Blooming of a Precious Rose

Introduction:

Pregnancy and childbirth are the most important events in a woman’s life, full of "Extraordinary dreams" and an intense feeling of self-contentment at having conceived. The limits of reality of these dreams outweigh the physical "handicaps" and pain imposed by pregnancy.

“Neonatology” meaning care of newborn baby. This is more critical in case of complicated and premature deliveries. Appropriate care of just born babies is essential to give its full potential physiologically proportionate to their genetic programme.

Neonatology

Neonatology, or in simplistic terms, ‘care’ of the newborn baby has evolved in the past 25 years or so to become a much wanted and sophisticated subspecialty of paediatrics, essentially limited to obstetrics. In fact the trend is now to integrate Neonatology and obstetrics into prenatal medicine, where in the close interaction between the above-mentioned specialties, streamlines all pregnancies including complicated and premature deliveries, to reach a holistic fruitful medical endpoint. That is to give a budding rose its fullest potential that implies delivering the baby at the appropriate time by using sophisticated electronic surveillance and giving the newborn baby a physiologically intact brain proportionate to its ultimate genetic programme. Inappropriate timing of the delivery due to lack of using electronic surveillance (CTG) could lead to the damage of unborn baby’s brain whose deficiencies could be detected only in school going age in many circumstances. Gross deficiency of oxygen leads to cerebral palsy and mental retardation.

It is hence imperative that mothers be informed on the "high risk" concept with appropriate referral of such matters to a perinatal center. The transport of the mother is ideal for the unborn baby since mother is the best transport incubator. Transferring a sick baby after birth is hazardous and imposes on his life and brain serious detrimental effects. These babies come for admission in cold state, with low sugar in the blood (leading to fits) and often with attacks of cessation of breathing (apnea) all of which have adverse effects on a baby’s brain, and life.

Guidelines for "high risk mother"

The mother who visits obstetric clinic for her first pregnancy has a whole encyclopedia of questions and the age-old line "All will be fine" will not comfort her. Hence some guidelines are given below.

High Risk Mother
1. Pregnancy in adolescence and teens.
2. High blood pressure in pregnancy.
3. Diabetes in pregnancy.
4. Premature labour. Less than 34 weeks pregnancy.
5. Previous pregnancy leading to premature delivery.
6. Abnormal position and presentation of baby in uterus viz Breech.
7. Prolonged labour especially on oxytocin (for about 8 hours).
8. Unexpected bleeding in pregnancy.
9. Poor foetal growth in II part of pregnancy.
10. Decreased movements of baby perceived by mother contrary to usual movement pattern. (VERY IMPORTANT)
11. Twin or Multiple pregnancy.
12.Suspected abnormality in baby by scan.
13. Mothers having heart, kidney, lung disease.
14. Mothers with weight less than 45kg and older than 35 years.
15. Mothers with haemoglobin less than 7gm%.
16. Inadequate weight gain during pregnancy.
17. Bad obstetric history. Previous abortions, still birth etc.
18. Maternal drug intake, alcohol, smoking etc.
19. Suspected intrauterine infection in mother (TORCH).
20. Pregnancy order exceeding 5.

These high-risk mothers should be referred to a good perinatal center where facilities for level III neonatal care (ventilator care) are available. The positive note on this strategy is that if all high risk mothers were transported to good neonatal centers. Only about 25% of such mothers would genuinely require extraordinary neonatal care (level III care). Another observation of grave significance is that even in 30% or more of so called "normal" pregnancies could become "high risk" in labour. Hence CTG monitoring is a must in all pregnancies ideally.

Strategy

DEFINE HIGH RISK PREGNANCY

®

TRANSFER TO PERINATAL CENTRE WITH III Neonatal ICU

Hence all mothers could essentially expect 3 basic questions to be answered by the turn of the century.1. Does the maternity hospital have adequate electronic surveillance, CTG monitoring, biophysical profile, Doppler flow of placenta etc by experienced doctors? 2. Does the hospital have a paediatrician to attend delivery? The timing of first breath of the baby is critical to the baby's brain. If the baby does not get artificial respiration within one minute or so of delivery, if he does not breathe, the developing brain of the baby could be irreversibly damaged (ASPHYXIA) due to lack of oxygen to his brain. 3. Does the maternity hospital have a neonatologist trained in high risk pregnancy? If so, does it have ventilatory assistance to be given if required to a high-risk newborn baby? Transferring a sick baby could have deleterious influence on the baby's brain and life.

Strategy of surveillance for a "high risk mother"

Every pregnant mother needs to know whether her baby is perfectly alright inside her uterus. Fortunately science has evolved electronic surveillance to give a reasonable reassurance to the mother.

