SEMINAR ON CARE

OF NEWBORN

SUBMITTED TO SUBMITTED BY
Mrs. SARALA P A NADIA AMANULLAH A R
ASSO.PROFESSOR 1 ST YEAR MSc NURSING
GOVT COLLEGE OF NRSING GOVT COLLEGE OF NURSING
 INTRDUCTION

Newborn care is of immense importance for the proper development and healthy life of a baby.
Although childhood and infant mortality in South Asia has reduced substantially during the last
decade, the rate of neonatal mortality is still high. According to one source, 60% of all neonatal
deaths and 68% of the world’s burden of perinatal deaths occur in Asia (Paul and Beorari,
2002). Further, although 70% of infant deaths occur during the first month of life, the policy-
makers and health professionals in developing countries, until recently, neglected newborn
care (Costello and Manandhar, 2000). On the other hand, this latter group of authors maintain
that the principles of essential newborn care are simple, requiring no expensive high
technology equipment: resuscitation, warmth to avoid hypothermia, early breastfeeding,
hygiene, support for the mother-infant relationship, and early treatment for low birth weight or
sick infants.

DEFINITION: A healthy infant at term (between 38-42 weeks) should have an average birth
weight for the country( usually 2500 gm), cries immediately following birth, establish
independent rhythmic respiration and quickly adapts to the changed environment.
The weight is variable from country to country but usually exceeds 2500 gm. In India, the
weight varies between 2.7 to 3.1 kg with a mean of 2.9 kg. The length (crown to foot) is 50-52
cm. the length is a more reliable criterion of gestational age than the weight. Occipito-frontal
circumference measures about 32-37 cm and the biparietal diameter measures about 9.5 cm.

STATISTICS OF NEWBORN

Infant mortality rate

World India Kerala

SRS NFHS - 2 SRS NFHS –

2002 2001 2002 2001

58 66 67.6 1 16.3

Neonatal
India IMR Post NMR PMR
mortality rate
India 74 48.1 25.9 44.6
Kerala 15 11 4.3 15.7
 The total deliveries and death of neonates in SAT hospital, Tvpm

Total No. of No. of death

Year
deliveries Within 1 week 1 wk – 1 month
2000 16,789 324 108
2001 17,278 284 13
2002 16,617 381 13

PHYSICAL FEATURES OF THE NEW BORN

The new born must be examined thoroughly within 24 hours of birth. Before the actual
examination & the important maternal and perinatal history should be reviewed. Maternal
history (age, parity, medical disorders, etc.), pregnancy problems - Present and past (drugs,
IUFD, Pre eclampsia, IUGR, Prematurity), Labour and Delivery history (duration, anaesthesia,
duration of PROM, Apgar score) should be obtained.

1. Examination of vital signs:

(I)Temperature: is recorded and the site (e.g. rectal, oral or axillary) is mentioned.
(ii) Respiration: Normal - 30-60 breaths/min.
(iii) Pulse: Normal - 100-160 beats per min (bpm) and when asleep it is around 70-80 bpm.
(iv) Blood pressure: Normal range 45-60/25-40mm Hg. BP is directly related to gestational age
and birth weight of the infant.

2. Gestational age :: ASSESSMENT OF GESTATIONAL AGE

Character <36 weeks 37-38weeks >39 weeks

Sole crease 1-2 transverse crease Multiple creases on Entire sole covered
on ant.1/3rd of sole anterior with crease
Breast nodule 2mm 4mm 7mm
Scalp hair Fine, wooly, fuzzy Fine, wooly, fuzzy Coarse, silky
Ear lobe No cartilage Moderate amount of Stiff ear lobe, thick
cartilage cartilage.
Testis and scrotum Testis partially Testis fully
descended, scrotum descended, scrotum-
small and few rugae normal size,
prominent rugae
3. General examination:

Head circumference: On overage it is 33-38 cm. It is measured tape measure drawn across the
centre of the forehead and the most prominent portion of the posterior head (the occiput)
Chest circumference The chest circumference in a neonate is about 2 cm (0.75 to 1 in) less than
head circumference .It is measured at the level of nipples
Length: Crown-foot length is 48-53 cm. The length is a more reliable criterion of gestational age
than the weight.
Weight: The weight is very variable from country to country but usually exceeds 2500 gm. In
India, the weight varies between 2.7 to 3.1 kg with a mean of 2.9 kg.

Skin colour - It is the single most important parameter of cardio respiratory Function. Most
term newborns have a ruddy complexion because of the increased concentration of red blood
cells in blood vessels and a decrease in the amount of subcutaneous fat.

(a) Pallor may be due to anaemia, birth asphyxia, or shock.

(b) Cyanosis
 Central cyanosis (bluish skin, including the tongue and lips) is caused by low oxygen
saturation. It may be due to congenital heart or lung disease
 Peripheral cyanosis - (bluish skin with pink lips and tongue) may be due to drugs
(nitrates or nitrites) or hereditary. It is often associated with methemoglobinemia
(haemoglobin oxidises from ferrous to ferric form).
 Acrocyanosis (bluish hands and feet only) - may be normal immediately following birth.
It may be due to cold stress.

(c) Plethora commonly seen in infants with polycythemia. It may be seen in an overheated or
over oxygenated infant.

(d) Jaundice: Bilirubin level > 5mg/dl.

(e) Extensive bruising :may be due to difficult or traumatic delivery.

(f) Vernix caseosa A white, cream cheese-like substance that serves as a skin lubricant, is
usually noticeable on a newborn's skin, at least in the skin folds, at birth.
Harsh rubbing should never be employed to wash away vernix, because the newborn's skin
is tender, and breaks in the skin from too vigorous attempts to remove the vernix may open
portals of entry for bacteria.

(g) Lanugo: Lanugo is the fine downy hair that covers a newborn's shoulders. back, and upper
arms. It may be found also at the forehead and ears. The newborn of 37 to 39 gestational age
has more lanugo than the 40 week old infant; postmature infants (over 42 weeks) rarely have
lanugo. Lanugo is rubbed away by the friction of bedding and clothes against the newborn's
skin. By age 2 weeks, it has disappeared.

(h)Desquamation: Within 24 hours of birth, the skin of most newborns has become extremely
dry. The dryness is particularly evident on the palms of the hands and the soles of the feet. This
is normal and needs no treatment

(i)Forceps Marks: If forceps were used for birth, there may be a circular or linear contusion
matching the rim of the blade of the forceps on the infant's cheek. This mark disappears in 1 to
2 days along with the edema that accompanies it.

(j) Skin Turgor: Newborn skin should feel resilient if the underlying tissue is well hydrated. If a
fold of the skin is grasped between the thumb and fingers, it should feel elastic. When it is
released, it should fall back to form a smooth surface. If severe dehydration is present, the skin
will not smooth out again but will remain in an elevated ridge.

Skin rashes :
 Milia - seen on the nose, cheeks and fore head are due to plugged sweat glands.
Disappear by 2 to 4 weeks of age as the sebaceous glands mature and drain.
 Mongolian spots are bluish, often large, commonly seen on the back, buttocks or thighs.
Usually present in Blacks and Asians (90%). They disappear by four years of age.
 Erythema toxicum - these are papular lesions with an erythematous base. Commonly
seen after 48 hours of birth. They resolve spontaneously.
 Diaper rash - usually the skin folds are involved. It appears as erythematous plaques and
the edges are well demarcated. It is a form of irritant contact dermatitis. It may be
infected with Candida albicans.
 Hemangiomas: The Hemangiomas are vascular tumours of the skin.
 Nevus Flammeus: It is a macular purple or dark red lesion
(sometimes called a port – wine stain because of its deep color) that
is present at birth. The lesions generally appear on the face, thighs,
at the nape of neck, occur mor often in females than in males.
 Strawbery hemangiomas: These are elevated areas formed by
immature capillaries and endothelial cells. Most are present at birth,
although they may appear up to 2 weeks after birth. Formation is
associated with the high estrogen levels of pregnancy, continue to
enlarge up to 1 year of age.
 Cavernous hemangiomas: These are dilated vascular spaces but can
be removed surgically. Assessed at health maintenance visits for
hematocrit level in order to determine internal blood loss

3. Head:
 Fontanelles
Large fontanelles are associated with hypothyroidism, osteogenesis imperfecta or
chromosomal anomalies. Bulging fontanelle may be due to increased intracranial pressure,
meningitis or hydrocephalus. Depressed fontanelles are seen with dehydration. A small
fontanelle may be due to hyperthyroidism, microcephaly or craniosynostosis.
 Caput succedaneum should be differentiated from cephalhaematoma.
 Moulding seen with prolonged labour. Usually moulding subsides within 5 days.
 Cephalhaematoma is due to subperiosteal haemorrhage resulting from a traumatic
delivery it never extends beyond the suture line. X-ray and CT scans should be taken to
exclude skull fracture. Haematocrit and bilirubin levels should be estimated. Aspiration
of haematoma is rarely needed as they often resolve in 4-6 weeks time.
 Raised intra cranial Pressure is diagnosed by the following signs: (i) Bulging anterior
fontanelle (ii) Separation of suture lines (iii) Paralysis of upward gaze (iv) Prominent
veins of the scalp.
 Craniosynostosis: is the premature closure of one or more of sutures of the skull. On
palpation, a bony ridge is felt over the suture line and the cranial bones cannot be
moved. X-ray studies of the skull should be done.
4. Neck: It is checked for movements, goitre, thyloglossal cysts, sternomastoid haematoma
(sternomastoid tumor) or short neck (Turner's syndrome).
5. Face and Mouth: Face is looked for hypertelorism (eyes widely separated) or low set ears
(trisomy 9,18, triploidy) or facial nerve injury. Mouth is checked for clefts (palate, lips) natal
teeth, lingual frenulum, (tongue tie), macroglossia (Beckwith syndrome) or oral thrush .Thrush
is treated with nystatin suspension. The palate of the newborn should be intact. Occasionally,
one or two small round, glistening, well-circumscribed cysts (Epstein's pearls) are present on
the palate a result of the extra load of calcium that is deposited in utero need no treatment
because they disappear spontaneously. It is unusual for the newborn to have teeth, but
sometimes one or two (called natal teeth) will have erupted. Small while epithelial pearls
(benign inclusion cysts) may be present on the gum margins.
6. Nose:A newborn's nose may appear large for the face. As the child grows, the rest of the face
will grow more than the nose, and the discrepancy will disappear

7. Eyes are examined for congenital cataract, Brushfield's spots in the iris (Down's syndrome) or
subconjunctival haemorrhage (traumatic delivery) and conjunctivitis.
8. Ears: The newborn's external ear is still not as completely formed as it will be eventually, and
the pinna tends to bend easily. The level of the top part of the external ear should be on a line
drawn from the inner canthus to the outer canthus of the eye. Ears that are set lower than this
are found in infants with certain chromosomal abnormalities

Small tags of skin are sometimes found just in front of the ear. Although these may be
associated with chromosomal abnormalities or kidney disease. It is good practice to test the
newborn's hearing by ringing a bell held about 6 inches from each ear. If he or she is crying, the
infant who can hear will stop momentarily; if quiet, a newborn will blink the eyes, appear to
attend to the sound, and may startle not highly accurate in 2 or 3 weeks.
9. Chest is examined for any asymmetry (tension pneumothorax), tachypnoea, grunting
intercostal retractions (respiratory distress) pectus exacavatum and the breath sounds. The
newborn's breasts may be enlarged (normal 1 cm in diameter) due to maternal oestrogen. The
white discharge from nipple is commonly known as “Witch milk".
10. Heart is examined for rate (normal 120-160 bpm), rhythm, the quality of heart sounds and
the presence of any murmur. Murmurs may be associated with VSD, PDA, ASD, transposition of
great vessels, tetralogy of Fallot, coarctation of aorta and others. Fetal echocardiography at 18-
20 weeks gestation can make the diagnosis in utero. Fetal cardiac intervention ln utero is a new
and promising method of treatment.
11. Abdomen is examined for any defect e.g. omphalocele ,hepatomegaly (sepsis),
splenomegaly (CMV, rubella infection) or any other mass. A scaphoid abdomen may be due to
diaphragmatic hernia.
12. Umbilicus is examined for any discharge, redness or infection. A greenish-yellow
coloured cord suggests meconium staining (fetal distress). Single umbilical artery (more
in twin births) indicates genetic (trisomy 18) and congenital anomalies, and IUGR . . For
the first hour after birth, the umbilical cord appears as a white, gelatinous structure marked
with the red and blue streaks of the umbilical vein and arteries. After the first hour of life, the
cord begins to dry, shrink, and become discolored like the dead end of a vine. By the second or
third day, it has turned black.

13. Male Genitalia: The Scrotum in most male neonates is edematous and rugated. It may be
deeply pigmented in black or dark-skinned neonates. Both testes should be present in the
scrotum. The penis of newborns appears small; it is about 2 cm long. It should be inspected to
see that the urethral opening is at the tip of the glands, not on the dorsal surface (epispadias)
or the ventral surface. Prepuce is normally long and phimosis is present.
Female Genitalia: is examined for clitorial enlargement (maternal drug), fused labia with
clitorial enlargement (adrenal hyperplasia). Blood stained discharge may be due to maternal
oestrogen withdrawal. Normally labia majora cover the labia minora and clitoris.
14. Anus and Rectum is checked to rule out imperforation and their position. Meconium should
pass within 48 hours of birth. Best determined by inserting a rectal thermometer into the
rectum for the length of the bulb or by inserting the tip of a lubricated, gloved, little finger.
15. Extremities, spine and joints are examined for syndactyly (fusion of digits), Polydactyly,
simian crease (Down irome), talipes equinovarus, hip dislocation (Ortolani and Barlow
maneuvers). The spine of a newborn appears flat curves seen in the adult appear only when a
child is able to sit and walk. The arms and legs of a newborn appear short. The hands are plump
and clenched into fists. Newborn fingernails are soft and smooth and are usually long enough to
extend over the fingertips. The sole of the foot appears to be flat.

16. Nervous system is examined for any irritability, abnormal muscle tone, reflexes, Cranial and
peripheral nerves (Erb's paralysis). Neurological development is dependent on gestational age.
The reflexes including Moro reflex are present at birth .

17. Haematological findings: Blood volume soon after birth is about 80 ml/kg body weight, if
immediate cord clamping is carried out. RBC — 6-8 million/cumm, Hb% —18-20 gm%, W.B.C. —
10,000 - 17000/cumm, Platelets — 3,50,000/cumm, Nucleated red cells 500/cumm,
Sedimentation rate — markedly elevated. Clotting power may be poor because of deficient
vitamin K which is necessary for the production of prothrombin from the liver

18. Reflex behavior

 Muscle tone –hypotonia and hypertonia are examined.
 Rooting reflex: A normal infant when touched on the check, turns eagerly towards the
stimulus and opens the mouth for a feed.
 Glabellar reflex: Tap gently over the fore head and the eyes will blink.
 Grasp reflex: Place a finger in the palm of the infant and the infant will grasp the finger.
 Moro's reflex: Support the infant behind the upper back with one hand then drop the
infant back 1 cm or more to - but not on the mattress. There is a sudden abduction of
both arms and extension of the fingers followed by slow abduction and flexion.
Asymmetry may signify a fractured clavicle, hemiparesis or brachial plexus injury.
 Sucking and swallowing reflexes: A normal infant starts sucking when something
(nipple and the areola) touches the palate. Baby swallows when the mouth is filled with
milk.
 Blink reflex

Protect the eye from any object coming near it by rapid eye lid closure,elicited by shining
a flashlight on the eye.
 Extrusion reflex
A newborn will extrude any substance placed in the anterior portion of lip. It disappears
by 4 months of age.
 Palmar grasp reflex
Grasp an object placed in their palm by closing their fingers on it. It disappears by 6weeks
to 3 months of age.
 Step(walk)-in-place reflex
Elicited by touching the anterior surface of newborn’s leg against the edge of a table. The
baby will make quick lifting motions as if to step on the table.
 Placing reflex
Newborns who are held in a vertical position with their feet touching a hard surface will
take a few quick, alternating steps. It disappears by 3 months of age.
 Plantar grasp reflex
When an object touches the sole of a newborn’s foot at the base of the toes, the toes
grasp in the same manner as fingers do. It disappears by 8-9 months of age.
 Tonic neck reflex
 When the newborns lie on their back ,turn the head to opposite side ,the arm and leg on
the side to which head turns extend, and the opposite arm and leg contract. Also called boxer
or fencing reflex. It disappears by 2-3 months of age.
 Babinski reflex
When the side of the sole of the foot is stroked in an inverted ‘J’ curve from the heel
upwards, the newborn fans the toe(Positive Babinski sign).It remains positive at least 3 months
of age. This occurs because of immaturity of nervous system development.

 Magnet reflex
If pressure is applied to the soles of the feet of a baby lying in a supine position, he pushes
back against the pressure. This is to test spinal cord integrity.
 Crossed extension reflex
When sole of the foot is stroked , the newborn makes an attempt to push away the
irritating object with the other foot.
 Trunk incurvation reflex
When the newborn lie in a prone position and touched along the paravertebral area, he
flex his trunk toward the direction of stimulation.
 Landau reflex
A newborn is held in a prone position with a hand underneath supporting the trunk
should demonstrate some muscle tone. Babies may not be able to lift their head or arch their
back in this position but neither should sag into an inverted U position.
THE SENSES
Hearing:
A fetus is able to hear in utero. As soon as amniotic fluid drains or is absorbed from the
middle ear ,hearing in newborns become acute, although they have difficulty in locating sound.
They respond with generalized activity to a sound. The newborns calm in response to a
soothing voice and startle at loud noises and they recognize their mother’s voice almost
immediately as if they have heard in utero.
Vision
Newborns demonstrate sight at birth by blinking at a strong light or following light a short
distance. They cannot follow past the midline of vision, lose track of objects easily. Focus best
on black and white objects at a distance of 9-12 in. A papillary reflex is present from birth.
Touch
Sense of touch is well developed at birth, demonstrated by sucking and rooting reflex.
They react to painful stimuli.
Taste
Taste beds are developed and functioning before birth to such an extent he have
discriminatory ability. A fetus in utero will swallow amniotic fluid more rapidly than usual if
glucose is added and swallowing decrease if bitter taste is added. A newborn turns away from
bitter taste and readily accepts the sweet taste of milk or glucose water.
Smell
The sense of smell is present as soon as the nose is clear of mucous and amniotic fluid.
Neonates turn towards their mother’s breast partly out of recognition of smell of breast milk
and partly as a manifestation of rooting reflex.
CHANGES DURING THE FIRST WEEK
During the first week of life, the baby continues to adjust himself to the extrauterine
environment.

Respiratory System: The first breath of a neonate is initiated by a combination of cold

receptors, a lowered P02, (P02 falls from 80 mm Hg to as low as 15 mm Hg), and an increased
PC02. PC02 rises as high as 70 mm Hg). As first breath requires a tremendous amount of energy
to pull in. A pressure of about 40 to 70 cm H2O is required.. Within 10 minutes of birth, a
newborn has' established a good residual volume. By 10 to 12 hours of age, vital capacity is
established at newborn proportions.

Cardiovascular system: Figure shows the respiratory and cardiovascular changes that occur at
birth, beginning with the first breath. The peripheral circulation of a neonate remains sluggish
for at least the first 24 hours

Circulatory events at birth

 Changes in the cardiovascular system at birth

Gastrointestinal System: Although the gastrointestinal tract is usually sterile at birth, bacteria
may be cultured from the intestinal tract in most babies within 5 hours after birth; they can be
cultured from all babies at 24 hours of life. Accumulation of bacteria in the gastrointestinal tract
is necessary for digestion as well as for the synthesis of vitamin K.

Although a neonate's stomach holds about 60 to 90 mL aneonate has limited ability to

digest fat and starch because the pancreatic enzymes, lipase and amvlase. are deficient for the
first few months of life.

The newborn regurgitates easily because of an immature cardiac sphincter between the
stomach and esophagus. Immature liver functions may lead to lowered glucose and protein
serum levels.

Position — The baby begins to assume an infantile position in preference to his position in-
utero. The feet are less dorsiflexed and the hands are less clenched.
Weight — There is approximately a 10% loss of birth weight by 4th-5th day which is gradually
regained by 7th to 10th day. The loss is due to loss of water through skin, lungs, urine and
bowel while very little food is taken. The bigger the baby, the more the weight loss. Subsequent
weight gain is at the rate of 25-30 gm a day

Skin — The skin colour is changed from pinkish to pale brown. The skin becomes dry and scaly.
Non specific rashes may appear. Slight yellowish tinge may appear in about 60% of the
newborns but disappears by 7th day. It is due to physiological jaundice. Lanugo gradually
disappears, beginning from the face first.
Head — Moulding gradually disappears within 24 hours, as does the caput.
Temperature — Within a few hours, the baby gradually acclimatizes to the external heat and
the rectal temperature shows a daily variation from 97-99°F.
Neonatal mastitis — The breasts of either sex may swell and become engorged. White, viscid
secretion (Witch's milk) may be expressed on 2nd-3rd day. Maternal steroid hormones
transmitted in-utero to the fetus is responsible for the breast change.
Umbilicus — The cord becomes dry and shrivelled up by 5th day and falls off by 7th day by
aseptic gangrenous process.The small granulating wound left behind heals by ingrowth of the
surrounding epithelium and leaves a puckered scar, called umbilicus.
Genitalia — Vulval engorgement, leucorrhoea or at times vaginal bleeding may occur during
first week and lasts for 24-48 hours. It is due to withdrawal of maternal oestrogen from the
newborn.
Stool — The first stool of the neonate is usually passed within 24 hours after birth and consists
of meconium, a sticky, tarlike, blackish-green, odorless material formed from mucus, vernix,
lanugo, hormones, and carbohydrates that accumulated during intrauterine life.

From the 3rd or 4th day, "changing stools" are passed which are non-homogenous, sour
smelling and yellowish brown in colour. In breastfed infants, the stools are soft and golden
yellow in colour, sour smelling and acid in reaction. In bottle-fed infants, the stools are hard,
pale in colour, foul smelling and alkaline in reaction. The number of stools passed is usually 2-3
times in 24 hours but it is not uncommon for single motion or upto 5-6 times in 24 hours to be
considered normal.
Urine — The baby usually passes urine shortly after delivery. During the first week, the urinary
output is very low to the extent of 60 ml in 24 hours. The colour is at first dark but soon
becomes colourless with low specific gravity, the urinary output increases to 200-300 ml / day
by the 7th day.

Autoimmune system: The neonate has difficulty forming antibodies against invading antigens
up to 2 months of age. For this reason immunizations against childhood diseases are not
generally given to babies younger than 2 months.

Neurological response — The neurological tests are made to elicit the reflex behaviour 24
hours after birth. A normal term infant has got a well developed "Moro reflex", sucking or
rooting response and grasp response.
Haematological findings : Haemoglobin level falls gradually to about 13 gm% with rise in
bilirubin level. Icteric index is slightly elevated by 3rd-4th day. Bilirubin level becomes highest
on 2nd-3rd day being 5-6 mg% and thereafter falls to 2 mg% at the end of 7th day.

IMMEDIATE CARE OF THE NEWBORN

I. CARE AT BIRTH:

Immediate care of a normal newborn at the time of birth

1) Call out the time of birth
It is important to tell loudly the time of birth - this helps in accurate recording of the time
and more importantly, alerts other personnel in case any help is needed
2) Receive the baby on to a warm, clean and dry towel or cloth on a warm dry surface
The baby should be delivered on to a warm clean towel and kept on the mother's chest. If this
is not possible, the baby should be kept in a clean, warm, safe place close to the mother.
3) Clamp and cut the umbilical cord
 The umbilical cord should be clamped using a sterile, disposable clamp or a sterile tie and cut
using a sterile blade about 2-3 cm (1-inch) away from the skin.
4) Immediately dry the baby with a warm clean towel or piece of cloth; wipe the eyes
The baby should be thoroughly dried to prevent from getting cold . Blood or meconium on
the baby's skin should be wiped away; however, the white greasy substance covering the baby's
body (vernix) should not be wiped off. Because this vernix helps to protect the baby's skin and
gets reabsorbed very quickly.
5) Assess the baby's breathing while drying, obtain Apgar scoring
 At the time of drying itself, the baby's breathing should be assessed. A normal newborn
should be crying vigorously or breathing regularly at a rate of 40-60 breaths per minute.
 Record the First Cry. A crying infant is a breathing infant, because the sound of crying is
made by a current of air passing over the larynx. The more lusty the cry, the more
assurance there is that the newborn is breathing deeply and forcefully.

If the baby is not breathing well, then the steps of resuscitation have to be carried out.
6) Wipe both the eyes with sterile gauze
Clean the eyes using sterile gauze/cotton. Use separate gauze for each eye. Wipe from the
medial side (inner canthus) to the lateral side (outer canthus).
7) Leave the baby between the mother's breasts to start skin-to-skin care
Once the cord is cut, the baby should be placed between the mother's breasts to initiate skin
to-skin care. This will help in maintaining the normal temperature of the baby as well as in
promoting early breastfeeding.
8) Place an identity label on the baby and take footprints

This helps in easy identification of the baby, avoiding any confusion. The label placed on
the wrist or ankle.
One traditional form is a plastic bracelet or bead necklace with permanent locks that
need to be cut to be removed. A number that corresponds to the mother's hospital number,
the mother's full name, and the sex, date, and time of the infant's birth are the information
necessary for identification. If an identification band is attached to a newborn's arm or leg, two
bands should be used. A newborn's wrist and hand, as well as ankle and foot, are not too
different in width, which enables the bands to slide off with little movement.
Footprints: After the attachment of the identification bands, the infant's footprints may be
taken and thereafter kept with the baby's chart for permanent identification. If footprints will
be obtained, care should be taken in securing them, since they will be part of the permanent
record.
9) Cover the baby's head with a cap.
 Cover the mother and baby with a warm cloth.
 Both the mother and the baby should be covered with a warm cloth, especially if the
delivery room is cold (temperature less than 25°C). Since head is the major contributor
to the surface area of the body, a newborn baby's head should be covered with a cap
to prevent loss of heat.
10) Encourage mother to initiate exclusive breastfeeding. Breastfeeding should be initiated
within half an hour of birth in all babies.

BASIC NEEDS OF BABIES AT THE TIME OF BIRTH

1. ENSURING WARMTH: ‘WARM CHAIN'
A baby's skin temperature falls within seconds of being born. If the temperature
continues to fall, the baby will become ill and may even die. This is why a baby be dried
immediately after birth and delivered onto a warm towel or piece of cloth, and loosely wrapped
before being placed naked between the mother's breasts.
This first skin-to-skin contact should last uninterrupted for at least one hour after birth
or until after the first breastfeed.
Warm chain' means that the temperature maintenance should be a continuous process
starting from the time of delivery and continued till the baby is discharged from the hospital.
The components of warm chain are summarized below:
'Warm chain'
1. At delivery
• Ensure the delivery room is warm (25° C), with no draughts
• Dry the baby immediately; remove the wet cloth
• Wrap the baby with clean dry cloth
• Keep the baby close to the mother (ideally skin-to-skin)
• Postpone bathing/sponging for 24 hours
2. After delivery
• Keep the baby clothed and wrapped with the head covered
• Minimize bathing especially in cool weather or for small babies
• Keep the baby close to the mother
• Use kangaroo care for stable LBW babies and for re-warming stable bigger babies
• Show the mother how to avoid hypothermia, how to recognize it, and how to re-warm a
cold baby. The mother should aim to ensure that the baby's feet are warm to touch
2. HELPING TO ESTABLISH NORMAL BREATHING
The baby’s breathing should be assessed at the time of drying. If the baby is crying
vigorously or breathing adequately, then no intervention is needed.

3.INITIATING BREASTFEEDING
During the initial skin-to-skin contact position after birth, the baby should be kept
between mother's breasts; this would ensure early initiation of breastfeeding. Initially, the baby
might want to rest and would be asleep. This rest period may vary from few minutes to 30 or 40
minutes before the baby shows signs of wanting to breastfeed. After period (remember each
baby is different and this period might vary), the baby will usually open his/her mouth and
start to move the head from side to side; he may also begin to dribble. These signs indicate that
the baby is ready to breastfeed.
The mother should be helped in feeding the baby once the baby shows these signs. Both
the mother and the baby should be in a comfortable position. The baby should be put next to
the mother’s breasts with his mouth opposite the nipple and areola. The baby should attach to
the breast by itself when it is ready.
4. PREVENTION OF INFECTIONS: 'CLEAN CHAIN'
Cleanliness at delivery reduces the risk of infection for the mother and baby, especially
neonatal sepsis and tetanus. Cleanliness requires mothers, families, and health professionals to
avoid harmful traditional practices prepare necessary materials. Hand washing is the single
most important step to be emphasized to both family members and health care workers.
Clean Chain
1. Clean delivery (WHO'S six cleans)
• Clean attendant's hands (washed with soap)
• Clean delivery surface
• Clean cord- cutting instrument (i.e. razor, blade)
• Clean string to tie cord
• Clean cloth to wrap the baby
• Clean cloth to wrap the mother
2.After delivery
• All caregivers should wash hands before handling the baby
• Feed only breast milk
• Keep the cord clean and dry; do not apply anything
• Use a clean cloth as a diaper/napkin
• Wash your hands after changing diaper/napkin. Keep the baby clothed and wrapped with
the head covered
IMMEDIATE CORD AND EYE CARE
Immediate cord care
The umbilical cord can be cut and clamped /tied while the baby is on the mother’s
abdomen or on a warm, clean and dry surface.
 Put the baby on the mother’s chest or on a warm, clean and dry surface close to the
mother.
 Change gloves, if not possible, wash gloved hands
 Put ties (sterile ties) tightly around cord at 2 cm and 5cm from the abdomen.
 Cut between the ties with a sterile instrument
 Observe for oozing blood. If blood oozes place a second tie between the skin and first
tie.
 Don’t apply any substance to the stump
 Don’t bind or bandage stump
 Leave stump uncovered
Eye care
A baby’s eyes should be wiped as soon as possible after birth. Both eyes should be gently
wiped with separate sterile swabs soaked in warm sterile water. Eye drops or ointment should
be given within one hour of delivery.
Eye care
Do's:
• Give prophylactic eye drops within 1 hour of birth as per hospital policy
Don'ts:
• Do not apply anything else (e.g. Kajal) in the eyes
APGAR Scoring
 Obtain APGAR Scoring at 1 min and 5 min
 Apgar test is a scoring system designed by Dr. Virginia Apgar, an
anesthesiologist,a systematic and measurable method to access the newborn in
the crucial minutes after birth.
Purposes:
 Evaluate the conditions of the baby at birth,
 Determine the need for resuscitation,
 Evaluate the effectiveness of resuscitative efforts,
 Identify neonates at risk for morbidity and mortality.
 If there are problems with the infant:
 An additional score may be repeated at a 10-minute interval.
 For a Cesarean section:
 The baby is additionally assessed at 15 minutes after delivery.
Scoring
 7-9 = free from immediate distress; normal
 4-6 = moderately depressed; may require additional resuscitative measures
 0-3 = severely depressed; necessitates immediate medical attention
 Note:
 Is strictly used to determine the newborn’s immediate condition at birth
and
 Does not necessarily reflect the future health of your baby.
 Scores done at 1 minute to identify who needs immediate intervention.
 Scores taken again at 5 minutes to assess recovery from depression or a
subsequent turn for the worse.
 Resuscitation takes precedence over determining score.
Table:: Apgar Scoring Chart
Score
Sign 0 1 2
Heart rate Absent Slow(<100) >100
Respiratory effort Absent Slow, irregular; Good; strong cry
weak cry
Muscle tone Flaccid Some flexion of Well flexed
extremities
Reflex irritability No response Grimace Cough or sneeze
Color Blue, pale Body pink, Completely pink
extremities blue
Heart rate: Auscultating the newborn heart with a stethoscope is the best way of determining
heart rate; however, heart rate also may be obtained by observing and counting the pulsations
of the cord at the abdomen if the cord is still uncut at 1 minute after birth.

Respiratory Effort. A mature newborn usually cries spontaneously at about 30 seconds after
birth. By 1 minute he or she is maintaining regular, although rapid, respirations.

Muscle Tone: Mature newborns hold the extremities tightly flexed, simulating their
intrauterine position. They should resist any effort to extend their extremities.

Reflex Irritability: One of two possible cues is used to evaluate reflex irritability: either the
newborn's response to a suction catheter in the nostrils or the response to having the soles of
the feet slapped.

Colour: All infants appear cyanotic at the moment of birth. They grow pink shortly after the first
breath.

Monitoring the baby

The health personnel should monitor these three parameters every 15 minutes in the
first hour afterbirth of the baby.
The three most important parameters that need to be monitored are:
i. Breathing
ii. Temperature or warmth
iii. Color
SPECIAL SITUATIONS
1. Caesarean section, instrumental delivery
1. Before delivery, preparation for newborn resuscitation should be made in all these cases.
2 If a long delay is expected between delivery and breast feeding, encourage the mother to
express colostrum. If the mother is too ill to express herself, do it for her.
3. A mother who has delivered by caesarean section should not be routinely separated from
her baby unless either the mother or the baby is sick and needs special care. The baby
should be kept in the same room as its mother.
4. Skin-to-skin contact and breastfeeding in difficult deliveries (caesarean section,
instrumental and breech delivery):
• A mother who was given a general anaesthetic agent should begin skin-to-skin contact as
soon as she is able to respond to her baby.
• A mother who has had an epidural (spinal) anaesthetia may be able to start skin skin
contact very soon after surgery
• These mothers will need additional assistance in positioning and attaching the baby
comfortably.
• Breastfeeding in lying down position may be more comfortable in first days
• Breastfeeding can begin as soon as the mother is comfortable and able to respond to her
baby. It does not have to be delayed
2. HIV and newborn care at birth

1. Universal precautions must be followed as with any other delivery.

2. Baby can have immediate skin-to-skin contact as any other mother and baby.
3. Breastfeeding can begin when the baby is ready after delivery.
4. If mother chooses replacement feeding, prepare formula for the first few feeds. . These
feeds should be given by cup NOT bottle. Avoid mixed feeding (breast and replacement).
5. All other care (including cord care and eye care) remains the same
2. CARE IN NURSERY:
Observation — The infant should be examined systematically beginning from the head followed
by inspecting the whole body to detect any congenital abnormality.
To estimate the gestational age — This may be made soon after delivery. A baby delivered at
39 weeks or more presents with the following features:
(1) Sole covered with creases (2) Breast nodule diameter of 7 mm (3) Scalp hair — coarse and
silky (4) Ear lobule — stiffened by thick cartilage (5) In male, scrotum is full with testes with
extensive rugae.
General care — The baby is placed in a cot, where neutral thermal condition is maintained.
Hypothermia must be avoided. The baby should be flat on the cot with the head slightly
lowered. Handling should be gentle and be kept to a minimum. Temperature should be
frequently recorded until it becomes stabilised.
The measures to prevent heat loss are :
 Keep the delivery room warm (thermoneutral zone 36.5°C).
 Dry baby immediately after birth,
 Cover baby (including the head) with a prewarm towel,
 Put baby close to mother's breast (Kangaroo method). Kangaroo mother care is a
humane low cost special way of caring preterm infant where the baby is placed in a
direct skin to skin contact with the mothers
 Wrap the mother and baby together,
 Commence early breast feeding.
Baby bath — Routine bath is delayed until the baby is able to maintain the body temperature
and has started breast feeding. The excess vernix, blood or meconium are wiped off from the
skin using sterile moist swab and then make the skin dry by using a soft towel. The water for
baby bath should be at body temperature a separate bath tub should be earmarked for each
baby.
Weight — Immediately following bath or cleaning, the baby should be weighed naked.
Care of the umbilical cord — The cord is to be inspected once more for evidence of slipping of
ligature. The cord is left exposed to the air, without any application of dusting powder, it dries
up and falls off. Daily cleaning with spirit and use of antibiotic powder is usually done.
Clothing : The dress should be appropriate for the climate. The extremities should be free for
movements. A napkin is applied which should be changed periodically.
Care of the eyes : Eyes are kept clean with cotton wool soaked with sterile isotonic saline. As a
prophylaxis against ophthalmia neonatorum and chlamydia trachomatis, application of
gentamicin ophthalmic ointment or erythromycin (0.5%) ophthalmic ointment every 6 hours
may be used.
Medication : (a) Intramuscular administration of vitamin K 1 mg is given as a routine to
minimise haemorrhagic disease, (b) Prophylactic antibiotic therapy is considered in (i) Delivery
following premature rupture of the membranes (ii) Instrumentation (laryngoscopic intubation
required to revive an asphyxiated baby) c)Hepatitis B vaccine 0.5ml IM.
Close observation for at least 4-8 hours — to note : (i) Any excessive mucus secretion
from the mouth, (ii) Any bleeding from the umbilical cord stump, (iii) Hourly temperature until
it stabilises and remains above 36°C.
DAILY OBSERVATION AND CARE OF NEWBORN
As the majority of complications occur during the first 24 hours, close observation is
mandatory during this period, noting specially the cardio-respiratory function. The infants are
observed and cared for as follows :
 Respiration is regular, smooth and quiet, the rate being 40 / minute.
 Temperature is to be taken twice daily.
 Weight is to be taken every 3rd day.
 Feeding schedules as described later are to be followed and difficulties if any, are to be
noted and rectified.
 Eyes are to be inspected for evidence of early infection suggested by discharge (sticky
eyes).
 The mouth should be inspected daily for detection of early evidence of thrush.
 The umbilical cord is to be inspected daily and cared as outlined earlier.
 Bath — Cleaning the skin may be repeated daily as required, specially the buttocks, to
remove the meconium. A daily bath is prescribed when the woman is at home.
 Rooming-in — Soon after birth if the mother is otherwise fit, the baby is kept in a cot by
the bed side of the mother. This not only establishes the mother-child relationship but
the mother is conversant with the art of baby care so that she can assume full care of
the baby when at home
 Number and character of the stools and rough estimation of the amount of urine
passed daily are to be noted. Napkins should be changed immediately following soiling
and the local parts should be cleaned dry.
 Any abnormal features and behaviour should be promptly detected and corrected.
BREAST FEEDING
 The baby should be put straight to the breast as soon as the mother has recovered from
the fatigue of labor.
 The first feed is usually offered within 1 to 2 hours after birth. There is no need to
administer any prelacteal feeds in the form of honey, glucose water, tea etc.
 The colostrum (milk secretions during the first three days of lactation) must never by
discarded and all babies should invariably receive it because it is rich in energy, proteins,
protective antibodies and cellular elements.
  The mother must be explained and reassured that the act of sucking is the best stimulus
for milk production and the small amount of concentrated milk produced during first
two to three days of lactation is adequate to meet the nutritional needs of healthy
normal babies.
 The child should be on demand feeding and most babies are satisfied with feeds taken
every two to three hours.
 The baby should be allowed to suck at the breast till he is satisfied which usually takes
15-20 minutes.
 The mother must be advised to burp the child after each feed to safeguard against the
risk of regurgitation
Adequacy of feeding
The baby is receiving adequate feeds if he sleeps well after a feed for at least 2 hours,
gains weight regularly on an average of 30 g per day (after the first week of life) and voids urine
six or more times in a day
Maintenance of Body Temperature
 The baby bath should not be given at birth and delayed till next day when his
temperature has stabilized.
 The child should be kept dried and adequately clothed.
 The baby should be nursed in close proximity to the mother so that the baby gains heat
from maternal warmth.
 In winter, the linen and clothes of the baby should be prewarmed. He should be provided
with a cap, socks and mittens.
 The room should be kept warm.
 The mother and health workers should be trained to assess the temperature of the baby
by touch alone.

BABY MASSAGE.
It improves the circulation and tone of the muscles, gives comfort to the baby,
strengthens maternal bonding and provides additional energy.
Oil massage is credited to improve weight gain, reduce stress and enhance immunological
functions of the baby. It prevents dryness and chaffing of skin
 Oil massage of the baby should be postponed till he is 3 to 4 weeks old and his body
weight is more than 3 kg.
 Use a non-irritating oil like olive oil or coconut oil but avoid mustard oil in young infants.
 The baby should be massaged before giving the bath in a room which is comfortably kept
warm and free from draughts.
 In winter massage is best done by placing the baby in front of a closed window through
which sunrays are peeping in the room.
Skin Care and Baby Bath
  The baby must be cleaned off blood, mucus and meconium before he is presented to
the mother.
 He should be bathed or sponged next morning using unmedicated soap and clean
lukewarm water.
 The barrier nursing with separate articles for each baby in their individual lockers is
desirable.
 It has been shown, that 'no bath' regimen during hospital stay of the baby reduces
incidence of superficial infections.
 During summer months, the babies can a bath. The room should be reasonably
warm and free of any draught.
 Avoid dip baths till the cord has fallen using any mild unmedicated soap.
 No vigorous attempts should make to rub off the vernix caseosa which protection to
the delicate skin.
 During winter the baby should preferably be sponged rather bathed to avoid the risk
of exposure. The talcum powder is unnecessary except for aesthetic purpose
Care of the Umbilical Stump
 The health personnel must use sterile instruments to cut and clamp the cord
 The cord is inspected for bleeding after 2 to 4 hours of birth.
 The dressing should not be applied. Inspect the infant's cord to be certain it is clamped
securely.the number of cord vessels should be counted and noted immediately after
cutting of the cord.
 Until the cord falls off, at about the 7th to 10th day of life, the infant should be sponge
bathed rather than immersed in a tub of water. The diaper is folded below the level of
the umbilical cord so that when it becomes wet, the cord does not become wet also.
 Keep the cord dry until it falls off after they return home. The use of creams, lotions,
and oils near the cord should be discouraged, because they tend to slow drying of the
cord and invite infection. Some health care agencies recommend dabbing rubbing
alcohol) on the cord once or twice a day to hasten drying, others prefer that the cord be
left strictly alone.
 After the cord falls off, a small, pink, granulating area about a quarter of an inch in
diameter may remain. This should also be left clean and dry until it has healed

Care of the Eyes

 Eyes should be cleaned daily with sterile cotton swabs soaked in normal saline using one
swab for each eye.
 If the eyes are sticky, 10 percent solution of suphacetamide should be instilled in the eyes
every two to four hours
 Prophylactic instillation of human colostrum into the eyes has been shown to reduce the
incidence of sticky eyes.
The practice of applying kajal in the eyes is not recommended because it may transmit
infection like trachoma and may even cause lead poisoning.
CREDE TREATMENT

Prophylaxis against gonorrheal conjunctivitis was first proposed by Crede, a German

gynecologist, in 1884. Silver nitrate is the drug that was exclusively used for prophylaxis in the
past; today, erythromycin ointment is the drug of choice (Isenberg, 1990). Erythromycin
ointment has the advantage of eliminating not only the organism of gonorrhea but that of
chlamydia as well.

