ASPHYXIA NEONATORUM-CLASS.MHFHGFFJ,Y,FGJYUFGpdf

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1. ASPHYXIA NEONATORUM

2. GENERAL OBJECTIVE
•AT THE END OF THE DISCUSSION STUDENTS
SHOULD BE ABLE TO DEMONSTRATE AN
UNDERSTANDING OF NEONATAL ASPHYXIA
AND BE ABLE MANAGE

3. SPECIFIC OBJECTIVES
•Define asphyxia neonatorum
•State Apgarscoring assessment
•Describe pathophysiology
•State etiological factors
•Explain signs and symptoms
•Discuss the management
•Describe the preventive strategies
•State the prognosis

4. Introduction
•Asphyxia neonatorum, also called birth or
newborn asphyxia, is defined as a failure to
start regular respiration within a minute of
birth. Asphyxia neonatorumis a neonatal
emergency as it may lead to hypoxia (lowering
of oxygen supply to the brain and tissues) and
possible brain damage or death if not
correctly managed.

5. •Newborn infants normally start to breathe
without assistance and usually cry after
delivery. By one minute after birth most
infants are breathing well

6. •If an infant fails to establish sustained
respiration after birth, the infant is diagnosed
with asphyxia neonatorum. Normal infants
have good muscle tone at birth and move
their arms and legs actively, while asphyxia
neonatoruminfants are completely limp and
do not move at all. If not correctly managed,
asphyxia neonatorumwill lead to hypoxia and
possible brain damage or death

7. DEFINITION
•This is failure of the baby or infant to breath
at birth or initiate sustain breathing at birth.
0r
•Asphyxia neonatorumis respiratory failure in
the newborn, a condition caused by the
inadequate intake of oxygen before, during, or
just after birth.

8. Etiology
•Worldwide, more than 1 million babies die
annually from complications of birth asphyxia.
According to the World Health Organization,
asphyxia neonatorumis one of the leading
causes of newborn deaths in developing
countries, in which 4 to 9 million cases of
newborn asphyxia occur each year, accounting
for about 20 percent of the infant mortality
rate.

9. CLASSIFICATION
Mild asphyxia
Severe asphyxia
MILD ASPHYXIA:
Apgarscorof 5-7
heart rate not severely depressed which may
be 60-80b/m
Short delay on onset of respirations
Good muscle tone

10. It is also called asphyxia lividabecause the
baby has apnea and is cyanosed.
SEVERE ASPHYXIA
Apgarscore is less than 5 meaning 4 going
down.
Slow feableheart rate (less than 40 beats/m)
Poor muscle tone muscles are limp
Unresponsive to stimuli

11. The skin is grey due to prolonged lack of
oxygen before and after delivery.
Circulatory failure
Baby is in shock
It is called asphyxia pallidabecause this is
where you find apnea and paller

12. PATHOPHYSIOLOGY
•The heart and the brain need good oxygen
supply to function well.
•The normal PH in the fetus or neonate is from
7.30 to 7.35 which shows that blood is slightly
alkaline tissue.
•When PH falls blood becomes acidic and this
leads to acidosis which means there is
excessive hydrogen ions in the body and

13. •this is related to a ratio of carbon dioxide to
bicarbonates.
•Reduced oxygen will lead to:
increased carbon dioxide
Reduction in PH
This will stimulate the respiratory centre.
Further reduction of oxygen leads to
utilization of alternative metabolic path ways

14. •of anaerobic glycolysisand this results in
exhaustion of glycogen reserves and this
produces metabolic acidosis. This leads to
depressed cerebral function and even
permanent damage to the brain despite the
infants BP been maintained. Such an infant is
cyanosed and apnenic= asphyxia livida.
•Increased hypoxia leads to circulatory collapse

15. •This baby passes to a phase called Asphyxia
pallida
•Brain damage begins after 8 minutes of total
asphyxia and is maximum after 12-13 minutes.
The baby may not die but will develop a lot of
complications.

16. PREDISPOSING FACTORS
•FETAL CAUSES
Blockage of airway by mucus, meconium,
blood or liquor.
Prematurity
Congenital abnormalities
Intra uterine infections
Intra uterine growth retardation

17. •MATERNAL CAUSES
Pre-eclampsia
Eclampsia
Chronic nephritis
D.M
Prolonged labour

18. •PLACENTAL CAUSES
APH
Infarctions
Diseases such as syphilis
UMBILICAL CAUSES
Cord presentation
Cord prolapse

19. Cord compression
True nots
DRUGS
Valium
Pethedine
Morphine taken by the mother
Anaesthesia
Misuse of oxytocinin labour

20. Causes / Predisposing factors
•prenatal hypoxia (a condition resulting from a
reduction of the oxygen supply to tissue below
physiological levels despite adequate perfusion of
the tissue by blood),
•umbilical cord compression during childbirth ,
•occurrence of a preterm or difficult delivery,
•maternal anesthesia (both the intravenous drugs
and the anesthetic gases cross the placenta and
may sedate the fetus).

21. CAUSES CONT’D
•High-risk pregnancies for asphyxia neonatorum
include:
maternal age of less than 16 years old or over 40
years old
low socioeconomic status
maternal illnesses, such as diabetes,
hypertension, Rh-sensitization, severe anemia
•mothers with previous abortions, stillbirths, early
neonatal deaths, or preterm birth

22. CAUSES CONT’D
•lack of prenatal care
•abnormal fetal presentation or position
•alcohol abuse and smokingby the mother
•severe fetal growth retardation
•preterm labor

23. CLINICAL PRESENTATION
•bluish or gray skin color (cyanosis),
•slow heartbeat (bradycardia)
•stiff or limp limbs ( hypotonia)
•a poor response to stimulation.

24. MANAGEMENT
•AIMS:
To establish and maintain a clear air way
To ensure effective blood circulation
To correct the acidosis
To prevent hypothermia, hypoglycaemiaand
haemorrhage

25. management
•Diagnosis
assessment
objectively assessed using the Apgarscore
(a recording of the physical health of a
newborn infant, determined after examination
of the adequacy of respiration, heart action,
muscle tone, skin color, and reflexes.
Normally, the Apgarscore is of 7 to 10.)

26. •Infants with a score between 4 and 6 have
moderate depression of their vital signs while
infants with a score of 0 to 3 have severely
depressed vital signs and are at great risk of
dying unless actively resuscitated

27. MGT cont’d
•Treatment
•The treatment for asphyxia neonatorumis
resuscitation of the newborn. All medical
delivery rooms need to have adequate
resuscitation equipment should an infant not
breathe well at delivery.

28. Resuscitation
•If stimulation fails to initiate regular respiration in
the newborn, attempt resuscitationby firstly
gently suction the oropharynx—the area of the
throat at the back of the mouth, with a soft
catheter.
•When stimulation and a clear airway do not
result in adequate respiration, then 100 percent
oxygen via a face mask should be given.
•If the infant is still not breathing, some form of
artificial ventilation is then required.

29. •The usual method is to use mask ventilation with
a resuscitator.
•The mask is applied tightly to the infant's face.
•If this procedure fails, the infant can be intubated
with an endotracheal tube to which the
resuscitator can then be connected.
•The more severe the fetal asphyxia, the longer it
will take before the infant starts to breathe
spontaneously.

30. •If the infant does not breathe despite
adequate ventilation, or if the heart rate
remains below 80 beats per minute, the
physician can give an external cardiac massage
using two fingers to depress the lower
sternum at approximately 100 times a minute
while continuing with respiratory assistance.
•Adrenaline may also be administered to
increase cardiac output.

31. •Once the infant starts breathing, he or she is
transferred to a nursery for observation and
further assessment.
•Temperature, pulse and respiratory rate,
color, and activity are recorded, and blood
glucose levels checked for at least four hours.

32. •Treatment may also include the following:
•medications to support the baby's breathing
and sustain blood pressure
•extracorporeal membrane oxygenation
(ECMO)
•ECMO is a technique similar to a heart-lung
bypass machine, which assists the infant's
heart and lung functions with use of an
external pump and oxygenator.

33. Immediate Care
•Aims:
To establish and maintain a clear air way
To ensure effective blood circulation
To correct the acidosis
To prevent hypothermia, hypoglycaemiaand
haemorrhage.

34. Immediate Care
•This is an emergency because the baby has an
APGAR score of 3/10. The baby has severely
depressed vital signs and is at great risk of
dying hence needs to be actively resuscitated.

