Show Summary Details
Page of

Problems on the postnatal ward 

Problems on the postnatal ward
Chapter:
Problems on the postnatal ward
Author(s):

Grenville Fox

, Nicholas Hoque

, and Timothy Watts

DOI:
10.1093/med/9780198703952.003.0003
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2020. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy and Legal Notice).

date: 30 October 2020

Approach to the dysmorphic baby

History

  • Ask for relevant family history

  • Check antenatal history, particularly screening tests and antenatal ultrasound scans

  • Observe parental features.

Examination

  • Examine the baby thoroughly and record all the dysmorphic features clearly and systematically in the notes

  • Record the weight, head circumference, and length on the appropriate centile chart

  • Consider passing an NG tube into stomach and check patency of both nostrils to exclude oesophageal and choanal atresia

  • Seek senior review +/– genetics opinion.

Possible further investigations (depending on other findings)

  • Genetics: tests ordered will depend on local guidelines, which might include:

    • array comparative genomic hybridization (CGH)

    • chromosomal analysis

    • rapid PCR test (polymerase chain reaction) for specific disorders (particularly trisomy 13, 18, and 21) if available

    • DNA analysis (seek prior genetics opinion if necessary, so that specific test can be arranged)

  • X-rays: chest, abdomen, and spine

  • Cranial, renal, and abdominal US

  • Echocardiogram

  • Eye examination by paediatric ophthalmologist

  • Ensure hearing screen is performed.

Communication with parents

  • This is often difficult, particularly if a diagnosis is not clear, as parental and staff anxiety will be high

  • Be sure to involve senior medical staff

  • Try to ensure any difficult news is imparted to both parents or at least with another supportive person present

  • Be open and honest with parents; if you are not sure, say so.

Down syndrome

Background

  • Caused by the presence of all or part of an extra chromosome 21

  • 1 in 800–1000 live births

  • Increased risk with increasing maternal age: risk under 30 years <1 in 1000; risk at 35 years 1 in 400; risk at 42 years 1 in 60. However, 75% of babies with Down syndrome are born to mothers <35 years old

  • Underlying genetics may be:

    • trisomy 21 (95%) (usually maternal non-dysjunction)

    • mosaicism (1–2%)

    • translocation (2–3%) where parent may carry balanced translocation; parental chromosome analysis is indicated.

Postnatal assessment

Diagnosis made antenatally

  • Check fetal echocardiogram findings for evidence of congenital heart disease

  • Full clinical examination, particularly of cardiovascular system

  • Check result of antenatal karyotype

  • Ensure the baby is seen by senior medical staff.

Diagnosis suspected postnatally

  • See early and perform full examination, particularly of cardiovascular system

  • Seek immediate senior medical review

  • Be sensitive to parents’ anxiety and, if necessary, say you are asking a more senior doctor to see the baby

  • Take blood for genetics and request urgent PCR (if available) for trisomy 21.

Once confirmed or if diagnosis likely on clinical grounds

  • Check FBC and blood film to exclude polycythaemia, transient abnormal myelopoiesis (TAM, also called Transient Leukaemia of Down Syndrome, or TL-DS), and thrombocytopenia. If TAM is present (occurs in up to 10% of babies with Down syndrome), the baby has a high risk (20–30%) of later myeloid leukaemia—refer to haematologist

  • Refer to paediatric cardiologist: congenital heart disease occurs in 45%; commonest diagnosis is atrioventricular septal defect (AVSD)

  • Consider presence of associated problems, e.g. duodenal atresia, Hirschsprung’s disease

  • Ensure appropriate feeding assessment and support

  • Ensure parents receive appropriate counselling from consultant (see next section, Problems on the postnatal ward Information that may be given to the parents, pp. [link][link]).

Information that may be given to the parents

  • Confirmation of the diagnosis, with discussion of the genetics (consider referral for geneticist follow-up)

  • Developmental delay and learning difficulties

  • High incidence of congenital heart disease

  • Potential for feeding problems, hypotonia, visual impairment (e.g. squint and cataracts), hearing impairment, duodenal atresia, hypothyroidism (1%), leukaemia (<1%), short stature, and recurrent upper respiratory tract infections and otitis media

  • Requirement for follow-up in the community with paediatrician and therapists

  • Written information about Down syndrome and support groups.

