Apgar Score

The Apgar Score, developed in 1952 by an anaesthesiologist called Victoria Apgar, is a quick check designed to determine the physical condition of a newborn baby immediately after birth.

The test is carried out by a doctor, midwife or nurse in the delivery room usually on two occasions: one minute after birth and then again five minutes after birth. Sometimes, if there are concerns about the baby's condition or the score at five minutes is low, the test may be taken for a third time 10 minutes after birth.

It is called the Apgar Score because it checks for Appearance (skin colouration), Pulse, Grimace (responsiveness), Activity (muscle tone), and Respiration (breathing rate and effort).

The scoring system

Each of the criteria is given a score of 0, 1 or 2 and then added together to generate a total score out of 10, which gives an idea of the overall health of the baby.

The scoring system works as follows:

Appearance:

• Normal colour all over (hands and feet are pink) = 2 points
• Normal colour (but hands and feet are blue-ish) = 1 point
• Blue-ish-grey or pale all over = 0 points

Pulse:

• Normal (above 100 beats per minute) = 2 points
• Below 100 beats per minute = 1 point
• Absent (no pulse) = 0 points

Grimace (responsiveness or ‘reflex irritability’):

• Pulls away, sneezes, coughs or cries with stimulation = 2 points
• Facial movement only (grimace) with stimulation = 1 point
• Absent (no response to stimulation = 0 points

Activity:

• Active, spontaneous movement = 2 points
• Arms and legs flexed with little movement = 1 point
• No movement - ‘floppy’ muscle tone = 0 points

Respiration:

• Normal rate and effort, good cry = 2 points
• Slow or irregular breathing, weak cry = 1 point
• Absent (no breathing) = 0 points

The majority of newborns are scored between seven and 10, meaning they do not require any immediate treatment. Scores of 10 are unusual, because most newborns will lose a point for having blue hands and feet, which is typical after birth.

Scores lower than seven suggests the baby needs medical attention, and if the score remains low after multiple tests, then there is a risk that the child will suffer longer-term neurological damage.

Emergency Caesarean Section

This procedure is usually carried out when a normal vaginal delivery would put the mother or the baby at risk.

However, an emergency caesarean is performed when circumstances before or during labour call for an unplanned procedure.

A caesarean section is usually carried out under an epidural or a spinal anaesthetic causing the lower part of the body to be numbed. The procedure usually takes 40-45 minutes but, during an emergency, can be performed quicker.

The risks to the mother in a caesarean section can include an infection of the wound or the womb lining, a blood clot (thrombosis) in the legs or excess bleeding.

Doctors now give the mother a dose of antibiotics before the operation to reduce the likelihood of any infections.

Risks to the baby during a caesarean, according to the NHS, are no greater than a normal vaginal delivery but the most common problem of babies delivered by caesarean is difficulty breathing, although this usually affects babies born prematurely.

Erb's Palsy

This condition is usually caused by a traumatic childbirth where the baby's arm is paralysed when the upper group of the arm's main nerves is injured.

Erb's Palsy, or otherwise known as brachial plexus paralysis, can occur if the infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal.

The condition can also be caused by excessive pulling on the shoulders during a cephalic presentation (head first delivery), or by pressure on the raised arms during a breech (feet first) delivery.

Other causes can include a raised BMI of the mother at time of baby's birth, a high weight at birth and a long second stage of labour.

The child is usually unable to abduct the arm from the shoulder, rotate the arm externally from the shoulder or supinate the forearm giving them a 'waiter's tip' appearance.

Hand grasp in children with Erb's Palsy is usually normal unless the lower part of the plexus is also damaged.

Some babies recover on their own but some need specialist treatment.

Gestational Diabetes

Diabetes is condition where there is too much glucose in the blood which is controlled by a hormone called insulin.

The illness is caused by either insufficient insulin being produced or the body is becoming resistant to insulin.

Gestational diabetes is when, during pregnancy, the woman's body produces a number of hormones which make her body insulin-resistant. The purpose of this hormonal effect is to allow the extra glucose and nutrients in your blood to pass to the foetus so it can grow.

Her body should produce more insulin in order to cope with the increased amount of glucose in the blood. However, some women cannot produce enough insulin in pregnancy to transport the glucose to the cells or their body is becoming more resistant to insulin.

Pregnant women may be more likely to have gestational diabetes if her body mass index is high, if they have previously had a baby weighing more than 10lbs at birth or if they have a family history of diabetes.

Some women may need medication to control their glucose levels but most can control the gestational diabetes through diet and exercise.

Gestational diabetes is usually developed after 28 weeks and usually disappears after the baby is born. However, women who develop gestational diabetes are more likely to develop type 2 diabetes later in life.

If the gestational diabetes is not detected it can cause problems during and after birth.

These include; a risk of the child becoming obese or have diabetes later in life, trauma during birth and placental abruption whereby the placenta starts to come away from the wall of the womb which can cause vaginal bleeding and abdominal pain.

Other complications which can occur include; needing to induce labour, premature labour and even perinatal death, where the baby dies around the time of the birth.

Hypoxic-Ischemic Encephalopathy (HIE)

This brain injury occurs in newborn babies and is caused by oxygen deprivation to the brain, also known as intrapartum asphyxia.

Although a newborn's body can manage for brief periods of time with reduced oxygen, if it lasts too long then the brain tissue is destroyed.

Hypoxic-ischemic encephalopathy due to fetal or neonatal asphyxia is a leading cause of death or severe impairment among infants.

Effects of this brain injury can include delays in neuro-development, cognitive impairment and epilepsy; the area of the brain injury can depend on the timing and severity of the asphyxia.

MRI scans are usually performed once hypoxic-ischemic encephalopathy is suspected to aid diagnosis.

Although there is no definite cure for HIE. any treatment includes helping the child adapt to symptoms of the brain injury and physical and occupational therapy is commonly used.

Necrotising Enterocolitis

Primarily found in premature infants, this medical condition is when parts of the bowel undergo 'necrosis' meaning tissues become inflamed and start to die.

A perforation (hole) may develop which can allow the contents of the intestine to leak into the abdomen which can cause a very dangerous infection.

The symptoms of Necrotising Enterocolitis (NEC) include problems feeding or vomiting a a swollen and tender abdomen. According to Great Ormond Street Hospital, NEC is the most common surgical emergency in newborn babies.

If a perforation does not form, then surgery may not be needed, instead, the baby's bowel should be rested from intravenous feeding.

There is a risk of further bowel damage during surgery as well as a risk of bleeding during of after the operation. Future progress can depend on how prematurely the child was born and whether the bowel was removed during surgery which can effect normal growth and development.

Ovarian Hyperstimulation Syndrome

This is a rare but serious consequence of taking fertility drugs during in-vitro fertilisation (IVF) treatment.

This complication occurs in women who are very sensitive to the fertility drugs taken to increase egg production, causing too many eggs are produced which makes the ovaries become very large and painful.

Symptoms of Ovarian Hyperstimulation Syndrome (OHSS) begin with abdominal pain and bloating; these symptoms usually appear 4 or 5 days after the eggs are collected.

More severe symptoms include low levels of protein in the blood and decreased output of urine which can become very dangerous.

OHSS is more common in women under 30 and those with Polycystic Ovary Syndrome.

A mild degree of OHSS occurs in 33% of IVF treatment whereas the more severe cases occur in 1-2% of IVF where the patient is ill with severe pain, nausea and vomiting.

Spinal epidural haematoma - Over Anti-coagulation

This injury can be caused by a number of factors including childbirth or surgery where bleeding into the epidural space in the spine can occur.

However, here we are focusing on epidural haematoma caused by over anti-coagulation.

In the spine, the epidural space contains loose fatty tissue and a network of large, thin-walled veins. This means that bleeding is likely to be venous.

Anatomical abnormalities and bleeding disorders make these lesions more likely. They may cause pressure on the spinal cord or cauda equina. The diagnosis may be made on clinical appearance and time course of symptoms. It usually requires MRI scanning to confirm. The treatment is surgical decompression.

However, when epidural haematoma is caused by over anti-coagulation, the sufferer will be on anticoagulant medication which prevents the blood from clotting.

Over anti-coagulation is when the patient has taken too many anticoagulant drugs which can result in bleeding or bruising easily. This can then affect the epidural space and can lead to haematoma and even paraplegia.

Read about a case of Helen Dolan's which settled for a lump sum of £2.3 million after an elderly woman suffered an epidural haematoma due to over anti-coagulation.