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The Fetus and Newborn

Board Prep

A mother presents to L&D at 36 weeks’ gestation with a CC of

decreased fetal movement for the past 6 hours. Continuous
monitoring reveals a fetal heart rate of 160 beats/min with
rare variable decelerations seen with infrequent contractions.
Further evaluation of fetal well-being includes a nonreactive
NST and a BPP of 4 our of 10. Due to the late pre term status,
the obstetrician seeks your input in the subsequent
Labor and management of the mother and fetus.

Delivery A. Continue to observe with continuous monitoring

B. Continue to observe with continuous monitoring
discharge home with outpatient follow-up
C. Initiate induction of labor
D. Perform an urgent caesarian delivery
C. initiate induction of labor
Monitoring of the fetus
1) Maternal perception of fetal movement
• Any concerns of decreased fetal movement should
prompt testing
2) Non-stress test
• Performed by external methods – detects the
presence of fetal heart rate accelerations with
fetal movement
• Reactive/reassuring = 2 or more FHR accelerations
within a 20 minute period (associated with fetal
survival rates of 99% for another week or more)
• Nonreactive = perform a biophysical profile
3) Biophysical profile –
assesses 5 factors with ultrasound
• Movement (by NST)
• Tone
• Reactivity
• Breathing
• Amniotic fluid volume

-Points (0-2) are assigned for each

-Score of 8-10 = normal, 6 =
-A combined total score of < or
equal to 4 generally indicates the
need for emergent delivery.
Monitoring of the Fetus

As a member of your QI team, you A. Apply plastic wrap over

Labor and are reviewing admission
temperatures for premature infants
neonates’ torsos and
Delivery born at your hospital. Delivery room
management is identical for B. Cover neonates’ heads
premature infants born vaginally and with caps
by cesarean section. You note a
higher incidence of hypothermia C. Increase operating room
temperature <36.5⁰C in premature temperature
infants born via cesarean section
compared with those delivered D. Place neonates skin to
vaginally. Of the following, the skin with parents
MOST effective intervention for immediately
decreasing hypothermia among
premature infants in your hospital is E. Use radiant warmers
C. Increase operating room temperature
Neonatal hypothermia
Defined as a rectal temp less than 36.5°C

Associated with poor neonatal outcomes

Among premature infants born before 37 weeks, hypothermia has been linked to increased rates of
intraventricular hemorrhage and hypoglycemia
Ideally, the operating room should be between 25.0°C (77°F) and 27.0°C (80°F)

Covering exposed skin with plastic wrap to minimize radiant heat loss, using caps, and radiant
warmers will prevent hypothermia
Low resource setting: skin-to-skin

Labor and Delivery (images for next question)


You are called to attend the delivery of a 40-week, LGA male

infant. The mother is a 29-year-old G4P2 woman with an
A. Brachial plexus injury elevated glucose level on the glucose challenge test. At delivery,
a tight nuchal cord and shoulder dystocia are noted. The
B. Cephalohematoma newborn was delivered vaginally with vacuum assistance. Upon
delivery, the neonate had poor tone and respiratory effort,
C. Left humeral fracture requiring positive pressure ventilation, with resulting
D. Tight nuchal cord improvement in tone, activity, and respiratory effort. Physical
examination demonstrates a cephalohematoma, decreased
abduction of his left shoulder. No movement is noted at the
elbow. Sensation and grasp in the left hand remain intact. A
student asks why the neonate is not moving his arm.
A. brachial plexus injury
Brachial Plexus Injury (BPI)
Incidence of 1 in 1,000 live births

Has been associated with maternal diabetes, uterine abnormalities, neonatal macrosomia, and failure to

Present with decreased movement of the affected arm and an asymmetric Moro reflex

Initial management: radiographs (arm and shoulder), minimal handling of the affected arm and short-term
immobilization (passive range of motion exercises at 7-10 DOL) and referral to physical therapy
• Damage to cervical nerve roots
• P/w asymmetric Moro reflex and
decreased abduction of the
shoulder, external rotation of the
arm, and supination of the
forearm (waiter’s tip)
• Palmar grasp and biceps reflexes
on the injured side remain intact
• Typically resolves 2-4 weeks after
birth; if persists beyond 3 months,
refer to surgery
• Damage to cervical roots
Klumpke paralysis C7, C8, and T1
• May have Horner
Syndrome on the affected
side (ptosis, miosis) due to
injury of the sympathetic
fibers of the first thoracic
• Weakness of flexor
muscles of forearm and
hand (“claw-like posturing
of the hand”
• Biceps reflex intact, palmar
grasp absent