Follow-up

  • Neonatologist (within a few weeks of discharge):

    • to ensure adequate feeding and growth

    • explore how parents and family are coping with diagnosis

    • further discuss implications and answer questions

    • ensure appropriate referrals (particularly to community services) have been made

  • Ensure hearing screening performed

  • Speech and language therapist (if there are significant feeding problems)

  • Local special needs support if available

  • Referral to community paediatrician

  • Inform GP and health visitor by phone, and supply typewritten discharge summary

  • Ophthalmologist (3–6 months).

Delayed passage of meconium

  • Most healthy babies pass meconium within 24 hours of birth. Delay beyond 24 hours is unusual and underlying pathology should be considered

  • Possible aetiologies are:

    • Hirschsprung’s disease

    • meconium ileus

    • meconium plug

    • intestinal dysmotility, particularly in growth restricted baby

    • imperforate anus

    • prematurity.

Management

  • Review full history with mother and midwives; ensure that no meconium was passed prior to delivery

  • Examine maternal notes for any evidence of polyhydramnios or other abnormalities on antenatal scans (e.g. dilated loops of bowel)

  • Take feeding history and elicit history suggestive of obstruction (e.g. bilious vomiting, abdominal distension)

  • Fully examine baby, particularly for clinical state of the baby (perfusion, etc.), abdominal distension, tenderness, and check anus is patent

  • If <24 hours old, baby is well with no vomiting, and normal examination then observe closely

  • If >24 hours old; or <24 hours but with concerning features in the history or on examination: consider bowel obstruction, Hirschsprung’s disease, enterocolitis, and sepsis:

    • admit to the neonatal unit

    • seek senior medical review

    • request AXR and discuss with consultant +/– paediatric surgeon

  • If a baby has been given a suppository to aid passage of meconium then this baby should still be discussed with a paediatric surgeon in view of the possibility of Hirschsprung’s disease

  • If a meconium plug is passed, IRT (spot of blood on Newborn bloodspot screening card) and cystic fibrosis genetic studies should be checked. Hirschsprung’s disease should also be considered.

Common skin problems in the newborn: naevi

Capillary naevi/port wine stains

  • Incidence 0.3%

  • Usually larger and darker than salmon patches (see Problems on the postnatal ward p. [link]); present at birth; grow with infant and do not fade or darken with age

  • Seek senior medical review

  • If face and orbital area involved, consider Sturge–Weber syndrome (SWS)

  • If naevus is in the region of the ophthalmic region of trigeminal nerve 25% have SWS. Consider:

    • neuroimaging +/– neurology referral for cerebral arteriovenous malformation

    • ophthalmological review for glaucoma

  • Consider dermatology referral, as pulsed dye laser therapy may be indicated for significant lesions.

Capillary haemangiomas: ‘strawberry’ naevi

  • Common (incidence up to 10%); male:female ratio 2:1. More common in preterm

  • Uncommonly visible at birth, but usually appear by 4 weeks

  • Course variable, but usually increase in size over 3–9 months, then involute, and resolve completely

  • Rarely, a large haemangioma may involve a large proportion of a limb, or cause haemorrhage, ulceration, or thrombocytopenia

  • If complicated (large or multiple):

    • seek senior review if uncertainty about diagnosis or if further assessment needed (e.g. if vision may be obstructed)

    • dermatology referral may be warranted and treatment with beta-blockers considered

    • if multiple, further investigation may be necessary to rule out visceral involvement (e.g. abdominal ultrasound).

Congenital melanocytic naevi

  • Brown/black lesions present at birth; incidence 1%

  • Small, medium-sized, large, or giant

  • Giant melanocytic naevus (‘bathing trunk’ naevus):

    • rare

    • seek senior medical review

    • refer to dermatologist

    • there is a small risk of later malignant change to melanoma (perhaps 5% over a lifetime).

