Oxford Handbook of Midwifery (133 page)

1. Ainsworth SB, Wylie JP, Wren C (1999). Prevalence and clinical significance of cardiac murmurs in neonates.
   Archives of Diseases in Childhood
   80,
   43–5.
   
2. Azhar AS, Habib HS (2007). Accuracy of the initial evaluation of heart murmurs in neonates: Do we need an echocardiogram?
   Pediatric Cardiology
   27
   , 234–7.
   

   CHAPTER 23
   Care of the newborn
   

   628‌‌
   

   Management of the small for gestational age baby
   

   Definition
   

   A small for gestational age baby is any baby whose weight falls below the 10th percentile for its gestational age.
   ¹
   

   A baby can be premature and small for dates, or term and small for dates, for example:
   

   • A baby born at 28 weeks who weighs 500g
     
   • A term baby who weighs 2500g.
     

     Determination
     

   • Gestational age is calculated using ultrasound scanning, where measurement and comparison of the fetal skull and femur enable determination of the age in days, size and weight.
     
   • Whether the baby is the correct size for its gestational age or if it is growth restricted can also be determined.
     ²
     

     Causes
     

     The small for gestational age baby will have been starved
     in utero
     due to poor placental supply of nutrients. Some of the causes relate to poor maternal health, others relate to socio-economic factors, and some are fetal, for example:
     

   • Pregnancy-induced hypertension
     
   • Antepartum haemorrhage
     

     •
     Congenital infection
     

   • Multiple pregnancy
     
   • Some congenital abnormalities
     
   • Poor diet
     
   • Smoking
     
   • Alcohol
     
   • Drug abuse
     
   • Poor housing
     
   • Unemployment.
     ³
     

     There may be genetic and racial inheritance reasons why babies appear small when weighed and measured using standard percentile charts designed for the average European Caucasian population. This is often the case for babies of Asian origin. Also, occasionally, it may also be linked to poor diet and health, where the mother, living in a different culture, finds it difficult to obtain food she would normally enjoy.
     ²
     

     Due to poor nourishment from the placenta, the fetus is unable to lay down any spare stores of fat or glycogen and, once born, the baby will have difficulty in maintaining temperature and blood glucose levels.
     

   • Although the baby will be small, his or her organs will be mature, especially if it is near to term.
     
   • If the baby is also preterm, then the problems will be compounded by immaturity of the main organs and, depending on its gestation, this baby will also be at risk of the complications of prematurity and will
     

MANAGEMENT OF THE SMALL FOR GESTATIONAL AGE BABY

629

need to be managed as a preterm baby (b see Management of the preterm baby, p. 634).

Poor fetal growth may indicate placental failure and, without intervention, the fetus may die. Caesarean section may be carried out when the fetus reaches a viable age.
³

Growth restriction

Growth of a fetus is referred to as symmetrical or asymmetrical, and is diagnosed using ultrasound scanning, when various measurements are taken:

Asymmetrical babies

Symmetrical babies

Congenital abnormalities

Small for gestational age may also be associated with some congenital abnormalities, such as trisomies (where there is an extra chromosome), leading to conditions such as Down’s and Edward’s syndromes.
³

Congenital infections

Babies with congenital infections tend to be small for dates.

CHAPTER 23
Care of the newborn

630

• The use of universal precautions are recommended for all personnel handling newborn babies.
  ⁴
  

  Taking the first letter from each name of an infection in this group spells out the word TORCH:
  

• Toxoplasmosis
  
• Others (chicken pox, measles)
  
• Rubella
  
• Cytomegalovirus
  
• Herpes.
  

  TORCH screening is the test carried out on the placenta and blood to detect these infections.
  ¹
  

  Characteristics of a small for gestational age baby
  

  At birth the baby:
  

• Will probably be active and wide awake
  
• Tends to look anxious and wizened
  
• Has a loud cry, possibly fuelled by hunger
  
• Has lax, dry, and cracked skin
  
• Has a flat or scaphoid abdomen, due to poor liver storage of glycogen and a lack of subcutaneous fat
  
• Has a dull, yellow, thin and stretchy cord
  
• May be jittery, due to a low blood sugar
  
• Has an apparently large head, disproportional to body size
  
• Is at increased risk of meconium aspiration:
  
  • Due to poor oxygenation through the placenta, the fetus may have become distressed and passed meconium before birth
    

    

  • The baby’s skin may also be stained with old meconium.
    ²
    ,
    3
    

    Management at birth
    

    Taking the above factors into consideration, management will depend on the gestation and condition of the baby at birth.
    

• If the baby is also premature (<37 weeks’ gestation) it may need to be admitted to the NICU or SCBU, where he or she will receive full support.
  
• Babies near to term may require intensive care if they have major problems e.g. meconium aspiration. If this has occurred, the baby must be taken to the NICU to clear the meconium from the lungs and to administer a course of antibiotics.
  
• If no major problems are apparent, then the baby can be managed in a transitional care setting, where he or she can be observed by the midwife but can be kept with or near to the parents.
  

  If on examination major problems are ruled out, care will entail management of:
  

• Temperature
  
• Glucose homeostasis
  
• Nutrition
  
• Prevention of infection
  
• Care of the family.
  

  MANAGEMENT OF THE SMALL FOR GESTATIONAL AGE BABY
  

  631
  

  Glucose homeostasis
  

  Small for gestational age babies have long been identified at risk of hypoglycaemia, due to: