Achieving Early Mother-baby Skin-to-skin Contact in Caesarean Section: A Quality Improvement Initiative

Objective: To improve rate of skin-to-skin contact for earlyinitiation of breastfeeding at birth on operation table amonghealthy term and late pretem babies born by caesarean sectionsfrom 0% to 80% in eight weeks.Methods: A quality improvement initiative was undertaken atmaternity-newborn care unit of a tertiary-care hospital. A teaminvolving Neonatologists/Pediatricians, Obstetricians,Anaesthesiologists, and Nurses in concerned areas identifiedproblem areas using Fish bone analysis. Situational analysis wasdone through process flow mapping. Three Plan-do-study-actcyles were undertaken. Firstly, sensitization of personnel wasdone and a written policy was made. Secondly, maternalcounselling and procedural modifications were done. Lastly,efforts were made to improve duration of contact.Results: Rate of earlyskin-to-skin contact after Plan-do-study-act cycle 1, 2 and 3, respectively was 87.5%, 90% and 83.3%. Itwas 100% after sustainability phase after four months.Conclusion: Early skin-to-skin contact was achievable throughsensitization of all persons involved and simple proceduralchanges. Prolonging duration of contact remained a challenge.

Encephalitic presentation of Neonatal Chikungunya: A Case Series

Objective: To describe clinical features and early neurological outcomes in neonatalChikungunya. Methods: Clinical, pathological and radiological details of neonates with acuteencephalitic features and typical rash, later diagnosed as Chikungunya, are presented.Neurodevelopmental evaluation and imaging was done at discharge/three months. Results:Abnormal neurological examination with fever was typical presentation in all 13 babies with/without seizures/peri-oral rashes; 12 had persistent neurological abnormalities at discharge.A follow-up at three months revealed continued neurodevelopmental deficits. Neuroimagingabnormalities were seen in eight out of ten cases. Conclusions: Perinatal Chikungunyashould be considered in neonates presenting within first week with fever, encephalopathy andperioral rashes with/without seizures with history of maternal Chikungunya within last weekbefore delivery.

Acute renal failure in neonatal sepsis.

OBJECTIVE: To evaluate the occurrence of acute renal failure (ARF) and the factors associated with it in cases of neonatal sepsis. METHODS: The case control study was conducted in the referral neonatal intensive care unit of a tertiary teaching hospital. 200 out born neonates with sepsis admitted to the nursery from January to July 2003 were evaluated for presence of ARF (cases) or not (controls). Sepsis was diagnosed on the basis of either a positive sepsis screen (immature: total (I:T) neutrophil ratio > 0.2, micro-ESR > age in days + 2 mm or> 15 mm, CRP> 6 mg/dl, TLC< 5000 cells/mm3; 2 or more positive) or a positive blood culture in symptomatic neonates. ARF was defined as blood urea nitrogen (BUN)> 20mg/dl on two separate occasions at least 24 hours apart. Oliguria was defined as urine output < 1 ml/Kg/hr. RESULTS: 52 out of 200 (26%) neonates with sepsis had ARF; only 15% of ARF was oliguric. The mean gestation of neonates with ARF was similar to those without ARF (36.1+/-4.1 wks vs. 36.6+/-3.5 wk; p = 0.41). A significantly higher number of babies with ARF weighed less than 2500 gm as compared to those without ARF (86.5% vs 67.6%; p = 0.008). The association of meningitis, disseminated intravascular coagulation (DIC) and shock was also significantly higher in neonates with ARF (46.8% vs 26.2%, p = 0.01; 65.4% vs 20.3%, p < 0.001; 71.2% vs 27.0%, p < 0.001 respectively). Mortality in neonates who developed ARF was significantly higher (70.2% vs 25%, p < 0.001). Factors including gestational age, weight, onset of sepsis, culture positivity, associated meningitis, asphyxia, shock, prior administration of nephrotoxic drugs were subjected to univariate analysis for prediction of fatality in neonates with sepsis and ARF; only shock was found to be a significant predictor of fatality (p< 0.001). ARF had recovered in 22 out of 49 neonates in whom data was available; three patients had left against medical advice. The mean duration of recovery in these 22 neonates was 5.5 days (range 1-14 days). Presence of co-existing morbidities (perinatal asphyxia/congestive heart failure (CHF)/ necrotising enterocolitis (NEC)) or nephrotoxic drugs did not alter the frequency of recovery of ARF in septic neonates (45.5% vs 44.4%,p = 0.944; 41% vs 52%, p = 0.308 respectively). CONCLUSION: Renal failure occurred in 26% neonates with sepsis. Although ARF in neonates has been reported to be predominantly oliguric, it was observed that ARF secondary to neonatal sepsis was predominantly non oliguric. Low birth weight was an important risk factor for the development of ARF. The mortality being three times higher in neonates with ARF demands a greater awareness of this entity among practitioners and better management of this condition.

Incidence of periventricular leucomalacia among a cohort of very low birth weight neonates(< 1500 g).

BACKGROUND: Periventricular leucomalacia (PVL) is the most important neuropathologic lesion underlying major neuro-motor deficits of pre-term very low birth weight (VLBW) infants. Published data regarding PVL is not available from our country. OBJECTIVES: A study was planned with main objectives to estimate incidence and describe natural history of PVL among a very low birth weight cohort. STUDY DESIGN: A cohort study was performed on inborn VLBW babies over one year period at a tertiary neonatal intensive care unit. Serial weekly cranial ultrasounds were performed on 97 enrolled subjects until discharge, to diagnose and describe natural history of PVL. RESULTS: 31 out of 97 enrolled subjects developed PVL. No case of PVL developed beyond 19 days of postnatal life. Serial ultrasounds for each baby were tracked until discharge or death. Majority of lesions at onset were flares. Cysts tended to develop in over one third of cases during course of hospital stay. About 50% of ultrasound had normalized at discharge and sequelae such as cerebral atrophy and ventriculomegaly had appeared in few, the rest of lesions being either flares or cysts of PVL. CONCLUSIONS: PVL is fairly common among very low birth weight neonates. Ultrasonographic lesions of PVL undergo dynamic evolution from time of first detection to either progress, regress or leave sequelae before discharge. Ultrasound remains an important bedside diagnostic tool for PVL.

Chorioangioma Syndrome: Co-relation of Color Doppler Ultrasound and Pregnancy Outcome

Large chorioangiomas are rare and associated with significant fetal and maternal risks. A case of chorioangioma syndrome is presented with polyhydramnios, pre-eclampsia, preterm labor and fetomaternal hemorrhage. Antenatal diagnosis is possible with ultrasound, and the prognosis for pregnancy outcome can be predicted by evaluating the vascularity of the tumor on color doppler sonography.

Preserved umbilical cord facilitates antenatal diagnosis of spinal muscular atrophy.

Spinal Muscular atrophy (SMA) Type I is a fatal autosomal recessive disease caused by homozygous deletion of telometric region of exon 7/8 of the SMN gene. Prenatal diagnosis is feasible and desirable by most families. We report on prenatal diagnosis of SMAI in a family where dried umbilical cord stump from the deceased affected baby was used to confirm the diagnosis. Prenatal diagnosis was provided in the subsequent pregnancy. We emphasize the need for storing DNA from individuals affected with suspected single gene disorders.