Sebaceous naevi (naevus of Jadassohn)

  • Yellow-brown sebaceous fleshy slightly raised lesions present at birth and most common on scalp; incidence 0.3%

  • Persist and become more nodular in adolescence. Have very small risk of malignant change later in life (predominantly basal cell carcinoma)

  • Refer to dermatologist.

Common skin problems in the newborn: other

Erythema toxicum

Also known as erythema neonatorum or urticaria neonatorum:

  • Common and benign (>50% newborn in first 2 weeks). More common if term or post-term

  • Variable erythematous patches with small eosinophilic ‘pustules’ (less pustular than Staphylococcus spots)

  • Reassure.

Transient neonatal pustular melanosis

  • Present at birth, more common in black infants (in whom the incidence is up to 5%)

  • Benign, superficial, non-erythematous, vesiculopustular rash, which may rapidly dry, leaving hyperpigmented macules that fade in weeks

  • Reassure.

Milia

  • Common (>50% newborn) and benign

  • Obstructed sebaceous glands

  • 1–2 mm yellow-white spots, most common on nose and face that resolve after 2 months

  • Reassure.

Miliaria

  • Obstructed sweat ducts

  • Pinpoint vesicles on forehead, scalp, and skin folds that resolve by 1–2 weeks

  • Reassure.

Staphylococcal skin infection

Presentation

  • Mildest form: a few pustules on erythematous base

  • Severe form: cellulitis and scalded skin appearance.

Management

  • If diagnosis is in doubt, puncture a lesion and send contents for MC&S (microscopy, culture, and sensitivities)

  • If systemically well in mild cases, start oral flucloxacillin

  • If systemically unwell or extensive skin changes (i.e. with cellulitis or skin loss):

    • admit to neonatal unit (NNU)

    • send FBC, CRP, blood culture

    • start IV antibiotics (e.g. flucloxacillin and gentamicin).

Salmon patches/stork marks

  • Very common, incidence up to 50%

  • Circumscribed lesions usually at back of neck, nuchal fold, eye-lids, forehead, and above upper lip

  • Fade with time, therefore reassure.

Mongolian blue spot

  • Common and benign, found in 90% Asian and Afro-Caribbean babies and 5% Caucasian

  • Blue/grey irregular patches, most commonly on the lower back, but can extend over whole back and on extensor surfaces of limbs

  • Should not be mistaken for bruising

  • Usually fade, but may persist.

Skin tags

  • Check for other dysmorphic features. If near the ear, check external auditory meatus patency and arrange hearing screening

  • Refer to plastic surgeon.

Polydactyly and accessory digits

  • Common, with a higher incidence in black babies; often positive family history (usually autosomal dominant)

  • Check no other dysmorphic features

  • Historically, these have been tied off with a suture and left to fall off. However, this is associated with neuromas at the site, so refer to plastic surgeon.

Talipes equinovarus

Background

  • Incidence of 1 in 1000 births, male preponderance

  • May be isolated or associated with syndromes (e.g. trisomy 13, 18), intrauterine restriction of movement (e.g. oligohydramnios) or neuromuscular disorders.

Assessment

  • Check mother’s antenatal notes and ultrasound scan results and ask about fetal movements

  • Look for any other abnormalities with particular attention to neuromuscular, spinal, and hip examination

  • Positional talipes:

    • passively corrects beyond the neutral position

    • baby also is able to actively correct foot posture

    • parents can be reassured that posture will fully correct without any further input

    • no physiotherapy or specialist follow-up required

  • Structural talipes does not correct beyond the neutral position.

Management of structural talipes

  • Examine the hips carefully and arrange a hip ultrasound scan to exclude congenital dislocation of the hips

  • Refer to physiotherapy and paediatric orthopaedic surgeons

  • Management is by foot stretches, splinting, strapping, or casting as required

  • Manipulation and application of well-moulded plaster casts may correct mild to moderate deformities and can improve severe deformities, making subsequent surgery easier

  • Casting is most effective when commenced in the first few days

  • Arrange for orthopaedic surgeons to assess the baby either prior to or soon after discharge

  • Early surgery may induce fibrosis, scarring, and stiffness, and thus is likely to be delayed until at least 3 months.

Neonatal hip problems: developmental dysplasia and congenital dislocation of the hip

Background

  • Spectrum from shallow acetabulum to frank dislocation

  • 1% of babies will have developmental dysplasia of the hip (DDH), 1 in 1000 will have persistent dislocation

  • Female preponderance.

Risk factors

  • Family history, especially first degree relative

  • Breech presentation at or after 36 weeks gestation, or at delivery if this is <36 weeks

  • Oligohydramnios

  • Sternomastoid tumour and torticollis

  • Talipes deformities, including equinovarus, calcaneovalgus, metatarsus adductus

  • Congenital myopathies and neurological disease.

Management

Screening

This is recommended for family history and breech presentation (see Problems on the postnatal ward Risk factors, p. [link]). (See Problems on the postnatal ward Further information, p. [link].) Some units will also recommend for other risk factors

  • Hip ultrasound scan at 4–6 weeks

  • Refer to orthopaedics if ultrasound abnormal.

Abnormal clinical hip examination

Findings may include positive Ortolani or Barlow tests, clicky hips, asymmetrical creases, or limited abduction:

  • Seek senior medical review

  • If hip examination confirmed to be abnormal:

    • discuss with paediatric orthopaedics team

    • arrange early hip ultrasound scan (should be completed by 2 weeks of age)

    • arrange early orthopaedic referral.

Orthopaedic treatment

  • Pavlik harness

  • Hip spica

  • Surgical reduction.

Lower spinal abnormalities: sacral dimples, pits, and spinal dysraphism

Natal dimples or pits

  • Very common within or just above the natal cleft

  • If skin overlying the defect is intact and there are no other abnormalities on examination then reassure

  • If there is uncertainty as to whether the skin is intact and there is no sinus or discharge:

    • check that neurological examination is normal

    • seek senior medical review

    • arrange ultrasound scan of the lower spinal cord (+/– kidneys and bladder) as an outpatient

    • arrange outpatient follow-up.

Spinal dysraphism

See Problems on the postnatal ward Malformations of the central nervous system, pp. [link][link].

  • Any lesion at any spinal level with a fat pad, significant hairy patch, atretic skin, sinus, or swelling—or if there are associated lower limb neurological signs or bladder dysfunction—warrants early investigation

  • Seek senior medical review

  • Arrange early AP and lateral X-rays of the lumbosacral spine and ultrasound scan of the lower spinal cord, kidneys, and bladder. If this is abnormal then it will be necessary to investigate further with an MRI scan. Discuss further follow-up with paediatric neurology or neurosurgical team

  • There is a small risk of recurrence and the advice is to take high dose folic acid pre-conception and during early pregnancy in subsequent pregnancies.

Brachial plexus palsies

  • Risk factors include: being large for gestational age, infant of diabetic mother

  • Usually precipitated by shoulder dystocia at birth.

Types of brachial plexus palsy

  • Erb’s palsy

    • C5–C6 nerve roots

    • ‘waiter’s tip’ position: decreased or absent shoulder abduction with elbow extension, forearm internal rotation, and wrist flexion

  • Klumpke’s palsy (rare)

    • C8–T1 nerve roots

    • ‘claw hand’: intrinsic muscles of the hand involved, along with wrist and finger flexors, sympathetic nerves leading to Horner’s syndrome, and also hyperabduction of shoulder

  • Erb-Duchenne-Klumpke palsy

    • C4–T1 nerve roots

    • entire arm paralysed

    • raised hemidiaphragm may occur if extensive enough lesion to involve C4.

Assessment

  • Look for signs of fracture of humerus or clavicle; if in doubt do X-ray of limb and shoulder

  • Assess and record full neurological examination of affected limb

  • Assess for signs of respiratory distress (implying diaphragm involvement) or unequal pupils (Horner’s syndrome) which may indicate a worse prognosis

  • CXR if lesion extensive or if C4 likely to be involved

  • Parents should be spoken to by senior doctor regarding prognosis and recovery.

Management

Refer to physiotherapy for advice on positioning and handling, sensory stimulation, and passive stretches of the hand, wrist, and elbow. Will need outpatient physiotherapy and medical follow-up.

Prognosis

  • 80–90% chance of full recovery in all but most extensive lesions

  • Onward referral for specialist assessment should be considered if no biceps recovery evident at 6 weeks or if weakness persists >3 months.

Management of vulnerable babies on postnatal ward and transitional care

  • Babies who require more than ‘routine’ postnatal care are increasingly cared for on postnatal wards, due to restricted capacity on NNUs and the desire to keep mothers and babies together

  • Some units will have a Transitional Care (TC) Unit for such babies. This may involve higher midwifery ratios, or staffing with neonatal nursing staff. What constitutes TC and the model of care used will vary between hospitals

  • Babies considered ‘vulnerable’ or qualifying for TC may include:

    • ‘late’ preterm (e.g. 34–37 weeks)

    • low birth weight (LBW) (i.e. BW <2.5 kg)

    • small for gestational age (SGA, <10th centile for gestational age)

    • babies with reported feeding difficulties

    • infants of diabetic mothers

    • babies requiring phototherapy

    • babies with medical problems (e.g. cleft palate, Down syndrome)

    • babies of drug using mothers (see Problems on the postnatal ward Care of the baby whose mother is drug dependent, pp. [link][link])

    • mothers with social concerns (e.g. depression, psychiatric disturbance, contact with social services, learning difficulties)

    • multiple births

    • babies transferred from NNU.

Assessment

  • Review maternal and pregnancy history:

    • evidence of placental insufficiency if LBW or SGA

    • maternal illness during pregnancy if suspecting congenital infection

    • infection risk factors, particularly if preterm

  • Take a good feeding history from midwives and mother

  • On examination: signs of congenital infection or dysmorphism if symmetrically SGA

  • Complications include hypoglycaemia, hypothermia, hypocalcaemia, polycythaemia, poor feeding, and jaundice

  • Consider viral serology and/or karyotype if suspected from examination, especially if significantly SGA.

Management

  • Regular observations (temperature, heart rate, respiration rate, activity level, feeding)

  • Avoid hypothermia by ensuring the baby is adequately wrapped and has a hat on, or using overhead heater if necessary. Criteria for admission to NNU vary, but most babies below 1800 g will not be able to maintain their temperature adequately on the postnatal wards

  • Encourage early and frequent (every 3–4 hours initially) breastfeeding, or, if formula feeding, ensure adequate volumes are being taken (60–90 ml/kg/day initially, increasing over the first few days)

  • Monitor for and treat hypoglycaemia according to guidelines. This will pertain only to those considered at risk such as infants of diabetic mothers, preterm, LBW, SGA (see Problems on the postnatal ward Hypoglycaemia: overview, pp. [link][link], Hypoglycaemia: management, pp. [link][link])

  • Consider the presence of polycythaemia if baby SGA; and check PCV (packed cell volume) with FBC if suspected, or if hypoglycaemia or jaundice becomes a problem

  • Careful assessment of fitness for discharge is required

  • For babies who are preterm or LBW:

    • ensure that feeding is adequate regardless of whether the baby is breast or bottle fed

    • babies should be weighed prior to discharge

    • if a baby is below birth weight at discharge, the percentage weight loss should be calculated. Babies with weight loss of 5–10% may need to stay longer to assess feeding and ensure that weight does not fall further. If weight loss >10% birth weight: assess state of hydration and review fluid intake. Consider looking for hypernatraemic dehydration

    • if a baby is ≥10 days old and still below birth weight, there should be at least 2 weights to show that weight gain is ≥10 g/kg/day. Ideally, babies should have started to gain weight prior to discharge.

    • earlier discharge can be considered if there is enhanced community support available

  • Ensure appropriate support in community after discharge. Consider neonatal outreach and/or outpatient follow-up.

Care of the baby whose mother is drug dependent

  • This may include mothers on opiates, cocaine and derivatives, benzodiazepines, and excessive alcohol

  • Monitoring is necessary to detect and treat withdrawal symptoms, and to assess the mother’s ability to adequately care for her baby.

