3.7.small For Ga-Livuka

CATHOLIC UNIVERSITY OF
HEALTH AND ALLIED SCIENCE

SCHOOL OF NURSING
BSN &BSNE
COURSE: MIDWIFERY
TOPIC: SMALL FOR GESTATIONAL AGE
OBJECTIVES
At the end of this session students will be able
to;
• Define relevant terms related to birth weight.
• Classify birth weight in relation to GA
• Assess infant gestational age
• Diagnose Small for Gestational age infant-SGA
• Recognize types of SGA
• Provide care to infant with SGA
• Provide care to infant with LGA
Introduction
• Before 1960s
1. Low Birth Weight or LBW less than
2500gm =Prematurity
2. All other babies 2500 gm and over = normal
3. Focus was on low birth weight babies because

of their increased mortality
Brainstorm
WHAT IS THE PROBLEM WITH THE

OLD CLASSIFICATION?
Introduction cont’d
• Problems with the old classification:
1.Not all small babies are premature
2.Not all premature babies are small
• Epidemiological studies revealed that full-term

babies with low birth weight had higher
mortality than full term-babies of normal
weight
Brainstorm
• A born with GA of 35 weeks weighs 2250gms
• Is this a low birth weight baby?
• Is this a Small for Gestational Age baby?

Low Birth Weight
• Low birth weight is defined as 2499gms or less
regardless of the gestational age
• Three categories;
1.Low Birth Weight (LBW) <2500gms
2.Very Low Birth Weight (VLBW)<1500gms
3.Extreme Low Birth Weight.(ELBW)<1000gms

Low Birth Weight cont. …
• Low birth weight less than 2.5kg can be;
• PRETERM
• SMALL FOR GESTATIONAL AGE

Classification on GA
• Large for gestational age: Weight is above the
90th percentile at gestational age (LGA)
• Appropriate for gestational age: Normal birth

weight (AGA)
• ▪Small for gestational age: Weight is below

the 10th percentile at gestational age (SGA)
Lowdermilk, 2012
Gestational Age Assessment
• Perinatal morbidity and mortality rates are
related to gestational age and birth weight.

• Simplified Assessment of Gestational Age scale
• Abbreviated version of the Dubowitz scale
• Measure gestational ages of infants between
35 and 42 weeks.
• Six external physical signs
• Six neuromuscular signs
• Each sign has a numerical score, and the
cumulative score correlates with a maturity

rating of 26 to 44 weeks of gestation.
• The New Ballard Score
• Newborns as young as 20 weeks of gestation.
• −1 to −2 scores that reflect signs of extremely
premature infants, such as fused eyelids;
imperceptible breast tissue; sticky, friable,
transparent skin; no lanugo; and square-window
(flexion of wrist) angle greater than 90 degrees
• Time for examination of infants;
• Gestational age of 26 weeks or less - postnatal age of
less than 12 hours.
• A gestational age of at least 26 weeks - up to 96
hours after birth- within the first 48 hours of life-
Accuracy.
• Neuromuscular adjustments after birth in extremely
immature neonates require that a follow-up
examination be performed to further validate
neuromuscular criteria
• Video on GA assessment of New born
Maneuvers used in assessing GA
SQUARE WINDOW
• With thumb supporting back of arm below
wrist, apply gentle pressure with index and third
fingers on dorsum of hand without rotating
infant’s wrist. Measure angle between base of
thumb and forearm. Full flexion (hand lies flat
on ventral surface of forearm)= score 4.*
ARM RECOIL
• With infant supine, fully flex both forearms on
upper arms and hold for 5 seconds; pull down
on hands to extend fully, and rapidly release
arms. Observe rapidity and intensity of recoil to
a state of flexion. A brisk return to full flexion =
score 4.*
POPLITEAL ANGLE
• With infant supine and pelvis flat on a firm
surface, flex lower
• leg on thigh and then flex thigh on
abdomen. While holding knee with thumb
and index finger, extend lower leg with
index finger of other hand. Measure degree
of angle behind knee (popliteal angle). An
angle of less than 90 degrees = score 5.*
SCARF SIGN
• With infant supine, support head in midline
with one hand; use other hand to pull infant’s
arm across the shoulder so that infant’s hand
touches shoulder.
• Determine location of elbow in relation
tomidline. Elbow does not reach midline =
score 4.*
HEEL TO EAR
• With infant supine and pelvis flat on a firm
surface, pull foot as far as possible (without
using force) up toward ear on same side.
• Measure distance of foot from ear and degree of
knee flexion(same as popliteal angle). Knees
flexed with a popliteal angle of less than 10
degrees = score 4.*
Classification of Newborns by Gestational
Age and Birth Weight
• The infant’s birth weight, length, and head
circumference are plotted on standardized
graphs that identify normal values for
gestational age.
• A normal range of birth weights exists for each
gestational week.
• More satisfactory method for predicting mortality
risks.
• Providing guidelines for management of the neonate.
Intrauterine growth: birth weight percentiles GA
based on live single births at 20 to 44 weeks.
Intrauterine growth: birth weight percentiles GA
based on live single births at 20 to 44 weeks.
Small for Gestational Age
Types of SGA;
1.Malnourished SGA
2.Hypoplastic SGA
3. Mixed SGA
1. Malnourished SGA
• Common
• Asymmetrical IUGR
• 2/3 of IUGR
• Later in pregnancy-malnutrition
• Placental dysfunction / placental insufficient