Proposed Strategy of Surveillance

FIRST 3 MONTHS	SECOND 3 MONTHS	LAST 3 MONTHS	NEWBORN ICU
Ultrasound scan	Poor foetal growth	1. CTG Monitoring
Chronic villus*		2. Biophysical Profile
Sampling	Doppler Flow of Placenta	3. Scalp ‘ph’ of Baby
Amniocentesis*		4. NIRS
		5. Foetal Pulse Oximetry

The first three months after conception are the period of formation of body parts of the baby. Hence it is essential to avoid all medications, radiation and contact with children with viral infections, all of which can potentially damage the developing baby. During this period a scan should be done by an experienced ultrasonologist to detect any abnormality in the baby (4 MONTHS).
The second 3 months (II Trimester) should be assessed by doppler flow of placenta, to grade depletion of placental blood flow, in a growth retarded baby. This prevents Intrauterine death (IUD). This situation also warrants evaluation for intrauterine infection and chromosomal anomalies especially if the growth retardation was noticed earlier.

The last 3 months (III Trimester) is the most dynamic and needs a bare minimum of cardiotocographic monitoring (CTG) during and prior to labour and delivery. Only if such a electronic device is used continuously can we be reasonably sure that the timing of delivery was appropriate and that the baby's brain has not been affected by oxygen deprivation due to poor timing of birth. In western countries CTG monitoring is used in all pregnancies. In India it is disheartening to note that only some hospital should use CTG routinely. It is suggested that all maternity hospital use CTG monitoring.

Biophysical profile is done by ultrasound observation of the baby's posture, heart rate accelerations etc during a 30 min observation. It is a sensitive test and supplements CTG monitoring.

Newer modalities of monitoring give specificity in addition to the sensitivity of the older surveillance techniques. NIRS (Near Infra Red Spectroscopy) and foetal pulse oximetry detect lack of oxygen supplied to the brain of the baby far ahead of the above mentioned surveillance techniques, showing abnormalities.

Categories of High Risk Baby

1. Premature baby less than 34 weeks.
2. Low blood sugar 40mg%. This could lead to fits and cause irreversible brain damage.
3. Asphyxia during delivery (Oxygen lack to baby’s brain).
4. Fits in a newborn baby.
5. Critical jaundice bilirubin >18mg% term baby.
6. Infant of diabetic mother.
7. Suspected bleeding disorder.
8. Suspected infection in an neonate.
9. Breathing difficulty in a neonate. Always refer early to a good center than delaying the baby to become more distressed and sick "WAIT AND WATCH" policy not appropriate in this situation.
10. Vomiting, abdominal distension in neonate.
11. Suspected cardiac or renal disease.
12. Suspected inborn error of metabolism.
13. Not passed motion in 48hrs
14. Not passed urine in 24hrs.
15. Excessive secretions or choking while feeding.

These babies should be referred EARLY, wrapped in blanket, with IV drip flowing to a good neonatal centre.

Levels of Neonatal Intensive Care

The future prospective of neonatal intensive care unit are as follows and are categorized into IV levels.

Level I care:	Giving warmth to baby, sterile cutting of umbilical cord. Infection control
Level II care:	Warmth by warmers / incubators + Intravenous fluid provision + Tube feeding (milk). + Infection control (HAND WASHING)
Level III care:	Ventilator (artificial lung) + Cardio respiratory monitoring (HR monitoring) + Blood pressure monitoring (NIBP, IBP monitoring) + IV fluids (Infusion pump) + Provision for total parental nutrition (TPN) + INFECTION CONTROL (VERY IMPORTANT)
Level IV care:	Neonatal cardiac surgery ± ECMO

To enlighten the reader on the future directions in level III neonatal care the centre point is always infection control (hand washing, disinfection etc) and innovations in ventilatory therapy.

Strategy for a Newborn with Breathing Difficulty

Broad generalisation for Parents

	Observe	Requirement
Term Baby	® 40% 02	Consider Ventilator Therapy Support
> 38 Weeks	Respiratory Rate >70(RR)
	(RR > 60)
Preterm Baby	®	Consider Ventilator Therapy Support
	< 40% 02	¯
	Surfactant	>40% 02
		Consider Intermittent Mandatory Ventilation (IMV)

New Therapies in Ventilator Care

• Breathing Difficulty not Responding to IMV
• Requirement 02%>70%-80% Oxygenation Problem
• High Frequency Ventilation HFO
• 02 Requirement 80-100% Oxygenation Problem
• Nitric Oxide Therapy
• Failure
• Extra Corporeal Membrane Oxygenation (ECMO), Needs a cardiac surgery back up.

Conclusion:
The reader is hopefully enlightened on the impact of maternal literacy, early referral of high risk mother (ideally) and baby to higher centre (not ideal) and the huge armamentarium of ventilator technologies available for lung rescue. The monologue is concluded with a positive note that all's well that ends well if early surveillance and early referral are adopted with use of appropriate technologies at the right time.

Contributed by:
Dr P K Rajiv
MBBS, DCH, MD (PED)
Fellowship in Neonatology (Australia)
Consultant Pediatrician & Neonatology in Charge
Mallya Hospital
#2, Vittal Mallya Road
Bangalore -560 001