Newborn Care

Routine testing of the fetus in utero start early in pregnancy with the mother having a hemoglobin and hematocrit, a urinalysis, blood group, an Rh determination, an antibody screen, rubella titer measurement, syphilis screen, cervical cytology, and hepatitis B virus screen..
As pregnancy goes on, an ultrasound should be done between 8 and 18 weeks if it's being used for dating purposes. Also, for an amniocentesis for diagnostic purposes. Chorionic villus biopsy sampling, of course, is also for chromosome imbalances and should also be done prior to 18 weeks. Maternal serum alpha-fetoprotein screening for neural tube defects should be done between 16 and 18 weeks. If the initial value is elevated, then it should be repeated. Subsequently, if that one is elevated, then an amniotic fluid alpha-fetoprotein should be done.
At 26-28 weeks, diabetes screening is recommended and repeat hemoglobin in the mother. An antibody test for Rh negative patients should be done by 28 weeks and prophylactic administration of RhoGAM should be done at that time. An ultrasound can be repeated at 32-36 weeks if one is suspicious of congenital malformations or for identification of sex, although it is very important to recognize that that is not a completely accurate test.
Prenatal diagnostic tests for birth defects. Cytogenetic indications are generally advanced maternal age; previous offspring with chromosome abnormality, especially trisomy; chromosome abnormality in either parent, especially if there is translocation such as in Down's syndrome; a need to determine the fetal sex when there is a family history of serious X-linked disease. Also, if there is a single gene disorder in a sibling or carrier or multifactorial disorders in first-degree relatives.
Documentation of dates. This should be done by the presence of fetal heart tones for 20 weeks by nonelectronic stethoscope, or 30 weeks by a Doppler ultrasound, or a positive pregnancy test of 36 weeks duration, or an ultrasound examination documenting a crown rump length between 6-11 weeks, or an evaluation at 12-20 weeks that confirms the clinical history and physical examination. An assessment of continued growth includes crown rump length, femur length, chest/abdominal circumference, and head circumference. Of course, the point here is to identify the baby's continued growth in utero. The femur length is really a very accurate tool to use in length of gestation throughout pregnancy.
In the absence of documenting length of pregnancy by any of the aforementioned methods above, the assessment of the fetal pulmonary maturity should be done when the pregnancy has to be induced, one of the most common tests to do this is a phosphatidylglycerol (PG) and if there is fetal maturity the presence of PG is positive. An L:S ratio is somewhat more accurate. It takes a longer period of time. An L:S ratio greater than two is equal to maturity. Other tests that are done, somewhat less commonly but are fairly reliable, are the foam stability index and a Delta OD 650 with a value greater than 0.15 indicating maturity.
Assessment of placental integrity is being done more and more frequently by our OB colleagues by ultrasound and by Doppler studies of blood flow. We can grade the placenta by ultrasound and determine whether or not there is calcium deposition, get a rough idea of the size placenta and whether or not placental function is normal with flow studies. There are two indices, the pulsatility index and BD index that are calculated and two ratios, systolic and diastolic and diastolic over average ratios that are being assessed as obstetricians evaluate blood flow through the umbilical vein. Absence of diastolic flow is a very bad prognostic sign suggesting that the fetus is not being perfused well and may well be better off out than in.
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