge diagnoses on
discharge documents made by
wardmaster.
• Maintain all info in postnatal register
• Discharge Prescriptions &
Medications
• Remember to coordinate Mother and
Baby discharge !
• Discharge advice
• BPNI Handouts
• Danger signs charts
• Hearing screen advice
• TSH report Collection

Routine
Discharge
Summary
(Postnatal
Ward)

Follow-up Visit @ 2 Days
• Ask: Any Problems? How is Breastfeed/ Urine Output/ Stool Colour?
• Check: Weight, Jaundice, Dehydration, Quick examination, TSH Report
On Follow-up: After initial wt loss, one should be worried about the
adequacy of the breastmilk if while on the exclusive breastfeeding:
• does not gain birth wt by 2 wks of age, or
• cumulative wt gain is <500 gm in a mth or
• passing small amt of concentrated urine <6 times a day

Neonatal Jaundice- What to ask & see
Ask
• Age
• Preterm/Term
• Mother bld gp
• Feeding, Urine output
• Family history
See
• Kramer Stage
• Wt Loss
• Sick/Well
• Cephalhematoma
• Hepatosplenomegaly
• ‘BIND’ Score

CHSC Practice- Inv in Neonatal Jaundice
• Send Serum Bilirubin and Start PT immediately for “Serious
Jaundice”: (1) Icteric within 24hrs, (2) feet/palms stained anytime, (3)
Signs of ABE: Hypertonia, convulsion, fever, high-pitched cry,
abnormal posturing (arching, retrocollis, ophistotonus)
• Send Serum Bilirubin* and then decide phototherapy : If (1) Bilirubin
appears more than PT Threshold, (2) Icteric till legs, (3) cannot make
out color
(* In these cases, can do TcB if available and send bili if TcB>15 or >PT
Cutoff)

CHSC Practice- Inv in Neonatal Jaundice
• If Hemolytic Disease suspected, also send: (1) CBC, Retic & PBS,
(2) Bld Gp & DCT
• If Wt loss >10% or C/F of Dehydration present: Urea, Creat, Na
• If ≥ Day 5: Do T4, TSH
• G6PD: If suggested by ethnic/geographic origin or/& poor response to
PT
• All Rh Negative Pregnancies: Send Cord Bld CBC, Bili, Bld Gp, DCT
• Sepsis screen only if sepsis is suspected.

CHSC
Neonatal
Jaundice
Case-sheet

Mgmt of NNJ ≥35 Wks Gest [AAP 2022]- Phototherapy

Mgmt of NNJ ≥35 Wks Gest [AAP 2022]- Exch Transfusion

CHSC Practice: NNH in Preterms - NICE
Guidelines

Phototherapy
• Ensure that baby is kept below the light

Covering Phototherapy Device
• Consider in cold weather. Avoid in summer.
• Do not cover the “Fan” of the Phototherapy unit.

CHSC Neonatal jaundice points
• If bilirubin:
Above PT line: SSPT
Within 3 mg of ET line or not improving with SSPT: DSPT
Above ET line: Inform Consultant telephonically Immediately. Shift to NICU.
Give DSPT (Or TSPT) + aluminium foil, Remove Diaper, No stopping PT for
breastfeed (“Crash-cart Phototherapy”)
Exchange Transfusion: is performed if intensive PT has failed to reduce bili
levels to a safe range and the risk of kernicterus exceeds the procedural risk.
The appearance of clinical signs suggesting kernicterus is an indication for ET at
any level of serum bilirubin.

Contd CHSC Neonatal jaundice points
• Oral Feeds: Supplement if Dehydrated/ Inadequate feeding
• IV fluid: Consider if bili approaching/above exchange line +
dehydration or rapidly ↑ Bili. 50mL/kg NS over 8 hrs
• IVIg: In isoimmune hemolytic disease and a TB rising despite intensive
PT or rising to within 2-3 mg/dL of ET level can consider IVIG (0.5-
1g/kg) and repeat if necessary (Controversial)
• Rpt Bilirubin: If Bili ≥ 20mg/dL (Unless the Cutoff is above 20)
• Documentation of “Exaggerated” Bilirubin reports:
“Sole/feet not stained, BIND ‘0’. Bilirubin reports appears erroneously
exaggerated and not correlating with clinical assessment of jaundice”

Antenatal Preparations for Suspected case of
Severe Rh Isoimmunisation
• Suspect Severe Rh Isoimmunisation if antenatal ICT ≥ 1:16 or
antenatal USG features of Hydrops.
• For Partial exch: 50ml/kg of O negative PRBC
• For DVET: 160mL/kg of either (i) ‘O’ Negative Cells suspended in ‘AB’
plasma OR (ii) ‘O’ Negative Whole Blood
• Must Discuss with Blood Bank in advance
• Ask OBG for delivery preferably during working hrs
• If suspected Hydrops: Keep Chest tubes and Needle for Ascitic tap
ready.

Rh alloimmunised infants - Indications for ET/PET
1. At birth, with a cord total serum bilirubin of ≥5 mg/dl or cord Hb ≤ 10 mg/dl OR
2. Subsequently when serum bilirubin crossed the ET threshold as per AAP chart
(≥35 wk gest) or NICE guideline (for <35 wk gest) and the rate of rise is >0.5 mg/dl/hr
despite PT OR
3. Any infant with hyperbilirubinemia and features of acute bilirubin induced
neurological damage (poor feeding, hypotonia, poor suck and shrilled/high pitch cry)
at any time during hospital stay.
Indications of partial exchange transfusion (PET): At birth, if baby shows signs of
hydrops or cardiac decompensation in presence of low PCV (<35%), PET with 50
mL/kg of PRBC should be done to restore O2 carrying capacity of bld, before doing
DVET.

Watch for “Late Peak” of Jaundice in Preterms

Neonatal Infections- Prevention &
Management

Investigations
• Sepsis screen (≥2)
• TLC < 5000/cu mm Sensitivity 93%
• ANC < 1800/ mm3 or Manroe charts Specificity 83%
• I/T ratio > 20 % PPV 27%
• micro ESR > 15 mm fall in 1st hr NPV 100%
• CRP > 1 mg/dl

• Blood culture – Gold standard
• Skin cleansing for minimum 30secs with chlorhexidine/ alcohol-iodine
• 1 ml blood for 5-10 ml culture media
• 72 hrs
• BACTEC/BACT ALERT
• Serum Procalcitonin
• Chest x ray
• CSF
• Urine Culture
Other Investigations…

ROM> 24 hrs
• Gastric aspirate for polymorphs in all cases of ROM>24hrs
• Send Septic screen if ROM associated with:
o Prematurity or LBW
o Birth Asphyxia (APGAR <4 at 1 min)
o Mother has suspected chorioamnionitis (fever, ↑TLC, etc)
o Gastric aspirate shows bacteria or numerous polymorphs
(Can use cord bld for sepsis screen)
Note: Send septic screen, bld culture and start antibiotics in all cases of
foul-smelling liquor or definite chorioamnionitis

Management
Supportive
• Warmth
• Oxygen/ CPAP/ ventilation
• Euvolemia (IV Fluids, inotropes)
• Normoglycemia
• PRBC/ FFP
• Optimal nutrition
• Vit K
Antibiotics
• Emperic (Unit specific policy)
• Specific

Indications for starting Antibiotics
EOS
(a) Presence of ≥ 3 risk factors for EOS
(b) Presence of foul smelling liquor
(c) Presence of ≥ 2 antenatal risk factor(s) and a positive septic
screen and
(d) Strong clinical suspicion of sepsis.
LOS
(a) Positive septic screen and/or
(b) Strong clinical suspicion of sepsis.

EOS- Risk factors
1. Spontaneous prematurity
2. Foul smelling liquor
3. Rupture of membranes >24 hrs
4. Single unclean or > 3 sterile vaginal examination(s) during labor
5. Prolonged labor (Duration of 1st & 2nd stage of labor ≥ 24 hrs)
6. Perinatal asphyxia (Apgar <4 at 1 min)
• Presence of foul smelling liquor or 3 of the above mentioned risk factors
warrant initiation of antibiotic treatment.
• Infants with 2 risk factors should be subjected to sepsis screen and treated if
sepsis screen is positive.
• If sepsis screen is negative and there is a lingering suspicion of sepsis, repeat
screen can be done after 12-24hrs.

CH(SC) NICU Antibiotic Policy (29.9.2022)
• DON’T START ANTIBIOTICS WITHOUT BLOOD
CULTURE
• Collect & preserve all culture reports
• Initial antibiotic: Piperacillin-Tazobactam +
Amikacin
• Use meropenem instead of Piperacillin-
Tazobactam if meningitis suspected.
• Use Vancomycin and Teicoplanin only if strong
suspicion of Staphylococcus sepsis
• Use Colistin or Tigecycline only based on
Culture reports.

Infant of HIV Positive Mother: CHSC Practice
• Get ARV Prophylaxis in advance (NVP/AZT Syrup)
• Coordinate with NACO
• Feeding as per AFASS Criteria.
• Testing of infant as per NACO protocol: PCR @ 6
wks, 6 mths, 12 mths or 6 wks after stopping
breastfeeding. Confirmation with Ab test at 18
mths.

Congenital Infections: Tests of Choice
Pathogen Test of choice Remarks
Toxoplasma Toxoplasma IgM by ELISA (Preferably performed at
>10 days age and which persists >1 mth of age) or
Toxoplasma IgG (Positive at >1 yr of age) or PCR
(Negative IgM & IgG: Cong Infection mostly ruled out)
Perform test before 3 wks
age. Preferably send
serology at > 10 days age.
Rubella Serum IgM Ab or PCR Cannot diagnose CRS
beyond infancy.
CMV Urine PCR or CMV IgM Perform test before 3 wks
age (To Label as
congenital infection)
HSV PCR of skin lesion, blood, CSF Preferably send at after
24-48hrs age

Neonatal Hypoglycemia,
Hypocalcemia and Seizures

Mgmt of
Neonatal
Hypoglycemia -
CH(SC) Practice

Hypoglycemia management: CHSC Practice
• Cut-off is Glucometer <40mg!
• If symptomatic: Be aggressive, start IV dextrose (Give
infusion immediately after bolus)
• If asymptomatic: No bolus
• If 2 consecutive Hypoglycemia reports (In asymptomatic
baby): Shift to NICU → oral EBM/RCM +/- oral dextrose
dextrose → start IV dextrose.
• Avoid central line in asymptomatic hypoglycemia

Mgmt of
Neonatal
Hypo-
calcemia

Neonatal Seizures
Neonatal Seizures (ICD-10-P90): Sudden alteration in motor, behavior
or autonomic activity, with or without alteration of consciousness.
Neonates At Risk For Seizures: Birth asphyxia, Sepsis, Meningitis,
Preterm, SGA, Metabolic or electrolyte abnormalities, Major bleeding

Identification of Neonatal Seizures
 Motor manifestations
• Rhythmic jerks of limb(s) or facial part(s)
• Tonic contraction of limb(s)
• Stereotypical movements of limbs, face, eyes
 Limbs: Pedalling, rowing, swimming, cycling, stepping
 Oral: Pouting of lips, mouthing, repeated sucking
 Eyes: Vacant stare, transient eye deviation, nystagmoid movements,
repeated blinking
 Behavioural manifestations: Sudden change in consciousness or cry
characteristic
 Autonomic manifestations: Fluctuations in HR, sudden change in BP, sudden
appearance of unexplained apneic episodes.