Malnourished SGA
• Appearance- long thin and marusmic
• Cell size decrease but number is normal
• Brain unaffected
• Internal organs; liver grossly shrunken
• HC greater than CC by 3cm
• Loose skin folds
• Nutritional rehabilitation
• Positive growth potential and Good prognosis
Malnourished SGA
2. Hypoplastic SGA
• Symmetrical IUGR
• 1/3 of IUGR
• Growth retardation in early pregnancy
• Intrauterine infection
• Chromosomal aberration
• Genetic defects
• 10-20 times higher incidence of anomalies
Hypoplastic SGA
• Features;
• All organs affected include brain
• Decrease in cell number
• All parameters are proportionately small
• Poor prognosis
• Permanent physical and mental retardation

3.Mixed SGA
• Adverse factors during both early and later in
pregnancy
• Neither grossly hypoplastic nor obvious
malnourished
• Both cell size and cell number decrease
Small for gestational age-SGA
• Causes can be;
• Maternal
• Fetal
• Placental
• Environmental
• CAUSES; Maternal factors
• Nutritional
• Parity-grand
• Diseases
• Life style- smoking, alcohol
• Poor weight gain

• CAUSES- Fetal factors;
• Genetic defect
• Multi-pregnancy
• IU fetal infection
• 1st born
• CAUSES- Placental
• Vascular thrombosis
• Abruption
• Structural abnormality
• Placental infarct
• CAUSES; - Environmental
• Ethnic / racial/ geographic
• Social-economic
• Diseases
• Nutritional
Characteristic features for SGA neonate
skull look inordinately large
 Reduced subcutaneous fat stores
 Loose and dry skin
 Diminished muscle mass (buttocks & Cheeks)
 scaphoid
 Thin, yellowish, dry, and dull umbilical cord
 Sparse scalp hair
 Wide skull sutures
Care of the SGA infant
• Based on the clinical problems.
• Maintaining a clear airway-GAS EXCHANGE.
• Oral feedings (e.g., breast, formula) or IV
dextrose- HYPOGLYCEMIA
• An external heat source (radiant warmer or
incubator)- HYPOTHERMIA
Common problems that affect SGA (IUGR)
infants.
Perinatal asphyxia
Meconium aspiration
Immunodeficiency
Hypoglycemia
Polycythemia
Temperature instability
Lowdermilk, 2012
Perinatal asphyxia
• Commonly
• exposed to chronic hypoxia
- Labor as stressor.
- severely compromised even by a normal labor
- difficulty compensating after birth
• Appropriate management and resuscitation are essential
for these depressed infants.

Perinatal asphyxia
• The birth of SGA babies with perinatal asphyxia
can be associated with;
• A maternal history of heavy cigarette smoking;
• Preeclampsia
• Low socioeconomic status
• Multifetal gestation;
• Gestational infections such as rubella,
cytomegalovirus, and toxoplasmosis
• Advanced diabetes mellitus and cardiac
problem.
Hypoglycemia
• Hypoglycemia as a result of;
 Decreased glycogen supply
 Inadequate gluconeogenesis
 Overutilization of glycogen stored during fetal
and postnatal life.

 Inadequate intake
Hypoglycemia
• Symptoms of hypoglycemia include;
• poor feeding, hypothermia, and diaphoresis.
• CNS symptoms can include tremors and
jitteriness, weak cry, lethargy, floppy posture,
convulsions, or coma.
• Blood glucose screening should be done on all
high risk infants soon after birth and frequently
during the first few hours until glucose levels
stabilize.
Polycythemia
• Common in SGA Infants
• Hyper viscosity of the blood
• An excess in circulating RBC mass.
fetal hypoxia
intrauterine stress
• With hematocrit greater than 65% or venous
hemoglobin greater than 22 g/dl, blood
viscosity is increased -compromised blood
flow- reduced oxygenation of the body organs.
Lowdermilk, 2012
Polycythemia
• Many infants with polycythemia are
asymptomatic Others present with plethora,
cyanosis, CNS abnormalities. (lethargy,
jitteriness, seizures), respiratory distress,
tachycardia, congestive heart failure, or
hypoglycemia
• Polycythemia is associated with;
• maternal preeclampsia, maternal smoking
• maternal diabetes and delayed cord clamping.
Lowdermilk, 2012
Temperature instability
• Heat Loss; susceptible to temperature
instability decreased brown fat deposits,
decreased adipose tissue, large body surface
exposure, poor flexion, decreased glycogen
storage in major organs such as the liver and
heart.
• Close attention must be given to maintain
thermo neutrality to promote recovery from
perinatal asphyxia because cold stress
jeopardizes such recovery.
Lowdermilk, 2012
Large for Gestational Age Infants
• The LGA infant is at greater risk for morbidity
than the SGA or preterm infant;

 An increased incidence of birth injuries,
asphyxia, and congenital anomalies such as

heart defects
Lowdermilk, 2012
• LGA newborns can be preterm, term, or post
term
• They may be infants of mothers with diabetes;
or they can be post mature.
• Each of these problems carries special concerns.
• Regardless of coexisting potential problems, the
LGA infant is at risk by virtue of size alone.
Lowdermilk, 2012
• Midwife assesses the LGA infant for;
• Hypoglycemia
• Trauma resulting from vaginal or cesarean
birth
• Any specific birth injuries are identified and
treated appropriately
Lowdermilk, 2012
References
• Dutta D. C (2015). Textbook of Obstetrics including
perinatology and contraception, 8th Edition
• Lowdermilk L. D., Perry, S.E. , Cashion , K. & Alden, K.R
(2012). Maternity &Women's Health Care (10th Ed)
Elsevier Inc
NAHAVACHENI
ASANTENI

3.7.small For Ga-Livuka

Uploaded by

Copyright:

Available Formats

3.7.small For Ga-Livuka

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

3.7.small For Ga-Livuka

Uploaded by

Copyright:

Available Formats

CATHOLIC UNIVERSITY OF

HEALTH AND ALLIED SCIENCE

2. All other babies 2500 gm and over = normal

3. Focus was on low birth weight babies because

WHAT IS THE PROBLEM WITH THE

• Epidemiological studies revealed that full-term

• A born with GA of 35 weeks weighs 2250gms

• Is this a low birth weight baby?

• Is this a Small for Gestational Age baby?

1.Low Birth Weight (LBW) <2500gms

2.Very Low Birth Weight (VLBW)<1500gms

3.Extreme Low Birth Weight.(ELBW)<1000gms

• SMALL FOR GESTATIONAL AGE

• Appropriate for gestational age: Normal birth

• ▪Small for gestational age: Weight is below

• Perinatal morbidity and mortality rates are

related to gestational age and birth weight.

• Abbreviated version of the Dubowitz scale

• Measure gestational ages of infants between

• Six external physical signs

• Six neuromuscular signs

• Each sign has a numerical score, and the

cumulative score correlates with a maturity

• Placental dysfunction / placental insufficient

• All organs affected include brain

• Decrease in cell number

• All parameters are proportionately small

• Permanent physical and mental retardation

• Adverse factors during both early and later in

• Causes can be;

• CAUSES; Maternal factors

• Life style- smoking, alcohol

• Poor weight gain

• CAUSES- Fetal factors;

• Ethnic / racial/ geographic

• Maintaining a clear airway-GAS EXCHANGE.

• Oral feedings (e.g., breast, formula) or IV

• exposed to chronic hypoxia

- severely compromised even by a normal labor

- difficulty compensating after birth

• Appropriate management and resuscitation are essential

for these depressed infants.

 Overutilization of glycogen stored during fetal

and postnatal life.

• The LGA infant is at greater risk for morbidity

than the SGA or preterm infant;

asphyxia, and congenital anomalies such as

• Midwife assesses the LGA infant for;

• Trauma resulting from vaginal or cesarean

You might also like