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Assessing an infant’s gestational age at birth2-1 What is gestational age?Gestational age (or the duration of pregnancy) is measured in weeks from the first day of the mother’s last normal menstrual period to the day of delivery. Note ‘Gestational age’ or menstrual age differs from post-conceptual age, which is the duration from conception to birth. Post-conceptual age is 2 weeks less than gestational age. It is important to remember this when assessing the gestational age of infants conceived by in vitro fertilisation.2-2 What is the average gestational age?The average gestational age is 40 weeks (280 days). Not all women with normal pregnancies deliver at exactly 40 weeks however. A range of 37 weeks (259 days) to 42 weeks (294 days) is accepted as normal. Infants with a normal gestational age are called term infants. Most infants are born at term and these infants have the lowest risk of problems in the newborn period.
2-3 When is the duration of pregnancy too short or too long?Infants that are born before 37 weeks are called preterm infants. About 5% of all infants are born preterm in an affluent community and often more than 20% in a poor community. Preterm infants have a high risk of neonatal problems. Therefore, any pregnancy ending before 37 weeks is regarded as too short. Infants with a gestational age of 42 weeks or more are called postterm infants. About 5% of infants are born postterm. As these infants also have an increased risk of neonatal problems, a pregnancy of 42 weeks or more is regarded as too long. Note The words ‘premature’ and ‘postmature’ are no longer used as they are confusing and difficult to define. 2-4 How do you assess the gestational age of an infant?If possible the gestational age should be determined before delivery from the mother’s menstrual history and clinical examination in early pregnancy. An ultrasound examination before 20 weeks is also an accurate method of determining the gestational age. From 20 weeks it is less accurate. If the duration of pregnancy is unknown or uncertain, the gestational age can be roughly estimated by simply observing the infant’s appearance and behaviour. This is an inaccurate method, however, unless the examiner is very experienced. A clinical scoring test can be used to assess more accurately the infant’s gestational age. The Ballard method of scoring an infant’s gestational age is based on both the infant’s physical appearance and behaviour. Note A modification of the original Ballard method is now used to give a more accurate assessment of gestational age in infants less than 32 weeks. Wasted and growth-restricted infants tend to underscore.2-5 What are the common complications of a preterm infant?These infants have immature organs because they are born too soon. They are also small and fragile and can, therefore, be easily damaged at delivery. The common neonatal complications in infants born preterm are:
Preterm infants are therefore at high risk of many complications after birth and need special care. Many preterm infants die as a result of these complications.
2-6 What are the common complications of a postterm infant?These infants usually are large, due to the prolonged period of intra-uterine growth and, therefore, may experience birth trauma due to cephalopelvic disproportion, e.g. fractured clavicle or Erb’s palsy. Commonly the placenta is unable to provide the large fetus with enough energy and oxygen during the last extra weeks of pregnancy. Therefore, there is an increased risk of fetal distress during labour and also soft tissue wasting with hypoglycaemia soon after birth.
Assessing an infant’s size at birth2-7 How do you determine an infant’s size after delivery?The size of a newborn infant is usually determined by weighing the naked infant after birth. While weight is often the only measurement of size that is determined after birth, it is also useful to measure the infant’s head circumference. Sometimes the crown-heel length is also measured at birth. However, length is difficult to measure accurately and, therefore, is usually not recorded routinely. 2-8 Why should you determine an infant’s birth weight?After delivery all infants should be weighed because:
2-9 How do you group infants by their birth weight?Infants can be divided into groups by their birth weight. This is particularly useful if the gestational age is not known. Most infants weigh between 2500 g and 4000 g at birth. These infants are usually healthy and require only routine care. Infants weighing less than 2500 g and infants weighing 4000 g or more have an abnormal birth weight and are at an increased risk of neonatal problems. They therefore may require special care. Infants weighing less than 2500 g are called low birth weight (LBW) infants.