35. Immediate Care
•Resuscitation
•Resuscitation treatment will begin with
assessment, thermal protection, proper
positioning of the newborn, and brief
stimulation.

36. Immediate Care
•Assessment
•ThebabywillbeassessedusingAPGARatone
minuteandfiveminutesofbirthtomakea
diagnosis.DuringresuscitationAPGARscorewill
bedoneevery5minutesforup20minutesto
observethebaby’sresponsetoresuscitation.The
vitalsignswhicharetemperatureandheartbeat
willbecheckedtoseeifthereisany
improvementinthegeneralconditionofthe
baby.

37. Immediate Care
•ProperPositioning
•Theinfantwillbepositionedonthebackorside,
withtheheadslightlyextendedtoopenthe
airway.Asmallrollofclothwillbeplacedunder
theshouldershelpinmaintainingheadposition.
•Stimulation
•Immediatelythebabyisbornthenostrilswillbe
wipedtoremoveanysecretionshenceclearing
theairwayandthiswillstimulatetherespiratory
system.Ifthisfailstoinitiateregularrespiration,I
willgentlysuctiontheoropharynxandthe
nostrilswithapenguinsuckerstartingwiththe
mouthbeforethenose.

38. Immediate Care
•If the infant is still not breathing, some form of
artificial ventilation using an ambuwill be used.
The head will be slightly extended to open the
airway. The mask will be applied tightly to the
infant's face to cover the mouth and the nose. I
will make an adequate seal using the fingers of
my left hand which will lift the chin forward and
upward and partially encircle the mask, placing
light and even pressure downward to open the
airway.

39. Immediate Care
•After making a seal I will deflate the bag to
ventilate the lungs which helps to achieve a
slight rise and fall in the chest. I will ask an
assistant to check the heart rate during
positive-pressure ventilation with a
stethoscope at the base of the umbilical cord
or over the left side of the chest.

40. Immediate Care
•Iftheinfantdoesnotbreathedespite
adequateventilation,oriftheheartrate
remainsbelow60beatsperminute,then
externalcardiacmassagewillbedoneusing
twofingerstodepressthelowersternumat
approximately100timesaminutewhile
continuingwithartificialventilationusingan
ambubag.

41. Immediate Care
•IwillensureIcontinuewithventilationwhich
shouldbecoordinatedwiththecompressions
withoutliftingthumbsoffthechestduringthe
compressioncycles.Theratioofventilationto
compressionwillbe1breathevery3
compressionsandthisshouldhelpthebaby
attainapinkcolorinthetrunkandmucous
membranes.Ifalltheseinterventionsfailthen
thebabywillbeintubatedandthiswillbe
donebytheanesthetist.

42. Immediate Care
•Drugadministration
•Whenstimulationandaclearairwaydonot
resultinadequaterespirationandcyanosis
persists,then100percentoxygenviaaface
maskwillbeadministered.

43. Immediate Care
•The following drugs will best be delivered via umbilical
vein:
•1.Adrenaline 0.1 –0.3ml/kg/dose of 1:10,000 IV
diluted in normal saline may be administered to
increase cardiac output.
•2.Sodium Bicarbonate 1 -2mg/kg IV administered
over at least 30 minutes to counteract metabolic
acidosis.

44. Immediate Care
•3.Normalsaline10ml/kgIVbodyweightwill
beadministeredover5-10minutestoexpand
bloodvolumehencesustainbloodpressure.
•4.Dextrose10%100–500mg/kg/doseIV(1-
5ml/kg/doseD10W)
•

45. Subsequent Care
•Aims:
•i.To maintain respirations
•ii.To prevent infections in the new born
•iii.To prevent hypothermia
•iv.To prevent hypoglycemia
•After the baby has been resuscitated it will be
thoroughly monitored and evaluated to note
any deterioration or improvement of the
condition. The baby will be shown to the
mother for identification.

46. Subsequent Care
•Environment
•Oncetheinfantstartsbreathing,heorshewillbe
transferredtospecialbabycareunit(SCUB)for
observationandfurthermanagement.Ifbaby’s
conditionisnotverystableafterresuscitationit
willbenursedpreferablyinanincubatorforeasy
observationsandforwarmthastemperaturecan
beregulated.Ifthebaby’sconditionisstableit
willbegiventothemothertoputskintoskin
againstherbodyforwarmth.Iwillensurethat
theroomiswarmtopreventhypothermia.