MGMT OF
NEONATAL
SEIZURES -
CH(SC)
PRACTICE

Management of Respiratory
Distress

Respiratory Distress
• NNPD defn: presence of any 2 of the foll:
1. RR >60/min
2. Subcostal/intercostal recessions
3. Expiratory grunt/groaning
• In addition nasal flaring, suprasternal retractions, decreased air entry
on chest auscultation also indicates the presence of resp distress

Respiratory distress- Etiology
Based in Maturity:
• Term Neonates: TTN, MAS, pneumothorax, pneumonia, RDS
• Preterm: RDS, sepsis, pneumonia, TTN, air leak, PDA
Based on time of onset:
• Onset at birth: TTN, RDS, pneumothorax or air leak, MAS, congenital
malformations
• Onset hrs to days later: Congenital heart disease, sepsis

Respiratory Distress scoring
DOWNES SCORE SILVERMAN SCORE

Respiratory distress- Score [CHSC Practice]
• Mild distress (1-3) but with cyanosis/desaturation: oxygen delivery
devices (oxygen hood or nasal prongs). (Preterm with
Grunt/Retractions: Consider Early CPAP/HHHFNC
• Moderate distress (4-6): CPAP/HHFNC.
• Severe distress (>6): intubation and mech ventilation.

CPAP
• Consider in Any preterm with grunt &/or retraction
• SAS/Downe score >3 (if score >6: Intubate & ventilate)
• CPAP: Start with 5cm, 50% FiO2 and Flow 5L/min.
• If RDS with FiO2 >40%: Consider surfactant
• HHFNC: “More Comfortable”
• CPAP: Preferred if ≤26 wks GA
• “Prophylactic” CPAP: Consider in <28wks gest
• MAS: Can consider HHHFNC/CPAP
(Watch for air leak)

Surfactant
replacement
therapy
(AIIMS Protocol,
2019)

Surfactant Dosing
Surfactant Source Phospholipid
content
(mg/mL)
Initial Dose
(mL/kg)
Rpt Dose
(mL/kg)
Availability Remarks
Survanta Cow Lung 25 4 4 4 mL, 8 mL
Curosurf Pork Lung 80 2.5 1.25 1.5 mL
Neosurf Bovine
Lung
27 5 3mL, 5 mL Upto 3 Rpt Doses
Alveofact Bovine
Lung
42 1.2 1.2 1.2 mL Upto 3 Rpt doses at
12-24hr intervals

Intubation & ventilation
• Failed CPAP/ HHFNC/
NIPPV/ NIV
• SAS/Downe score ≥7
• Resp failure
• Resp distress + shock

Preterm- Fluid guidelines
D1: 60-80 ml/kg/day
D2: 80-100 ml/kg/day
D3: 100-120 ml/kg/day
D4: 120-140 ml/kg/day
D5: 140-150 ml/kg/day
Fluid
D1: 10 % D, D2: N/5 in 5 or 10% D (Or Isolyte P)
< 1 kg: Consider Starting with 5% D at 80 ml/kg/day on D1

Apnea- Emergency treatment
Apnea (Raise Alarm)
Gentle Tactile Stimulations
Positioning, Gentle Oropharyngeal & Nasal Suction, O2 By Hood
PPV
Intubation And IPPV

ROP- Whom to Screen (CHSC Practice)
1. Gestation <34 wks or birth wt <1500 g
2. Birth wt <2000 g if reliable gest at birth not known
3. Gestation 34-36 wks AND Any of the following:
a) CPAP or ventilation for any duration
b) O2 therapy for ≥6 hrs
c) Episodes of Apnea
d) Inotropic support
e) Unstable Clinical Course
f) Needing bld transfusion or Exchange Transfusion
g) Sepsis
h) In absence of reliable records, admission in NICU or SCNU can be taken
as a surrogate risk factor.

ROP- When to Screen (CHSC Practice)
1. The first screening for ROP should be
performed at 4 wks postnatal age (PNA).
2. Exception: If baby stable, consider 1st Screen
at 3 wks postnatal age (PNA) if:
(a) Born at < 28 wks of gest or
(b) Birth wt <1200g if gest at birth is not
known conclusively

Preterm- Discharge Criteria
1. No life threatening illness/ significant apnea
2. Stable temperature
3. Gaining Weight on Oral feed (3 Days)
4. Confident mother

Preterm- Discharge Advice & FAQs
• ADVISE: Routine Discharge Advice +
Supplements (Multivit, Ca, Iron, Vit D),
Massage, Follow-up.
FAQs
• Bath: After 2.5 kg
• Oil Massage: Coconut/ Olive Oil
• KMC: Till 2.5kg or baby uncomfortable
• Vaccination

CH(SC)
Neonatal
Discharge
Checklist

The Late Preterm
• Late Preterm: A subgroup of infants born at 34 through 36 wks GA (238-258
days; 34 0/7 to 36 6/7 wks)
• They are still premature despite often looking relatively big!
• Monitor for poor feeding, hypoglycemia, neonatal jaundice.
• Consider discharge at 8 days age especially if coming from far-away as
jaundice peaks later in these babies. Else, review every day after discharge
till 8 days age.

