BABY AT RISK:

Complications of the Neonate

• Preterm baby, Low Birth Weight (LBW), Small for
gestational age (SGA) and large for gestational age (LGA)
baby
• Asphyxia Neonatorum
• Respiratory Distress Syndrome
• Meconium Aspiration Syndrome
• Neonatal Jaundice
• Hypothermia Neonatorum
• Ophthalmia Neonatorum
• Birth Injuries
• Hemorrhagic Disease of the Newborn
• Congenital abnormalities
 Content Outline
1. Introduction
 Admission Criteria into NBU
 Infection Control in the NBU
 First Examination of the Newborn Baby
 Characteristics of a Normal Neonate
2. Preterm Baby
3. Small for Gestational Age (SGA)
4. Asphyxia Neonatorum
5. Respiratory Distress Syndrome (RDS)
6. Hypoglycemia
7. Neonatal Hypothermia
8. Ophthalmia Neonatorum
9. Neonatal Jaundice
10. Haemorrhagic Disease of the Newborn (HDN)
11. Birth Injuries
12. Hydrocephalus
 1. INTRODUCTION
ADMISSION CRITERIA INTO THE NEWBORN UNIT
• The new born unit does not only admit babies at risk but also offers
accommodation to normal neonates due to unstable condition or death of the
mother.
• Reasons for admitting a baby into the nursery include the following:
 Pre-maturity
 Asphyxia neonatorum
 Haemorrhagic disease of the new born
 Ophalmia neonatorum
 Birth injuries
 Congenital abnormalities e.g hydrocephalus
 Respiratory distress syndrome
 Infants of diabetic mothers(risk of hypoglycaemia)
 Maternal death
 Unstable maternal condition
 INFECTION CONTROL IN NEW BORN UNIT
• Due to low immunity of the babies in the NBU, infection control is
critical to protect the babies from infection during their stay in the
unit. This is necessitates high infection control measures within the
unit.
• The following are some ways of ensuring infection control in the
nursery.
 Keep the unit clean, free from dust. The windows should remain
closed at all times to prevent flowing in of dusty air.
 Daily dump dusting and cleaning of the incubator and cots
 Isolation of infected babies for barrier nursing.
 Restriction of visitors to ensure adequate control of human traffic
into the nursery. Visitors should see the babies through the window
glass.
 Washing hand before and after handling the baby for any procedure.
 Strictly observing aseptic technique while performing procedures.
 Feeding utensils should be rinsed, decontaminated, cleaned
thoroughly in soapy water and kept in presept till the next feed.
 Staff working in isolation room should not move into other
nurseries
 Cleaning of incubators upon discharge or death of a baby, before the
next baby is put.
 Mothers changing clothes whenever they come to feed the babies
 Health educating the mothers on the importance of personal hygiene
and care of the baby.
 FIRST EXAMINATION OF THE BABY
• This is a routine procedure done after third stage of labour in labour
ward but is also done in the nursery as part of admission procedure.
• The main aims of first exam are;
1. To rule out congenital abnormalities
2. To rule out birth injuries
3. To assess maturity of the baby
Head
• Measure the head circumference (average is 35 cm)
• Check for the moulding of the foetal skull
• Width of the fontanelles and sutures; bulging of fontanelles and wide
sutures may indicate hydrocephalus
• Depression on the skull may imply a fracture
• Injuries e.g. caput succadenium and cephalohaematoma
Eyes
• Absence of eyebrows
• Conjunctival haemorrhage / bleeding
• Any discharge and squint
Nose
• Check for any deformities e.g. well formed septum
• Bleeding from the nose
• Check for nasal flaring which is a sign of respiratory
distress
• Check for blocked nostrils
 Mouth
• Bleeding from the mouth
• Check for tongue tie
• Abnormalities e.g. cleft palate or cleft lip
• Frothing of the mouth
Ears
• Bleeding from the ears
• Leakage of CSF through the ears (otorrhoea)
• Shape of the lobes to rule out malformations
• Extra lobe of the ears
Neck
• Check out for abnormalities e.g. congenital goiter
• Check for meningocele
Chest
• Shape of the chest for symmetry
• Chest movement during respiration
• Take apex beat (at level of 5th ICS, LMCL).