You are called to the newborn nursery to evaluate a neonate with

tachypnea. She was born at 38 weeks’ gestation to a 29-year-old
A. Congenital diaphragmatic hernia gravida 6, para 4 woman with a history of mild intermittent asthma and
limited prenatal care. She presented to the hospital fully dilated, with
B. Meconium aspiration syndrome meconium-stained amniotic fluid. The infant was delivered vaginally,
without assistance, by precipitous delivery. Upon delivery, she had a
C. Respiratory distress syndrome spontaneous cry with good muscle tone. Her vital signs in the nursery
show the following: temperature, 36.7°C; heart rate, 142 beats/min;
D. Transient tachypnea of the respiratory rate, 62 breaths/min; and blood pressure, 86/52 mm Hg.
newborn Pulse oximetry demonstrates oxygen saturation of 85% on the left foot
and 96% on the right wrist. She has mildly increased work of breathing,
E. Tricuspid atresia a 2/6 systolic ejection murmur at the left lower sternal border, and +1
peripheral pulses. The remainder of her examination results are
unremarkable. Chest radiography shows decreased lung markings.
E. tricuspid atresia

In this case: lack of respiratory distress and 11-point differential between her pre- and
post-ductal saturations suggest a cardiac cause of hypoxemia. Also the location of her

• Present with severe respiratory distress, scaphoid abdomen,

and audible bowel sounds in the thorax
• Intestines are visible in the thoracic cavity on CXR
• Require immediate intubation to prevent distention of the
intrathoracic intestines and compression of lung tissue
Meconium aspiration
• Presents with signs of respiratory distress
shortly after delivery – tachypnea, retractions,
and frequently cyanosis
• Meconium obstructs smaller airways, leading to
areas of hyperinflation and atelectasis = patchy
opacities on CXR
• Meconium inactivates surfactant and many
cases surfactant is administered
• Meconium also alters pulmonary vasculature,
increasing the risk of pulmonary hypertension
• Supplemental oxygen is usually required and
mechanical ventilation is often necessary
Respiratory Distress
• Most common cause of respiratory failure in the newborn
• Due to surfactant deficiency and lack of development of the
alveoli, usually due to prematurity
• CXR – homogenous ground glass appearance
• As gestational age increases, more surfactant is synthesized
and stored in Type II alveolar cells; mature levels of surfactant
are present at 35 weeks gestation
• Antenatal corticosteroid therapy is recommended in pregnant
women at 23-34 weeks of gestation who are at risk for preterm
• Infants < 28 weeks of gestation, whose mothers did not receive
glucocorticoids, require prophylactic surfactant therapy
Transient tachypnea
of the newborn

• Present with mild to moderate respiratory distress

within the first 6 hours after birth
• Usually occurs in late preterm infants born at 34-
37 weeks gestation soon after a precipitous
vaginal or, more typically, C-section delivery
• Caused by failure of adequate lung fluid clearance
at birth
• CXR – fluid in the fissures, flattening of the
diaphragms due to over-aeration
• Symptoms usually resolve within 12-24 hours;
oxygen is provided if needed

You are called to attend a vaginal delivery requiring

forceps. The mother is a 37-year-old G3P0 woman with a
h/o multiple sclerosis. Due to maternal infertility, this
A. Congenital myasthenic syndrome pregnancy was the result of in vitro fertilization, and had
an uncomplicated course. The mother received pulse
B. Facial nerve palsy
corticosteroids during the third trimester. The infant was
C. Hypoxic-ischemic encephalopathy delivered with forceps due to arrest of descent. Upon
delivery, the newborn had a spontaneous cry and active
D. Maternal corticosteroid use flexion of the arms and legs. On PE, you note an
asymmetric cry and incomplete closure of the left eyelid.
Forehead movement is decreased on the left compared to
the right.
B. facial nerve palsy
Facial nerve palsy (CN VII)
• Present with an asymmetric cry and partial eye closure
on the affected side; may also see decreased movement
of the forehead muscles
• Though facial nerve palsy is associated with delivery
assisted by forceps or vacuum, the injury likely results
from positioning and the duration of labor rather than
direct nerve damage from instrumentation
• Occurs more frequently in neonates with macrosomia
or abnormal presentation during delivery; also at risk
for subgaleal hemorrhage …
• Must be recognized promptly – neonates have
the potential to rapidly lose large quantities of
blood into this space
Subgaleal • Presents as a boggy mass at the nape of the
hemorrhage neck, which increases in size after delivery
• Diagnose with ultrasound or CT – requires
prompt consultation with peds neurosurgery