Grouping infants by their weight for gestational age2-10 How can you group infants by both their weight for gestational age?Weight for gestational age can also be used to group newborn infants into low-risk and high-risk categories. It is, therefore, possible to group infants into low-risk and high-risk categories by their:
Each method is useful as it tells you something different about an infant. 2-11 How do you determine weight for gestational age?Once you have weighed an infant and assessed the gestational age, this information can be plotted on a weight for gestational age chart. Gestational age is plotted in weeks along the bottom of the chart and is divided into preterm, term and postterm categories. Birth weight in grams is plotted on the left hand margin of the chart. Note that the birth weight steadily increases with gestational age:
In a well-nourished community 80% of infants will be appropriate for gestational age, 10% overweight and 10% underweight for gestational age. However, in a poor community there may be far more underweight and far fewer overweight for gestational age infants. Many weight for gestational age standards (charts) have been used. They differ depending on the nutritional status of the study population. The international weight for gestational age standard used in this chapter is both simple and useful to screen infants. Head circumference and length standards may also be used to further classify infants. The 10th and 90th centiles are used to identify infants at increased risk and not a definition of what is optimal growth. 2-12 Why do some infants weigh more than others?You will now understand that a heavy infant may weigh more than usual at delivery because the infant is either:
Likewise a low birth weight infant may weigh less than usual at delivery because the infant is either:
2-13 What is the value of plotting an infant’s weight for gestational age?The exercise of classifying all newborn infants by their weight for gestational age is extremely useful as infants born overweight for gestational age and infants born underweight for gestational age commonly have problems during the first weeks of life. It is important, therefore, to identify these infants as soon as possible after delivery. Infants that are born at term and are appropriate for their gestational age have the lowest risk of problems in the newborn period and, therefore, usually need routine care only. An infant’s head circumference can also be plotted against gestational age on a head circumference for gestational age chart. The method is the same as that used for plotting weight for gestational age. Head circumferences between the 10th and 90th centiles are regarded appropriate for gestational age. A head circumference above the 90th centile is abnormally large while a head circumference below the 10th centile is abnormally small for gestational age. A head circumference below the 10th centile indicates that the infant’s brain is small and has not grown at the normal rate. An infant’s length for gestational age is not routinely plotted unless the length has been accurately measured.
2-14 What are the causes of an infant being born overweight for gestational age?There are 2 main causes of a fetus growing faster than usual, resulting in an overweight for gestational age infant:
However, in many cases the cause of the infant being overweight for gestational age is not known.
2-15 What are the complications of overweight for gestational age infants?Overweight for gestational age infants are at an increased risk of neonatal problems:
2-16 What are the causes of an infant being born underweight for gestational age?There are both maternal and fetal causes of slow fetal growth resulting in the birth of an underweight for gestational age infant.
Maternal hypertension and smoking result in decreased blood flow to the placenta. However, in many cases no obvious cause can be found. Note Placental causes are rare. Chronic hypertension, pre-eclampsia (gestational proteinuric hypertension) and smoking are maternal causes as the problem is in the spiral arteries not the placenta. 2-17 What is the clinical appearance of an underweight for gestational age infant?This will depend on whether the cause of slow fetal growth affected the fetus from early pregnancy or only during the last few weeks of pregnancy:
2-18 What are the clinical signs of wasting in a newborn infant?Wasting of the soft tissues, such as muscle and subcutaneous fat, may be recognised in the infant at birth by the following features:
These clinical signs suggest that the fetus has been undernourished during the last weeks of pregnancy and, as a result, has very few energy stores at birth (i.e. little glycogen, fat and muscle). 2-19 What are the common complications of an underweight for gestational age infant?All underweight for gestational age infants, whether they are wasted or not, are at an increased risk during the first weeks of life because they have often received too little food and oxygen during pregnancy. Underweight for gestational age infants, therefore, need special care after delivery. The common complications of infants born underweight for gestational age are:
If the infant is born underweight for gestational age because of congenital abnormalities, chromosomal abnormalities (e.g. Down syndrome) or chronic intra-uterine infections (e.g. syphilis), then these causes will also result in clinical problems. 2-20 Are all wasted infants either postterm or underweight for gestational age?No. Although many wasted infants are postterm or underweight for gestational age, some wasted infants are born at term with a birth weight that is appropriate for their gestational age. These infants have only been starved for a few days before delivery and, therefore, have not lost enough weight to become underweight for gestational age at birth. Therefore, all wasted infants, even if they are born at term and have a birth weight between the 10th and 90th centiles, are at an increased risk of those problems expected in underweight for gestational age infants, i.e. poor breathing at birth, hypoxia, meconium aspiration, hypothermia and hypoglycaemia. Note When a wasted infant with a birth weight that is appropriate for gestational age is plotted on the chart, the infant’s weight will be lower than the head circumference, although both measurements still fall between the 10th and 90th centiles. These are infants with acute undernutrition rather than growth restriction. Their weight rapidly returns to normal after delivery.