• Check breast for swelling and discharge
Abdomen
• Check for skin colour and presence of rashes
• Check whether the cord is well ligated
• Bleeding from the umbilical cord
• Abdominal abnormalities e.g. hernia
Genitalia
• For males check for the testis to rule out undescended
testis
• Female check for vaginal discharge, labia should be well
formed; check size of a clitoris
Hip joint
• Rule out congenital hip dislocation
Limbs
• Check if arms and hands are moving freely
• Rule out dislocation, fractures and Erb’s paralysis
• Check for equality of the arms and to rule out
abnormalities
• Fingers for webbed and extra digits
• Legs for equality, abnormalities and movement
• Rule out talipes and club foot
Back
• Abnormalities of the back e.g. spina bifida,
myelomeningocele
• Check for skin colour and septic spots
Anus
• While taking rectal temperature, check for imperforate
anus
• Bruises on the skin or rashes
Check for the following reflexes:
• Sucking reflexes – full term infant sucks the small finger
• Moro reflex – tested by gently lifting the baby up by its
fingers from a flat surface and suddenly releasing it. It
will respond by spreading its hands then move them
together as though hugging.
• Rooting reflex – the baby turns in search of the nipple
• Grasping reflex – it will grasp your finger if you put it in
its palm.
• Stepping reflex – when held on a flat surface in standing
position, it makes stepping movement.
 NORMAL NEONATE
• This refers to a baby born at term or as near term as possible after
37 weeks of gestation and has no complications.
• Upon birth the infant has to undergo physiological changes in
order to adapt to life outside the uterus to have independent
existence.
 CHARACTERISTIC OF NORMAL NEONATE 
• Weight is 2.5 -3.5 kg.
• Length from vertex to heel is 45-52 cm
• Head circumference is 35 cm and increases by 1-2 cm during the
first month
• Fontanelles and sutures are patent. Anterior fontanel closes at 18 -24
months while the posterior closes at 6-8 weeks.
• Skin is covered by vernix caseosa, a secretion of the sebaceous gland
that helps in heat retention and acts as a lubricant during delivery.
• Umbilical cord shrivels by necrosis and falls off in 7 days. The
remaining part forms abdominal ligaments. Hernia may develop but
usually disappears spontaneously.
• Reflexes are fully developed.
• Senses are developing.
 PRE TERM BABY
• This refers to a baby born before 37 complete weeks of pregnancy.
• Some of them may have growth retardation and therefore be small
while others may be excessively large for gestational age
(macrosomia)
• Low birth weight baby is one with less than 2500g
Categories of Low Birth Weights;
 Low birth weight < 2500g
 Very low birth weight < 1500g
 Extremely low birth weight < 1000g
 Predisposing factors to Prematurity
I. Maternal factors – maternal age e.g. Primigravida below 17 years
or above 35 years; Maternal disease in pregnancy such as
anaemia, hypertension, pre-eclampsia.
II. Foetal factors – congenital abnormalities; multiple pregnancy
and polyhydramnios due to over distension of the uterus; rhesus
incompatibility interfering with foetal viability
III. Placental factors – APH due to placenta praevia and placenta
abruption
IV. Social factors – strenuous exercises, excessive drinking of
alcohol and smoking, previous history of miscarriage,
physiological stress.
 Clinical Features 
 Small stature with low birth weighs less than 2500g
 Thin and sparsely distributed hair on the head.
 Skin is reddish with plenty of lanugo
 Widely open sutures
 Eyes are closed most of the time
 Pinnae of the ears are soft and fold easily on pressure and slow to
uncoil
 Narrow sinuses and the nose a bit flat
 Swallowing and sucking reflexes absent or very weak
 Weak cry and there are no tears
 Chest is small, soft with underdeveloped breast tissue
Clinical Features Cont’…
 Poor muscle tone and the baby lies inactive most of the time
 In females, labia majora are widely separated and labia minora is
protruding in between
 In males, scrotal muscles are smooth and testis are undescended
 Palmer and planter creases are absent
 Grasp reflexes are absent
 Physiology of the Preterm Baby
1. Immunity is low due to:
 Low gamma globulins responsible for immunity.