DRESSES FOR THE BABY

 The clothes should be loose, soft and preferably made of cotton. They should be open on
the front or back for ease of wearing.
 Avoid the use of large buttons which may hurt the tender skin of the baby.
 The nappies should be made of thick, soft and absorbant material in order to readily soak
the urine and stools.
 The use of plastic napkin should be avoided at home due to increased risk of nappy rash
EARLY DETECTION OF SERIOUS DISEASE
The following danger signs should be closely watched and brought to the notice of the
consultant.
 Bleeding from any site; appearance of jaundice within 24 hours of age or deep jaundice;
failure to pass meconium within 24 hours and urine within 48 hours; vomiting or diarrhea;
poor feeding; undue lethargy or excessive crying; excessive frothiness or drooling; choking
at feeds; respiratory difficulty, apneic attacks and / or cyanosis; seizures; sudden rise or
fall in the body temperature and any evidences of superficial infection (conjunctivitis,
pustules, umbilical sepsis and oral thrush etc.)
WEIGHT RECORD

 The infant is weighted nude once a day at approximately by the same time every day.
The weight each day should be compared with that of the preceding day to be certain
that the infant is not losing more than the normal physiologic amount

 Most babies lose weight during first 2 to 3 days of life.. The weight remains stationary
during next 1 to 2 days and birth weight is regained by the end of first week. The factors
contributing to initial weight loss include removal of vernix, mucus, and blood from skin,
passage of meconium and reduction of extracellular fluid volume.
Deliberate starvation and delayed feeding is associated with excessive weight loss.
During first year of life average daily weight gain is around 30 g, 20 g and 10 g during first,
second and third 4-months periods respectively. Most infants double their birth weight by 4-5
months of age and triple it by their first birth day.
Birth Registration
The physician or nurse-midwife who delivered the infant must be certain a birth
registration is filed with the Bureau of Vital Statistics of the state in which the infant was born.
The infant's name, the mother's name, the father's name (if the mother chooses to reveal this),
and the birth date and place must be recorded. Official birth information is important in proving
eligibility for school and later for voting, passports, Social Security benefits, and so on.
Document Birth Record
Be certain the birth record lists the following: the time of birth; the time the infant
breathed; whether respirations were spontaneous or aided; the child's Apgar score at 1 and 5
minutes of life; whether eye prophylaxis was given; whether vitamin K was administered; the
general condition of the infant; the number of vessels in the umbilical cord; whether cultures
were taken (they are taken if at some point sterile delivery technique was broken or the mother
has a history of vaginal or uterine infection); and whether the infant (1) voided and (2) passed a
stool.Many nurses indicate a three-vessel cord with the symbol
Immunizations
 BCG and first dose of OPV and hepatitis B vaccine (HBV) are given at birth or before the
baby is discharged from the hospital.
 The Centers for Disease Control (1993) have recommended that all newborns receive a
first vaccination against hepatitis B within 12 hours after birth. Infants whose mothers
are HBsAg+ also receive concurrently hepatitis B immunoglobulin (HBIG).

 The OPV may preferably be given after 3 days because colostrum may interfere with its
uptake.
 The BCG site should be checked for 'take' response after 4 weeks.
Supplements and Follow-up
 Vitamin K 1.0 mg 1M is given to all babies at birth to prevent occurrence of hemorrhagic
disease of the newborn. There are recent reports to suggest that some healthy breast
fed babies may develop rickets at 3-4 months of age and should be provided
supplements of vitamin D.
 The infants should be followed up in the Well Baby Clinic for evaluation of their growth
and development, immunizations, nutritional advice, early diagnosis of abnormalities
and guidance to the parents for the management of day to day problems of their
children. When complementary feeds are started after 6 months of age, supplements of
vitamins and minerals should be provided.
NURSING DIAGNOSIS: FOR THE FIRST 2 HOURS

1. High risk for ineffective airway clearance related to presence of mucus in mouth and nose
at birth

Expected outcome

The neonate will maintain patent airway with respiratory and hearty rate within normal
limits.

Interventions

 Measure Apgar score at 1 and 5 minutes following delivery.

  Note presence of nasal flaring, chest retractions, expiratory grunting, crackles or rhonchi.
 Clear airway, gently suction nasopharynx, as needed using a bulb syringe Monitor apical
pulse during suctioning.
 Place newborn in modified Trendelenburg position at a 10-degree angle.Facilitates
drainage of mucus from nasopharynx and trachea by means of gravity.
 Note pitch and intensity of cry.
 Auscultate / evaluate apical pulse. A heart rate less than 100 bpm indicates severe
asphyxia and the need for immediate resuscitation.
 Provide appropriate tactile and sensory stimulation.
 Observe skin colour for location and extent of cyanosis. Assess muscle tone.Generalized
cyanosis and flaccidity indicate inadequate tissue oxygenations.

2. High risk for ineffective thermoregulation related to newborn's transition to extrauterine

environment.

Goal: Newborn will establish adequate body temperature by 1 hour after birth

Interventions

 Dry newborn’s head and body and remove the wet linen, wrap in warm blankets. Dry
infant with warm blankets.
 Place the newborn in pre-warmed environment or in parent’s arms. Warm the objects
coming in contact with infant such as weighing scale, stethoscope, hands and
examination table.
 Assess neonate’s core temperature, monitor skin temperature continually with skin
probe as appropriate
 Postpone initial bath until body temperature is stable and reaches 97.70F (36.50C).
 Bathe neonate working rapidly, exposing only a portion of the body at a time and drying
each part immediately

3. High risk for infection related to newly clamped umbilical cord and exposure of eyes to
vaginal secretions.

Outcome

 Newborn will show no signs of infection during health care agency stay.

Interventions

 Monitor vital signs including skin temperature.

 Scrub hands and arms with antiseptic preparation prior to entering nursery/neonate's
room.
 Teach parents and siblings proper hand washing technique to use before handling
infantry.
 Monitor personnel handling and visiting newborn for infectious illnesses.
 Maintain individual equipment and supplies for each newborn.
  Instruct parent(s) to inspect skin daily for rashes or interruptions in skin integrity.
 Encourage early breastfeeding as appropriate,
 Administer hepatitis B vaccine per institutional policy.

4. Ineffective breast feeding related to increased metabolic rate, ignorance regarding breast
feeding.

Goal: The neonates will breastfed adequately

Interventions

 Encourage demand feedings instead of scheduled feedings. Note frequency, amount

and appearance of regurgitation.
 Monitor color, concentration and frequency of voiding
 Observe newborn for indications of feeding problems.
 Weigh infant on admission to nursery and daily thereafter.
 Asculate bowel sounds. Note absence of abdominal distension.
 Neonate will display weight loss of 5 to 10% or less of birth weight by the time of
discharge.

CONCLUSION
Caring for a newborn is very important as the care a newborn receives during the early period
of its life determines the health and wellbeing of the child.

REFERENCES
 D.C DUTTA Textbook of obstetrics 7th edition page no 137,444-447.
 Pillitteri Adele,”Maternal Child Health Nursing”:2nd edition,1991,J.B Lippincot
Company,Philadeiphia:648-675
 www.wikipedia.com
 www.pubmed.com.