2-21 Which infants need their gestational age and weight assessed at birth?The gestational age should be clinically assessed and the weight measured in all infants at delivery. Many women will know their duration of pregnancy. With experience the gestational age can be roughly estimated by simple observation alone. As the Ballard score takes time to perform, it is not done routinely on all infants. However, the following high-risk infants should be scored by the Ballard method if the gestational age is uncertain. In addition their weight and head circumference should be accurately measured and plotted on the size for gestational age charts:
The risk of complications can be best assessed if both birth weight and gestational age are known and weight for gestational age determined.
2-22 Why are all infants not the same size at birth?You should realise by now that all newborn infants are not the same size at birth because the gestational age and weight may vary widely and they may or may not be wasted. Similarly all infants do not have the same risk of neonatal problems. By dividing infants into separate groups, using gestational age, weight and wasting, you should be able to identify high-risk infants and also predict the sort of problems that a particular infant will develop during the first weeks of life. This is extremely important as many of these problems are preventable with correct management soon after delivery. At the birth of every infant, the following 3 questions should be asked:
If any of these 3 questions reveals an abnormal result, then you should ask whether the infant’s weight for the gestational age falls within the normal range (i.e. between the 10th and 90th centiles)? With all this information you will be able to answer the following questions:
Now you should be able to decide whether the infant is at high risk or low risk of problems and what level of care is needed during the first days of life.
An accurate measurement of the head circumference at birth is very helpful and should be done routinely. A normal head circumference (and length) for gestational age at birth indicates that the infant has grown normally during pregnancy. A normal head circumference but low weight for gestational age suggests wasting. Knowing the head circumference at birth also assists in the clinical assessment of an older child with developmental delay or cerebral palsy. 2-24 Do low birth weight infants grow normally after birth?It depends on the reason for being low birth weight. Preterm, wasted or underweight for gestational age infants with a normal head circumference and length for gestational age at birth usually grow well during childhood. However, infants with a head circumference and length below the 10th centile at birth usually remain small for their age as children and become short adults. Case study 1A woman presents in labour at a district clinic. By her dates and abdominal palpation she is 32 weeks pregnant. After a short labour she delivers a male infant weighing 1400 g. The Ballard score confirms the gestational age. The infant’s weight falls between the 10th and 90th centiles. 1. How would you classify this infant by weight alone?This is a low birth weight infant as the weight is less than 2500 g. 2. How would you classify this infant by gestational age alone?The infant is preterm because the infant was born before 37 weeks of gestation. 3. How would you classify this infant by both weight for gestational age?The infant should be classified as appropriate for gestational age because the weight falls within the normal range for gestational age. 4. What problems is this infant at high risk of in the first few weeks of life?As a preterm, appropriate for gestational age infant, the important risks after delivery are poor breathing at birth, hypothermia, hypoglycaemia, hyaline membrane disease, apnoea, poor feeding, jaundice, infection, anaemia, intraventricular haemorrhage, patent ductus arteriosus and separation from the parents. Management must, therefore, be aimed at preventing or treating these problems. Case study 2A female infant weighs 2200 g at birth. The mother is unbooked and does not know the date of her last menstrual period. She smokes 20 cigarettes a day. The infant has loose, wrinkled, dry skin. The infant scores at 42.5 weeks on the Ballard score. When plotted on a weight for gestational age chart, the infant falls below the 10th centile. 