 Delicate skin that is vulnerable to injuries and infection
 Lack of passive immunity which usually develops around 38 weeks
gestation
2. Blood system
 Has poor peripheral circulation with high tendency to hemorrhage
because of weak vascular walls.
 Prone to hemorrhage due to lack of clotting factors (vitamin K is
administered to promote clotting)
 Unable to store iron hence at risk of iron deficiency anemia.
 They have very few blood cells and may develop non pitting anemia
 3. Weight;
 Initially they lose up to 10% of their birth weight and start gaining
and reach birth weight 2-3 weeks post delivery.
4. Temperature regulation is poor due to:
 Immature heat regulatory centre
 Limited food intake and low metabolic rate
 Inability to shiver and generate heat
 Excessive heat loss due to little or no subcutaneous fat. The brown fat
is usually in baby’s body by 36 weeks gestation.
 
5. Respiratory system
 Under developed respiratory centre leading to difficulty
in initiation of respiration.
 Frequent apnoeic attacks with irregular respiration.
 Abdominal movements more than chest movements.
6. Renal system
 Immature kidneys are unable to concentrate urine
hence they excrete chlorides and phosphates.
7. Digestive system
 Absence of swallowing and sucking reflexes lead to
poor feeding
 Regurgitation after feeds due to underdeveloped
cardiac sphincter
8. Nervous system
 All regulatory centres are under developed.
 NURSING MANAGEMENT
OF PRETERM BABY
• Delivery of a preterm baby should be conducted in a
warm room and subsequently nursed in a preterm
incubator.
• Temperatures of the incubator should be maintained
within normal range of about 36 – 37oC
• Perform first examination of the baby to assess
maturity.
• Fix NG tube and feed the baby with breast milk and
substitute only where breast milk is not available.
• Feed the baby using the oral feeding regime as follows:
 Baby is given 60 - 65 mls per kg of body weight in 24 hrs in 8 divided
doses e.g. 2.5 kg baby will have 2.5 x 60/8 =18.99 mls per feeding
thus should be fed 3 hourly.
 If the baby tolerates, the feed can be increased
 If the baby can’t tolerate the oral feeds, give IV fluids e.g. 10%
dextrose
 Introduce cup and spoon feeding gradually as the baby gains weight
 Aspirate the gastric content to rule out indigestion.
• Close observation to include:
 Vital signs Temp, Pulse, Resp.
 Respiratory rhythm to note apnoeic attack
 Umbilical stump for signs of infection
 Vomiting or retaining food
 General activity and emotional status
• Provide care of IV line i.e. securing, cleaning and dressing.
• Give nutritional supplements e.g. iron, folic acids, vitamin from the
second week.
• Administer broad spectrum antibiotic prophylactically for
prevention of infection
• Take weight on alternate days to monitor the progress.
• Discharge the baby at 2000 – 2500g
• Give BCG vaccine on discharge or advice the mother to go for it.
• Advice mother on family planning so that she gets another baby
by choice and not by chance i.e. when stress has reduced.
 Complications of Prematurity
• Hypothermia neonatorum
• Haemorrhagic disease of the newborn
• Respiratory distress syndrome
• Retrolental fibroplasias
• Failure to thrive
• Jaundice
• Infections
• Anaemia
• Rickets
 SMALL FOR GESTATIONAL AGE (SGA)
• This term refers to a baby whose birth weight is below 10th
percentile of his gestational age; commonly referred to as low birth
weight but this includes preterm babies.
• SGA babies are susceptible to various problems including:
 Congenital abnormalities
 Foetal hypoxia that may lead to intrapartal death
 Birth asphyxia due to inadequate perfusion, meconium aspiration
leading to airway obstruction.
 Hypothermia due to little subcutaneous tissues
 Apnoeic attacks
 Hypoglycemia
 Signs and Symptoms of SGA
 Mostly they are born after 37 weeks gestation.
 Pale, dry loose skin with wrinkles and have little or no lanugo
 Subcutaneous fat is minimal
 Shows features of retarded growth
 The abdomen appears sunken
 Sutures and fontanel appear normal
 Eyes are alert and has mature facial expression
 Skull bones are hard and allow little mobility
 Have strong cry
 Umbilical cord is thin
 Swallowing and sucking reflexes are present so they feed well
 Normal muscle tone are active
 NURSING MANAGEMENT of SGA Babies
• The baby is predisposed to the risks similar to those of preterm
baby thus the management principles are the same.
• Management should start in labour by closely monitoring foetal
condition for signs of foetal distress.
COMPLICATIONS of SGA
Hypoglycaemia
Respiratory distress syndrome
Aspiration pneumonia
Brain damage
 ASPHYXIA NEONATORUM
• This is a term which refers to a condition in which the baby fails to
breath at birth.
Types of Asphyxia
• The degree of asphyxia is determined by APGAR score in which
the following features are observed and score 0-2;
 Appearance (colour of the body)
 Pulse (heart rate)
 Grimace (response to stimuli)
 Activity (muscle tone)
 Respiration /respiratory effort
• A score between 8-10 does not show asphyxia.
• There are three types of asphyxia namely:
1. Mild asphyxia – Apgar score is 6-7. It
requires clearing of the airway and application
of external stimuli to in initiate breathing
2. Moderate asphyxia – Apgar score is 4-5. It
requires resuscitation, administration of
oxygen and drugs to initiate breathing.
3. Severe asphyxia – Apgar score is 0-3. It
requires intensive resuscitative measures and
intubation to survive.
 Predisposing Factors to Asphyxia Neonatorum
• Any condition causing foetal distress e.g.
 cord prolapse,
 prolonged labour,
 APH,
 intrauterine hypoxia due to placental insufficiency,
 post maturity,
 placenta abruption.
 anaemia,
 pre-eclampsia
• Pre-maturity due to under development of the respiratory centre.
• Blockage of the airway by mucus or liquor amnii at birth.
• Birth injuries e.g. intracranial injury
• Severe maternal disease in pregnancy e.g. sickle cell anaemia,
cardiac disease
• Depression of respiratory center due to drugs e.g. GA and narcotics
 Signs and Symptoms
a) Mild and Moderate Asphyxia
 Apex beat (pulse rate) 100/min or less
 Skin colour is pink with blue extremities
 Response to stimuli may be present
 Cry may be weak or strong
 Makes effort to breath and may gasp with
irregular respiration
b) Severe Asphyxia
 No attempt to breath and may gasp periodically
 Baby does not cry
 Entire body skin is blue i.e. cyanosed-central.
 No response to stimuli
 Pulse rate very low or absent
 Poor muscle tone
 NURSING MANAGEMENT
• Clear the airway as soon as possible.
• Nurse the baby in an incubator for at least 48 hrs to keep it warm at
body temperature.
• Resuscitation may be needed to promote ventilation and ensure
effective circulation to prevent acidosis, hypoglycaemia and
intracranial hemorrhage
• Do suctioning whenever necessary
• Closely observe the baby for skin colour, TPR.
• Administer oxygen by mask, ambu bag or nasal catheter whenever
there is an apnoeic attack
• Give IV fluids for rehydration.
• Aspirate mucus to unblock the airway or may intubate the baby.
• Give fluids with electrolytes to maintain fluid – electrolyte balance.
• If the mother was given narcotics during labour, administer its
antidote naloxone thro the umbilical vein.
• Give anticonvulsants to control convulsions if present
• Administer the following drugs:
 Sodium bi-carbonate 1-2 mls to combat acidosis.
 Vitamin K 0.5 -1 mg i.m to prevent haemorrhagic disorders.
 Aminophylline (with caution) to improve respiration.
 Calcium gluconate to strengthen heart muscles.
• Maintain accurate input output chart to prevent over hydration and
under hydration
• When the baby is stable pass NG tube and start feeding.
• Observe aseptic technique to prevent cross infection.
• Administer broad spectrum antibiotic prophylactically.
 Prevention of Asphyxia 
• Proper screening of mothers to detect those mothers at risk and
advice on hospital delivery for proper management.
• Pelvic assessment should be done at 36 weeks gestation to rule out
pelvic inadequacy e.g. CPD.
• Proper management of maternal diseases in pregnancy.
• Drugs that depress respiratory center e.g. sedatives, GA and
narcotics should be avoided in late first stage.
• Early detection and management of foetal distress.
• Clearing baby’s airway as soon as the head is born.
• Avoiding instrumental deliveries but rather prepare for caeserian
section.
 Complications of Asphyxia Neonatorum
• Brain damage
• Cardiac arrest
• Respiratory acidosis.
• Respiratory distress syndrome
 Respiratory Distress Syndrome (RDS)
• This is a condition that occurs due to lack of or inadequate
surfactant in the lung tissue.
• Mature lungs have adequate surfactant factor that lower the surface
tension in the alveoli, stabilizes the alveoli and prevents them from
adhering together and collapse. This leads to breathing with ease.
Surfactant is produced slowly from 20 weeks gestation and reaches
a surge at 30-34 weeks gestation and another surge at onset of
labour.
• The premature infant lack this function thus the alveoli walls
pressure rise as s/he breaths out and alveoli collapse leading to
severe difficulty in breathing.
NB: Other names for RDS are:
 Hyaline membrane disease
 Pulmonary syndrome of the newborn
 Developmental respiratory distress
• RDS is a disease of prematurity and self limiting with recovery
phase or death.
 Predisposing Factors to RDS
• RDS may be a complication of asphyxia and develops within 4hrs
of birth
• Prematurity due to inadequate surfactant factor
• Prenatal hypoxia e.g due to APH which reduces surfactant
synthesis
• Perinatal hypoxia
• Trauma to CNS due to difficult delivery or precipitate labour
• Profound hypothermia – leads to injury of cells that produces
surfactant
• Congenital heart disease
 Clinical Features of RDS
• Difficulty in breathing - dyspnoea
• Flaring of the alae nasi (ala of the nose)
• Tachypnoea with respiration of above 60/min
• Hypothermia
• Generalized cyanosis
• Costal and sternal retraction
• Grunting expiration (prevent atelectasis)
• Reduced or increased heart rate
• Chest X-ray shows collapsed alveoli
• The baby has poor muscle tone and is motionless
• Poor digestion due to diminished bowel movement
• Resolves or death occurs within 3-5 days
 Nursing Management of RDS
• Management is symptomatic until the disease resolves.
• If RDS is anticipated, inform the pediatrician to resuscitate the baby.
• Nurse the baby in an incubator to prevent hypothermia by controlling
the body temperature.
• Administer oxygen or do artificial ventilation to prevent hypoxia.
• Closely monitor the blood PH to prevent acidosis and support
pulmonary circulation because high carbon dioxide level leads to
constriction of pulmonary arterioles leading to poor pulmonary blood
flow.
• In case there is acidosis, Sodium Bicarbonate is added to 10 %
dextrose drip.
• Keep the baby nil per oral till the distress resolves.
• Administer IV fluids eg.10% dextrose and add Calcium Gluconate
to strengthen heart muscles; Sodium Bicarbonate to ensure fluid
electrolyte balance.
• Check haematocrit (PCV) and if less than 40% transfuse with
blood.
• Maintain the normal BP with volume expanders e.g. n/saline.
• Position the baby to provide greatest air entry(prone position with
extended head)
• Suction and do postural drainage to remove secretion and keep the
airway patent.
• Close observation to monitor the progress whether improving or
deteriorating i.e. the heart rate, respiration, chest in- drawing,
grunting respiration and cyanosis.
• When the condition resolves, introduce oral feeds. In case the baby
develops abdominal distention due to ingestion, stop the oral feeds
and start IV fluids.
NB: Principles followed during care of babies with respiratory
problems are;
 observation,
 oxygenation,
 positioning,
 nutrition and
 hydration.
 Prevention of RDS
• Early detection and management of high risk pregnancies to
prevent premature delivery
• Conditions such as diabetes mellitus should be properly managed
so that delivery can be prolonged to 36 -38 weeks.
• The mother is then given Dexamethasone 4mg tds 48 hrs before c/s
to stimulate lung maturity.
• Prevent prenatal hypoxia by ensuring there is no intracranial injury
at birth.
• Effective resuscitation at birth of high-risk babies.
• Assessment of gestational age and lungs maturity through
amniocentesis so that elective c/s or delivery can be delayed if
lungs are not mature enough.