47. Subsequent Care
•Observation
•Temperature,pulseandrespiratoryrate,color,
andactivitywillbecheckedandrecordedto
seeifthereisanyimprovementinthebaby’s
condition.Temperaturewillbemonitoredto
noteanyhypothermia.Respirationswillbe
assessedforthepatternofbreathingandto
seeifthereisanyimprovementinthe
breathingofwhichthenormalrateis30-60
breaths/minute.

48. Subsequent Care
•Bloodglucoselevelswillbecheckedforatleast
fourhourstoruleoutanyhypoglycemia.The
skinofthebabywillbecheckedforcyanosis
whichindicateslowoxygensupplytothe
tissues.Theskinwillalsobecheckedforany
signsofbleeding,Jaundiceandifthereisitis
meconeumstained(indicationthatatsome
pointinuterobabywasstressedandpassed
meconeum).

49. Subsequent Care
•Thebabywillbeassessedforany
abnormalitiesthatmayneedurgentmedical
attention.Dextrostixtestwillbedoneevery4
to6hourstocheckifbabyisgoingintohyper
orhypoglycaemia.Ifbabyhasintravenous
lineitwillbemonitoredthatitisinsitu.Baby
willbecheckedifithasopenedthebowels
thencolour,consistenceandfrequencywillbe
noted.Itwillbeobservedforirritabilitywhich
couldbeduetobraindamageresultingfrom
lackofoxygensupplytothebrain.

50. Subsequent Care
•PreventionofHypothermia
•Thebabywillbewellcoveredtopreventitfrom
exposuretocold.Theroomtemperaturewillbe
maintainedbetween20–24oCwhichiswarm
enoughtopreventhypothermia.Themotherwill
beencouragedtoputthebabyskintoskin
againstherbodytokeepbabywarmhence
preventhypothermia.Skintoskinwillalso
facilitatemotherbabybonding.Duringbathing
thebabywillbeexposedlessandtopandtailwill
bedonetopreventhypothermia.

51. Subsequent Care
•Hygiene
•Topandtailwillbedonetoremovedirty
hencepromotehygiene.Whenthebaby’s
conditionimprovesabigbathwillbegivento
promotehygieneandcomfort.Eyecareand
cordcarewillbedoneforbaby’shygieneand
preventinfections.Baby’snapkinswillbe
changedwheneversoiledtopreventskin
excoriationandodours.

52. Subsequent Care
•Nutrition
•Themotherwillbeencouragedtobreastfeedin
thefirsthourifconditionallows,ifnotacupand
spoonwillbeusedtopreventhypoglycemia.The
babyshouldbebreastfedwithinthefirsthour
afterbirthsothatitcanreceivecolostrumwhich
providesprotectionagainstinfection.
Breastfeedingthebabyimmediatelyafterbirth
willalsohelpcolonizationofthegutfastwith
normalflorahencepreventneonataljaundice.

53. Subsequent Care
•Themotherwillbeencouragedtoexpressmilkin
acupifbabyisunabletosuckfromthebreast
andthiswillbegiventothebabyusingcupand
spoontopreventdehydrationandthisalsohelps
tomaintainthebaby’snutritionalstatus.
•Medication
•Afterresuscitationthebabymaybeputon
phenorbabitonetopreventconvulsionsandthis
willbeadministeredaccordingtothedoctor’s
prescription.

54. Information, Education and
Communication
•Careathome
•Themotherwillbeadvisedtotakecareofthe
babyproperlyathome.Bothparentswillbe
encouragedtoshowlovetothebabyasthis
facilitatesgrowthanddevelopmentofthebaby.
Themotherwillbeencouragedtobaththebaby
toremovedirtyandpromotebaby’scomfort,
breastfeedbabyondemand,protectbabyfrom
fallsbynotallowinglittlechildrentoholdthe
baby.

55. Information, Education and
Communication
•Themotherwillalsobeadvisedtoprotectthe
babyfromcoldbycoveringthebabywith
warmblanketstopreventcomplicationssuch
ashypothermia.

56. Information, Education and
Communication
•Conditionofthebaby
•Themotherwillbeinformedaboutthe
conditionofherbabydependingonthe
degreeofasphyxia.Shewillbetoldabout
someeffectsofasphyxiasuchasdelayingin
thedevelopmentofmilestones.Shewillbe
informedthatthemilestonesmaydelay;for
examplethebabymayexperiencelatesitting,
walkingortalking.