Neonatal & Infant mortality by gest age

CHSC
Neonatal
Follow-up
Practice

Vaccination of Preterms
• Start vaccination before Day 15 or
at 6 wks age (Avoid b/w 15 days - 6
wks). Avoid different immunization
dates for twins.
• If <2kg and mother HBsAg negative:
defer Hepatitis B Vaccine till 2kg
• VLBW babies: Consider Influenza
vaccine at 6mths & 7mths
chronological age
• Personal Practice: Start Vaccination
after 2 kg wt

Early Intervention Centre CH(SC)

Advice to Mother of Baby with NTD
• Tab Folic acid 5mg OD beginning 1 mo before the time of the planned
conception and contd until at least the 12th wk of gest
• Screening for NTD in next pregnancy

Infant & Young Child Feeding -Recommendations
• Initiate breastfeeding within 1 hr of birth
• Exclusive breastfeeding for 1st 6 mths of life
• Introduce nutritionally adequate and safe complementary foods after
the infant reaches 6 mths of age
• Continue to breastfeed for 2 yrs or beyond

Umbilical Cord Blood Banking (UCB)
• UCB can be used for allogenic transplantation of an awaiting family
member (biological parents or sibling only) who is confirmed to be
suffering from an illness that can be cured by allogenic HSCT.
Thalassemia is an example where UCB from unaffected matched
sibling donor can be used for thalassemia transplants
• Because of limitations of autologous UCB, storage of cord blood for
personal use is not recommended

“CODE PINK” (CHILD ABDUCTION)
• All must read the SOP
• Responsibility of ALL staff members to always be alert for persons in all
areas who exhibit unusual behavior and to be aware of patients who may
be at risk due to family situations.
• Immediately raise “code pink” and must inform the Ward MO, HOD, DMO,
Brig IC Adm and Dy Commandant
• Details to be given as: “Code Pink, age, gender, area child missing from
and name (with the description of the child)”
• During a CODE PINK, it is the responsibility of the hospital staff to stop and
question anyone with children, bulky packages, suitcases, baby in their
arms, wearing a heavy coat or jacket, or anyone who may appear
suspicious.

“Indian” Neonatology
• Sepsis, Sepsis, sepsis
• Equipment malfunction
• “Jugaad”
• Lab Errors
• Social Problems
• Yet, babies can & must be saved!

Please ….
• Give Antenatal steroids where indicated
• Consider Antenatal MgSO4
• Inform Pediatrician of any High-Risk
Patient/ Delivery
• Call Paediatrician to attend delivery where
required
• Take out “Good” baby at “Suitable” time
• Avoid delivering ≥2 High-risk cases on the
same day/night
• Joint/ Same counselling of parents

“High Risk Cases” include…..
• Congenital Diaphragmatic hernia
• Preterm Twins/Triplets
• “Late-Preterm” babies!

Transferring a Baby ….
• Discuss with Pediatrician/ Neonatologist.
• If stable: With Nursing Officer
• If “Unstable”: With Medical officer + Nursing Officer
• If Respiratory failure/Severe Shock: Call Anaesthetist to intubate & ventilate
• Keep phone number of Civil Neonatologist (Govt/Private)
• Medical college may not have ventilator available
• Difficult for patients to claim costs
• “All is well that ends well”

Thank You!!
Col Karthik Ram Mohan:
• 8336926559
• 8106437850 (Whattsap)
• 6126 (O)
• 6427 (R) (Through 199)

Neonatology for Obstetricians: Initial Steps

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