 Complications of RDS
• Retrolental fibroplasia
• Hypothermia
• Hypoglycaemia
• Patent ductus arteriosus
• Abdominal distension
• Hypocalcaemia
• Intracranial haemorrhage
• Infection
HYPOGLYCAEMIA
• This is a metabolic disorder in which the blood glucose level falls
below 2.6 mmol/L.
• At term, the baby’s glucose level is almost equal to that of the
mother but gradually drops within 3-4 hrs after birth. This is why
the baby has to be fed within 1 hour of life.
• The baby’s blood glucose rises steadily following feeds to 2.8-
4.5mmol/l in 6-12 hours
• Term babies can maintain their energy requirements as long as they
are kept warm.
• Hypoglycemia is common in infants of diabetic mothers. Due to
excess glucose, the fetus produces more insulin which increases its
body fat and muscle mass leading to large babies (macrosomia).
• At birth, the glucose level falls rapidly while insulin levels remain
relatively high so the baby is at risk of hypoglycemia. This is why
such babies are admitted into the NBU.
• Prolonged hypoglycaemia can lead to mental retardation,
permanent neurological damage and death due to respiratory and
metabolic acidosis.
 Predisposing Factors to Hypoglycemia
• Low birth weight
• Prematurity
• Birth injuries
• Maternal diabetes mellitus
• Asphyxia
• Septicaemia
• Respiratory distress syndrome
 Clinical Features of Hypoglycemia
• Low blood glucose less than 2.6 mmol/L
• Poor feeding
• High pitched cry
• Lethargy
• Irritability
• Hypotonic muscle activity
• Hypothermia
• Apnoea
Nursing Management of Hypoglycemia
• Give 10% dextrose infusion until normal glucose levels are
achieved.
• Encourage the mother to breastfeed the baby
• Feed through NG tube or cup and spoon expressed breast milk.
• If the hypoglycemia is severe, put up 10% dextrose infusion and
give 65-85 mls/kg of body weight in 24hrs.
• Give a bolus dose of 25% dextrose 2mls/kg body weight i.v slowly
for 30 min.
• Closely monitor the glucose levels 1 hourly until the general
condition is stable or normal levels have been achieved.
• Once the normal levels have been achieved, wean off the dextrose
and observe closely for changes in the condition.
 Prevention of Hypoglycemia
• Taking blood glucose levels at birth and introducing glucose feeds
e.g. dextrose or breastfeeding within 1hr of life.
• Prevent hypothermia.
• Monitoring glucose level 2hrly for the first 6-8 hours.
• Infants of diabetic mothers should be admitted into NBU and blood
glucose levels regularly checked.
 Complications of Hypoglycemia
• Hypothermia
• Convulsions
• Brain damage
• Neonatal death as an outcome.
 
 NEONATAL HYPOTHERMIA
• This is a condition in which the neonate’s body temperature falls
below 36oC.
• The baby losses heat through radiation, conduction, convection
and evaporation.
Predisposing Factors
Prematurity
Asphyxia Neonatorum
Maternal diabetes mellitus
Respiratory Distress Syndrome
Cold environment
 Clinical Features of Neonatal Hypothermia
• Rectal temperatures is below 36oC
• Baby feels cold on touch
• Paleness of extremities and face
• Very weak cry
• Low respiration rate
• Baby not eager to feed (poor feeding)
 Nursing Management of Neonatal Hypothermia
• Nurse the baby in a warm environment in a resuscitaire or wrap it
in warm clothings
• Feed the baby with expressed breast milk via NGT
• Give the baby extra glucose e.g. dextrose
• Closely observe the baby for signs of hypoglycaemia and if
present, give 10% dextrose
• Check for and treat convulsions with anticonvulsants
 Prevention of Neonatal Hypothermia
• Delivery should be conducted in a room with controlled
temperature,
• Put the baby on resuscitaire or in incubator to compensate heat
loss to the environment.
• Baby should not be bathed within 1hr of life but top-tailing can be
done after one hour.
• Encourage skin to skin contact (kangaroo method) when carrying
the baby.
Complications of Neonatal Hypothermia
• Convulsions
• Hypoglycaemia
• Brain damage
 OPTHALMIA NEONATORUM
• This is a condition that occurs in neonates within 21 days of life and
is characterized by purulent discharge from the eyes.
• It is common in infants of mothers who had vaginal discharge e.g.