1. What is the explanation for the appearance of this infant’s skin?The loose, wrinkled, dry skin suggests soft tissue wasting due to an inadequate supply of food to the fetus during the last weeks of pregnancy. 2. Why was it important to score this infant?Because the patient did not know the duration of pregnancy and because the infant weighed less than 2500 g and was wasted. 3. How would you classify this infant by gestational age alone?The scored age of 42.5 weeks indicates that the infant was born postterm. 4. How would you classify this infant by weight for gestational age?This infant is underweight for gestational age. 5. Why is it important to identify this infant as being both underweight for gestational age and wasted?Because the diagnosis places the infant at high risk of poor breathing at birth, meconium aspiration, hypothermia and hypoglycaemia. The infant may also have organ damage due to the lack of oxygen before delivery (prenatal hypoxia). 6. Are all postterm infants wasted or underweight for gestational age?No, but postterm infants often are wasted or underweight for gestational age. 7. What is the probable cause of this infant being underweight for gestational age?The mother’s heavy smoking. Case study 3A woman who booked early and attended an antenatal clinic regularly delivers an infant at a primary care clinic. She is 39 weeks by dates and the infant appears to be of normal size. The infant appears normal and feeds well. The birth weight is 3100 g. 1. Why should this infant be weighed?All infants should be weighed routinely after delivery, even if they appear normal and healthy, in order to identify all low birth weight infants. An accurate birth weight is also important to determine weight gain or loss during the first days and weeks after birth. 2. Should you score this infant’s gestational age?There is no need to score this infant as the mother knows her menstrual dates and the infant appears normal. 3. How would you classify this infant by its weight and gestational age?This is a term, appropriate-for-gestational-age infant and, therefore, is at low risk for problems in the newborn period. As the infant also appears normal and feeds well, the infant should receive routine, primary care at the clinic. 4. Are all infants who weigh 3100 g born at term?Most will be term infants. However, some may be underweight for gestational age postterm infants while others may be overweight for gestational age preterm infants. Head circumference should be measured routinely after birth. However, length is difficult to measure accurately and usually is not recorded. Case study 4An obese diabetic patient delivers an infant at 36.5 weeks. The infant appears very fat and weighs 3700 g. 1. How would you classify this infant?Preterm and overweight for gestational age as the infant was born before 37 weeks and must be above the 90th centile with a weight of 3700 g. This should be confirmed by plotting the infant’s weight for gestational age on a chart. 2. What is the probable cause of the infant being overweight for gestational age?The mother’s diabetes and obesity. 3. Why should this infant receive more than just primary care?Because infants of diabetic women, especially if they are preterm and overweight for gestational age, are at high risk of problems in the first weeks of life. Case study 5A woman who has hypertension and proteinuria (i.e. pre-eclampsia) for the last month of pregnancy delivers at 38 weeks. The infant appears wasted but has a birth weight between the 10th and 90th centiles. The Apgar scores were low and the infant required resuscitation. 1. How would you classify this infant?Term and appropriate for gestational age. 2. Why is this infant at high risk of problems during the first weeks of life?Because the infant is wasted. Even though this infant is appropriate for gestational age and born at term, the risk of clinical problems is high because of the wasting. 3. What is the probable cause of the wasting?The maternal pre-eclampsia. As a result of decreased placental blood flow, the fetus did not receive enough energy (calories) during the last few weeks of pregnancy and, therefore, became wasted due to weight loss. 4. What was the probable cause of the poor breathing at birth?Hypoxia during labour. Wasted infants are at high risk of fetal hypoxia. |
A nurse is assessing a newborn who was born at 39 weeks of gestation
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