57. Information, Education and
Communication
•Therefore;sheneedstobepatientwiththe
babyandsheshouldnotbeanxiousbut
shouldgivethebabyenoughtimetodevelop.
Shewillbeadvisedtobemonitoringthebaby
closelyandnoteanyabnormalitiesinthebaby
suchasconvulsionsandirritability.Sheshould
alsomonitorthetypeofcrybecauseahigh
pitchedcrymayindicateirritationtothebrain.

58. Information, Education and
Communication
•Infection prevention
•To prevent infections to the baby the mother
will be advised to be cleaning the umbilical
stump until it gets healed so as to prevent it
from infection. She will be advised to clean
the umbilical stump with clean cotton wool
and pre boiled cooled water that is kept in a
clean covered container to prevent
introducing microorganisms on the stump.

59. Information, Education and
Communication
•Shewillbeadvisedtobewashinghandsevery
afterchangingbaby’snapkintoremove
microorganismsfromherhands.Shewillalsobe
advisedtocleanthebreastsbeforegivingitto
thebabyinordertoremovesweatanddirtythat
cancauseinfectiontothebaby.Themotherwill
beadvisedtokeeptheroomwherebabyisbeing
keptcleanandwelldumpdustedtoprevent
respiratorytractinfectionssincethebaby’s
immunitysystemisnotfullydeveloped.

60. Information, Education and
Communication
•Shewillbeadvisedtobebathingthebabyevery
daytoremovedeadtissueswhichcanbea
sourceinfectionsontheskin.Shewillbe
encouragedtobechangingbaby’sclothesasdirty
clothescanattractflieshencemultiplicationof
microorganismsthatcanleadtoinfections.

61. Information, Education and
Communication
•Nutrition
•Motherwillbeadvisedtoexclusivelybreastfeed
thebabyandnottogivebabyanyliquidsapart
frombreastmilktopromotegoodnutritional
statushencepromotinggrowthand
development.Shewillbetoldthatbreastmilk
containsallnecessarynutrientsthatthebaby
needsforgrowthanddevelopmenthencethe
babyneedstobebreastfedondemand.

62. Information, Education and
Communication
•Importanceofimmunization
•Themotherwillbeenlightenedonthe
immunizationschedule.Shewillbeadvised
thatthebabyneedstoreceivepoliozero
beforethe13thdayoflife.Shewillalsobe
advisedonothervaccinessuchasBCG,DPT–
HepB–HibandMeaslesthatthebabyis
supposedtoreceivetoprotectbabyfrom
childhoodillnesses.

63. Information, Education and
Communication
•Cordcare
•Motherwillbeshownhowtocleanthecordat
hometopreventinfectionontheumbilicalarea.
Shewillbeadvisedtocleanthestumpwellwith
pre-boiledcooledwaterandnottoputany
substancessuchaspowder,soilorcowdungon
thestumpasthesecanbeasourceofinfection.

64. Prevention
Anticipationisthekeytothepreventionof
asphyxianeonatorum.
Itisimportanttoidentifyfetusesthatare
likelytobeatriskofasphyxiaandtoclosely
monitorsuchhigh-riskpregnancies.

65. Prevention
High-riskmothersshouldalwaysgivebirthin
hospitalswithneonatalintensivecareunits
whereappropriatefacilitiesareavailabletotreat
asphyxianeonatorum.
Duringlabor,themedicalteammustbereadyto
interveneappropriatelyandtobeadequately
preparedforresuscitation.

66. Prognosis
•Theprognosisforasphyxianeonatorum
dependsonhowlongthenewbornisunable
tobreathe.Forexample,clinicalstudiesshow
thattheoutcomeofbabieswithlowfive-
minuteApgarscoresissignificantlybetter
thanthosewiththesamescoresat10
minutes.

67. Prognosis
With prolonged asphyxia, brain, heart, kidney,
and lung damage can result and also death, if
the asphyxiation lasts longer than 10 minutes.
•Alternativetreatment
Givingthemotherextraamountsofoxygen
beforedelivery

68. Prognosis
•Ifaninadequatesupplyofoxygenfromthe
placentaisdetectedduringlabor,theinfantis
athighriskforasphyxia,andanemergency
deliverymaybeattemptedeitherusing
forcepsorbycesareansection.

