Oxford Handbook of Midwifery (132 page)

of a scalp electrode in labour. Small superficial haemorrhages of the head, face, and neck may resemble cyanosis, but are due to congestion of blood vessels in the head. This may occur due to trauma or a precipitate delivery—no treatment is required.

Practice points

CHAPTER 23
Care of the newborn

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Congenital abnormalities

The incidence of congenital abnormalities varies between 2% and 7% of livebirths. They are classified into two groups, malformations and defor- mations. Malformations result from disturbed early embryonic growth,

e.g. congenital heart disease. Deformations result from late changes to normal structures by pathological processes or intrauterine forces.
¹

Causes

• Teratogens: substances like chemicals, drugs, viruses or radiation
  
• Excessive alcohol intake: fetal alcohol syndrome
  
• Infections: e.g. rubella
  
• Chemicals: e.g. mercury
  
• Maternal disease: e.g. diabetes, maternal PKU.
  

  Examination
  

  The most obvious defects will be detected shortly after birth during the neonatal examination.
  ²
  

  The face
  

• There is a wide range of recognizable features called dysmorphic features which may suggest congenital abnormality.
  
• The position of the eyes in relation to the nasal bridge should be noted. If they are too far apart this is called hypertelorism and if they are too close together this is called hypotelorism.
  
• Low-set ears are seen in a variety of conditions including Potter’s syndrome.
  

  •
  Cleft lip and/or palate occurs in 14.6 per 10 000 births.
  

• A large or protruding tongue may suggest hypothyroidism or Down’s
  

  syndrome.
  

• An underdeveloped jaw, called micrognathia, is seen in Pierre Robin syndrome.
  

  The chest
  

• It should be symmetrical and move equally on respiration.
  
• A small chest may occur with hypoplastic lungs and in a variety of rare syndromes.
  

  The abdomen
  

• Distension suggests intestinal obstruction.
  
• A scaphoid abdomen suggests diaphragmatic hernia.
  
• An umbilical hernia may be present.
  
• The anus should be patent.
  

  The genitalia
  

• Testes should be present in the scrotum in 98% of full term boys.
  
• Hypospadias occurs if the opening of the urethra is on the underside of the penis.
  
• Epispadias occurs if the urethral opening is on the upper side of the penis.
  
• A hydrocele (fluid filled cyst) may be present in the scrotum. No treatment is required as they usually spontaneously resolve.
  

  CONGENITAL ABNORMALITIES
  

  625
  

The extremities

Recommended reading

Davies L, McDonald S (2008).
Examination of the Newborn and Neonatal Health: A Multidimensional Approach
. Edinburgh: Churchill Livingstone.

1. Levene MI, Tudehope DI, Thearle MJ (2000).
   Essentials of Neonatal Medicine
   , 3rd edn, Oxford: Blackwell, 25–31.
   
2. Baston H, Durward H (2001).
   Examination of the Newborn. A Practical Guide
   . London. Routledge, 65–91.
   

   CHAPTER 23
   Care of the newborn
   

   626‌‌
   

   Heart murmurs in the newborn
   

   Murmurs are caused by the sound of turbulent blood flow into the cham- bers and vessels of the heart. This will usually be detected during the neo- natal examination undertaken prior to the baby being discharged home from hospital after the birth.
   

   Increasingly this holistic examination is being performed by suitably trained midwives as part of the continuing care given to all mothers and babies. Community midwives undertaking the assessment in the mother’s home have clear referral guidelines to follow if a problem is detected. It is common for babies to have a heart murmur in the first 24h following birth. This is the time during which two structures of the fetal circulation complete their closure in response to onset of respirations and the establishment of a normal pulmonary circulation.
   

   The two structures are:
   

   • The foramen ovale—an opening in the atrial septum
     
   • The ductus arteriosus—a vessel connecting the pulmonary artery to the aorta. This normally closes within 24h.
     

     Another examination is carried out at the age of 6 weeks on all babies, during which the heart is examined again.
     

     Significance of heart murmurs
     

     In one study murmurs were detected in 0.6% of babies, of whom around half had a cardiac malformation.
     ¹
     Some babies who were later diagnosed with cardiac malformations had a normal neonatal examination.
     ²
     The study concluded that the neonatal examination only detects 44% of cardiac mal- formations, but if a murmur is heard there is a 54% chance of it being due
     

     to a cardiac malformation. Occasionally heart murmurs are not diagnosed
     

     for several months.
     

     Management
     

     2 Babies presenting with a murmur during examination should be referred to a consultant paediatrician. This needs to be sensitively explained to parents who are waiting to go home with their baby after this examination takes place.
     

     If the consultant suspects an abnormal murmur an echocardiogram is arranged. If a problem is suspected, the baby will be referred to a cardiologist for more detailed investigations.
     

     Other signs that may become apparent in the baby in the first few days of life if there is a cardiac malformation are:
     

   • Tachypnoea
     
   • Feeding difficulties
     
   • Cyanosis around the lips
     
   • Failure to gain weight.
     

Provided the baby is otherwise well and there are no feeding problems parents may take the baby home in the interim period while awaiting appointments and tests.

HEART MURMURS IN THE NEWBORN

627

The two most common cardiac defects in children are: