Routine care of the healthy newborn — formative SAQs

SAQ 1 — Golden hour, vitamin K refusal and discharge readiness (20 marks, ~15 minutes)

A vigorous term newborn is born to a 28-year-old first-time mother by normal vaginal delivery. The parents decline intramuscular vitamin K. They also request discharge at 24 hours of age. The mother intends to breastfeed but the first feed was at 4 hours of life due to a prolonged second stage and maternal exhaustion. [9]

Questions

1. List the evidence-based elements of the golden hour for this infant and explain why delayed cord clamping is recommended. (5 marks) [9]
2. Describe your counselling approach for the vitamin K refusal, including the evidence for IM versus oral prophylaxis and your documentation plan. (5 marks) [6]
3. State the discharge readiness criteria you would assess before allowing discharge at 24 hours. (5 marks) [19]
4. Describe the follow-up plan and safety-net advice you would give to these first-time parents. (5 marks) [4] [19]

Model answer (must-hit)

1. Skin-to-skin contact, thermoregulation (drying, warmth, hat), delayed cord clamping for at least 60 seconds, early breastfeeding initiation, Apgar assessment. Delayed cord clamping improves iron stores through 6 months per Cochrane evidence without significant maternal harm. [9]
2. Explore reasons respectfully; correct specific misconceptions; offer IM as the evidence-based standard (most reliable for preventing all forms of VKDB including late disease). If IM declined, offer oral regimen where available but explain it requires complete multi-dose adherence and still carries residual risk. Document discussion, decision and follow-up. Do not coerce. [6]
3. Feeding established with adequate latch and output; weight loss within acceptable limits (typically under 10 percent); jaundice risk assessed (predischarge bilirubin); vitamin K pathway documented; newborn examination complete; safe sleep counselled; follow-up booked. [19]
4. Follow-up within 48 to 72 hours by a clinician who can assess feeding, weight, jaundice and parental confidence. Safety-net: warning signs (poor feeding, temperature change, increasing jaundice, lethargy, breathing difficulty, fewer wet nappies). Teach-back to confirm understanding. Safe sleep: alone, on back, firm flat surface, room-share. [4] [19]

SAQ 2 — Late-preterm infant with feeding failure and hypernatraemia (20 marks, ~15 minutes)

A 35+5 week gestation infant born to a mother with gestational diabetes is on the postnatal ward. On Day 3, the infant has lost 12 percent of birth weight, is lethargic, feeds poorly, and has a serum sodium of 155 mmol/L. The infant is afebrile. [1] [20]

Questions

1. Explain why late-preterm infants and infants of diabetic mothers are at higher risk of hypoglycaemia and feeding difficulty. (5 marks) [1]
2. What is the significance of a 12 percent weight loss and serum sodium of 155 mmol/L, and what complications are you concerned about? (5 marks) [20]
3. Outline your immediate and stepwise management. (5 marks) [20] [1]
4. What was missed in routine care that allowed this to develop, and how would you prevent it? (5 marks) [19]

Model answer (must-hit)

1. Late-preterm infants have limited glycogen reserves, immature feeding coordination, slower gut maturation and less subcutaneous fat. Infants of diabetic mothers have fetal hyperinsulinaemia causing reactive hypoglycaemia after cord clamping. Both groups need proactive glucose screening and intensive feeding support. [1]
2. Weight loss above 10 percent with serum sodium above 150 mmol/L indicates hypernatraemic dehydration. Complications include cerebral venous thrombosis, seizures, neurological injury and refeeding complications. This is a medical emergency requiring supervised management. [20]
3. Senior review; admit for monitoring; controlled rehydration (avoid rapid sodium correction); establish adequate feeding or IV fluids; check glucose, renal function and acid-base; monitor sodium decline rate; assess for sepsis; lactation support. The correction rate must be supervised by neonatal protocol. [20] [1]
4. Feeding assessment should have been more intensive given late-preterm status and diabetic mother. Weight should have been checked at 24 to 48 hours with earlier intervention at 7 percent loss. Glucose should have been screened proactively. Closer monitoring and later discharge with intensive follow-up would have caught this earlier. [19]