70. POSTMATURITY
•The normal length of pregnancy is from 37 to
41 weeks. Postmaturityrefers to any baby
born after 42 weeks gestation or 294 days past
the first day of the mother's last menstrual
period. Other terms often used to describe
these late births include post-term,
postmaturity, prolonged pregnancy, and post-
dates pregnancy.

71. CAUSES OF POSTMATURITY
•It is not known why some pregnancies last
longer than others. Postmaturityis more likely
when a mother has had one or more previous
post-term pregnancies. Sometimes a mother's
pregnancy due date is miscalculated because
she is not sure of her last menstrual period. A
miscalculation may mean the baby is born
earlier or later than expected.

72. Persistence of progesterone block by the
placenta and failure of softening of the cervix
or lack of stimulatory factors such as oxytocin
and prostaglandin.
Patients who take large doses of aspirin
leading to inhibition of synthesis of
prostaglandins.
Lack of stimulus of the cervix and lower
segments and presenting part=in mal-

73. •Presentation such as OPP, short umbilical cord
resulting into failure of the fetus to descend.
Extra uterine pregnancy. There is nothing to
stimulate laboursince the pregnancy is not in
the uterus.

74. WHY IS POSTMATURITY A CONCERN?
•Post-maturebabiesarebornattheveryend,
orpast,thenormallengthofpregnancy.The
placenta,whichsuppliesbabieswiththe
nutrientsandoxygenfromthemother's
circulation,beginstoagetowardtheendof
pregnancy,andmaynotfunctionasefficiently
asbefore.Otherconcernsincludethe
following:

75. Amniotic fluid volume may decrease and the
fetus may stop gaining weight or may even
lose weight.
Risks can increase during labor and birth for a
fetus with poor oxygen supply.
Problems may occur during birth if the baby is
large.

76. Why Is Post-maturity a Concern?
Postmaturebabies may be at risk for
meconiumaspiration, when a baby breathes
in fluid containing the first stool.
Hypoglycemia (low blood sugar) can also
occur because the baby has too little glucose-
producing stores.

77. Signs/Symptoms of Post-maturity
•Thefollowingarethemostcommon
symptomsofpost-maturity.However,each
babymayshowdifferentsymptomsofthe
condition.Symptomsmayinclude:
dry,peelingskin
overgrownnails

78. Signs/Symptoms of Post-maturity
abundant scalp hair
visible creases on palms and soles of feet
minimal fat deposits
green/brown/yellow coloring of skin from
meconiumstaining (the first stool passed
during pregnancy into the amniotic fluid)

79. Management of Post-Maturity
•Diagnosis of Post-maturity
•Post-maturity is usually diagnosed by a
combination of assessments, including the
following:
baby's physical appearance
length of the pregnancy
baby's assessed gestational age

80. Management of Post-Maturity
•Treatment of post-maturity:
•Specific treatment for post-maturity will be
determined based on:
Baby's gestational age,
Overall health, and
Medical history

81. Management of Post-Maturity
Extent of the condition
Baby's tolerance for specific medications,
procedures, or therapies
Expectations for the course of the condition.
•In a prolonged pregnancy, testing may be
done to check fetal well-being and identify
problems.

82. Management of Post-Maturity
•Testsoftenincludeultrasound,non-stress
testing(howthefetalheartraterespondsto
fetalactivity),andestimationoftheamniotic
fluidvolume.
•Thedecisiontoinducelaborforpost-term
pregnancydependsonmanyfactors.During
labor,thefetalheartratemaybemonitored
withanelectronicmonitortohelpidentify
changesintheheartrateduetolow

83. Management of Post-Maturity
•Oxygenation. Changes in a baby's condition
may require a cesarean delivery.
Special care of the post-mature baby may
include:
•Checking for respiratory problems related to
meconium (baby's first bowel movement)
aspiration.
•Blood tests for hypoglycemia (low blood
sugar).

84. Prevention of Post-maturity
Accuratepregnancyduedatescanhelp
identifybabiesatriskforpost-maturity.
Ultrasoundexaminationsearlyinpregnancy
helpestablishmoreaccuratedatingby
measurementstakenofthefetus.Ultrasound
isalsoimportantinevaluatingtheplacentafor
signsofaging.

85. •THE END