See UpToDate image Neonatal extracranial and intracranial

birth injuries

You are reviewing discharge plans for a 2-day-old neonate

born at 35 weeks of gestation with a birthweight of 2.62
A. East Asian race kg. His mother, a recent immigrant from Sri Lanka, has
blood type O positive. The neonate’s blood type is O
B. Excess weight loss positive. He has been breastfeeding well, with 4 wet
C. Hemolytic disease
diapers and 2 stools in the past 24 hours. He received 1
feeding of formula. On physical examination, his weight is
D. Jaundice 2.58 kg and he has mild facial jaundice. His total bilirubin is
10.2 mg/dL (174.5 μmol/L) at 48 hours of age. Using the
E. Prematurity Bhutani nomogram, the pediatric resident labeled his
bilirubin risk level as low intermediate with no
recommendation for a repeat bilirubin level on discharge.
E. Prematurity
Premature neonates (< 37 weeks) have relatively slower
clearance of bilirubin
• Risk is greater if enteral feeds cannot be started immediately after
birth because of respiratory distress, leading to increased
enterohepatic circulation

East Asian race (Chinese, Japanese, or Filipino)

Risks for
hyperbilirubinemia Exclusively breastfed neonates who have lost more than
10% of their birthweight within the first 3 days after birth

Hemolytic disease due to Rh or ABO isoimmunization

• Rho (D) immune globulin for mothers who are negative for the Rh
antigen has decreased the incidence of Rh isoimmunizations
• ABO isoimmunization occurs when a mother with type O blood
delivers a neonate with type A, B, or AB blood (mothers have anti-A
and anti-B antibodies)
Quick response!

What is one of the most

frequent abnormalities
in infants with a single
umbilical artery?
Trisomy 18

• Trisomy 18 is one of the most

frequent abnormalities in
infants with a single umbilical

• Congenital abnormalities are

present in up to 30% of these
infants and many are stillborn
or die soon after birth.


An infant presents with the following: vernix

on the back and creases only, the upper 2/3
of the ear is incurving, the thin cartilage
(pinna) springs back from folding, heel
creases are present, lanugo present on
shoulders only, breast tissue is a 3-5 mm
nodule, and labia majora almost covers the
clitoris. What is the gestational age of this
38 weeks


At a newborn’s examination, you note

edema and blood over the parietal
bone, which does not appear to cross
suture lines. You can palpate an “edge”
that is finely demarcated. What is the
most likely diagnosis?
• Collection of blood under the periosteum of the
outer surface of the skull.
• It most commonly occurs over the parietal bones
and it does not cross suture lines because it is
below the periosteum.
• Most self resolve and do not require X-ray


An infant is born to a mother with a

positive RPR. The newborn has the

jaundice, hepatosplenomegaly, rhinitis,

vesicular skin rash, and chorioretinitis.
What is the best treatment?
Penicillin G
• Congenital syphilis should be treated with
aqueous crystalline penicillin G 50,000
units/kg/dose IV q12h x 7 days, then q8h to
complete 10 days.
• An alternative is procaine-penicillin 50,000
units/kg/dose IM 1x/day for 10 days.


A 1 month old boy who was born at 31

weeks gestation presents with progressive
tachypnea, dyspnea with feeding, occasional
cyanosis, and couth with wheezing. CXR
shows bilateral reticular infiltrates with
development of multicystic lesions. What is
the most likely diagnosis?
Seen in infants without a history of
hyaline membrane disease who are <
32 weeks of gestation and birth weight
of < 1500 grams.

Interstitial It is gradual in onset during the first

month of life. Symptoms increase over
Pulmonary a 3-6 week period and persist for
Fibrosis several months.
Then they can either gradually resolve
or the infant becomes progressively
worse with respiratory and cardiac

At the newborn examination, you

note a collection of edematous
fluid and blood in the soft tissue of
the skull. The edema crosses suture
lines and the midline of the skull.
What is the most likely diagnosis?
Caput Succedaneum

• Generally due to the forces

of labor as the presenting
part is pushed through the
birthing process.
• The “caput” is above the
periosteum, which allows
the edema to cross suture
lines and the midline. Skull
x-rays are not indicated and
the caput with resolve over
several days.


What is the reason for his persistent

oxygen requirement?

An infant was born at 28 weeks gestation.

He was given surfactant at birth and
intubated for acute respiratory distress.
He was transitioned to nasal CPAP but had
to be re-intubated with pneumonia and
sepsis twice. He is now term but has a
persistent oxygen requirement. He is fluid
restricted and on a concentrated formula.
Also called neonatal chronic lung
disease, occurs most commonly in
preterm infants less than 30 weeks
It is defined by persistent oxygen
Bronchopulmonary requirement past 36 weeks gestational
Dysplasia (BPD) age.

Infection and fluid overload are known

risk factors for the development of