General postnatal care

  • Neonatal review after birth: attention to what drugs the mother has been taking, by what route, and how recently

  • Check mother’s HIV, hepatitis B (HBV), and hepatitis C (HCV) status, and act accordingly

  • Some units will recommend HBV vaccination regardless of maternal status

  • If the mother is taking opiates, naloxone should not be used as there is some evidence that it may provoke a serious withdrawal reaction

  • Inform the appropriate allocated or duty social worker of the birth as soon as possible

  • The baby should be kept with mother on the postnatal ward unless it has seizures, or withdrawal symptoms cannot be controlled, or a social services assessment recommends separation

  • Mothers may breastfeed unless there is another contraindication (e.g. multiple drug use), although the adequacy of the milk supply may be affected by narcotics in particular

  • All babies should be kept in hospital for at least a week or until symptoms have been controlled and maternal care is adequately assessed or appropriate alternative care is organized for the baby

  • Regular observations (temperature, heart rate, respiration) and drug withdrawal symptoms should be scored regularly from birth. Most units will have a ‘drug withdrawal chart', which will score the baby according to withdrawal symptoms (although scoring systems and guidelines vary). An example of a ‘Neonatal abstinence chart’ is shown in Fig. 3.1

  • Minimal handling

  • Send urine (or urine dipstick) for toxicology

  • Decision for discharge should involve multidisciplinary input, with maternity, neonatal, and social services involvement. A case conference may need to be organized before discharge

  • Inform GP/health visitor of discharge

  • There is evidence that babies who withdraw may have long-term developmental concerns. Arrange outpatient follow-up for neurodevelopmental assessment.

Relevant drugs

Opiates

  • May be illicit or prescribed. May include morphine, heroin, pethidine, and methadone. Also be aware of mothers who have had prolonged analgesia (e.g. in sickle cell disease)

  • Withdrawal symptoms in the baby may occur from day 1 up to day 7, and in mothers dependent on methadone, seizures may occur even later (methadone has a long half-life)

  • Symptoms of withdrawal include:

    • central nervous system: irritability, high-pitched cry, sleep disturbance, seizures

    • autonomic nervous system: yawning, sneezing, sweating, hiccups

    • gastrointestinal: poor feeding, disordered suck, vomiting, diarrhoea

    • respiratory: tachypnoea.

Treatment

  • Indications:

    • withdrawal score persistently high

    • seizures

    • inability to feed, sleep, or gain weight

  • Oral morphine is the drug of choice for babies withdrawing from narcotics. Dose should be adequate to control symptoms. Length of withdrawal process is very variable and may take many weeks. Weaning should be gradual and according to baby’s needs

  • Consider discharge on medication (e.g. morphine if baby is stable and the community support is appropriate).

Cocaine

  • Features of withdrawal typically occur during first 5 days of life

  • Signs are usually mild (in contrast to opiate withdrawal)

  • Effects of fetal cocaine exposure may include:

    • vasoconstriction: fetal hypoxia and stillbirth, placental abruption, preterm labour, intrauterine growth retardation (IUGR), microcephaly, intracerebral ischaemic lesions, limb reduction defects

    • increased neurotransmission: hyperactivity, irritability, abnormal sleep patterns, increased tone

  • Postnatal cranial ultrasound scan should be done prior to discharge.

Cannabis

  • Inconsistent clinical signs in infant

  • May cause IUGR, preterm delivery, and some neurobehavioural problems.

Further information

American Academy of Pediatrics Committee on Drugs. Neonatal drug withdrawal. Pediatrics 1998; 101: 1079–1088.Find this resource:

Down’s Syndrome Association. Problems on the postnatal ward www.downs-syndrome.org.uk/.

Hudak ML, Tan RC, The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics 2012; 129: e540.Find this resource:

National Institute for Health and Clinical Excellence (2006) NICE guidelines (CG37). Postnatal care up to 8 weeks after birth. Problems on the postnatal ward www.nice.org.uk/guidance/cg37

NHS Population screening programmes guidance, Newborn & Infant Physical Examination: ultrasound scan for hip dysplasia. Problems on the postnatal ward www.gov.uk/government/publications/newborn-and-infant-physical-examination-ultrasound-scan-for-hip-dysplasia