Gonorrhoea during pregnancy.
• NB: Syphilis does not predispose an infant to Opthalmia
Neonatorum but it causes congenital syphilis that is characterized
by gross congenital malformation.
 Causative Organisms of Ophthalmia Neonatorum
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Staphylococcus aureus
• Escherichia coli
• Haemophilus influenza
• Streptococcus pneumoniae
• Pseudomonas spp
• Klebsiella
 Clinical Features
• Eyes have sticky watery discharge
• Eyes are slightly red
• Oedematus eyelids
• Yellow purulent discharge if the infection is by Neisseria
gonorrhoeae
• Inflamed conjunctiva
 Nursing Management
• All perinatal mothers presenting with vaginal discharge suggestive
of gonorrhoae should be treated before delivery.
• Correctly swab the baby’s eye at birth.
• Instill 1% tetracycline ointment (TEO) to all babies at birth
prophylactically.
• All infected babies should be isolated
• Take eye swab for culture and sensitivity
• Administer drugs such as;
 Gentamycin eye drops
 TEO but not systemic tetracycline
 Penicillin eye drops
 Kanamycin eye drops
• Swab the eyes with warm saline 3 times a day from inside
outwards
• Administer some broad–spectrum systemic antibiotic but not
tetracycline because it deposits in bone leading to depressed bone
growth.
Complications of Opthalmia Neonatorum
 Partial or permanent blindness
 NEONATAL JAUNDICE
• This is condition in neonates characterized by yellow discoloration
of the skin, sclera and mucous membrane.
• It develops when there is an excessive bilirubin level in the blood
stream.
• When there is increased rate of haemolysis of RBC or decreased
conjugation of bilirubin, there are high amounts of free bilirubin
in circulation leading to jaundice.
 Bilirubin Metabolism
• When RBC’s are broken down by haemolysis, they produce haeme
and globulin.
• The haeme part produces bilirubin and iron.
• Unconjugated (indirect) bilirubin is fat soluble hence has to be
converted to water soluble form (conjugated/direct bilirubin) by
process of conjugation for it to be excreted.
• Conjugation of bilirubin occurs in the liver and thus it has to be
transported to the liver by binding to transport protein, albumin.
• On arrival to the liver, bilirubin detaches itself from the albumin.
• Conjugation is done by glucoronyl transferase in which bilirubin is
added to glucoronic acid to become bilirubin diglucoronide that is
water soluble.
• Excretion of the bilirubin is done through the biliary system into
the intestine. While in the intestine, it is converted to
stercobilinogen by the gut normal flora and excreted in stool. Some
of it is absorbed from the gut and becomes urobilinogen which is
excreted in urine.
• If conjugation process is interfered with, there will be accumulation
of unconjugated bilirubin leading to hyperbilirubinaemia and
jaundice. This bilirubin may cross the blood brain barrier (BBB)
and cause brain damage, a condition known as kernicterus that is
characterized by seizure, hyper-tonicity, lethargy, and stiff neck with
hyper extended head.
 Types of Jaundice
a) Physiological Jaundice
• This type of jaundice affects both preterm and term babies in the
first few days of life. It is apparent with the signs on the third day
when the unconjugated bilirubin levels in serum is 25-125 mmol/L.
• In term babies, it never appears before 24 hrs of life but it can be
in preterms and the serum levels never exceeds 200mmol/L.
• It is also self limiting in term babies.
 Causes of Physiological Jaundice
• Excessive haemolysis of RBCs greater than conjugation rate.
• Glucoronyl transferase enzyme deficiency
• Increased enterohepatic reabsorption
• Decreased albumin binding capacity thus less bilirubin is
transported to the liver for conjugation.
 Nursing Management of Physiological Jaundice
• Admit the baby into the NBU and assess the general condition.
• Start early and frequent breastfeeding for it provides glucose to the
liver cells and also encourages bowel colonization with normal flora
which is important in formation of stercobilinogen for excretion in
stool and also leads to increased gut motility leading to faster
excretion of bilirubin.
• Feeding also enhances enzyme production and conjugation.
• Closely monitor serum bilirubin levels at 12 -24 hrs interval.
• If bilirubin levels takes time to clear, put the baby on phototherapy.
 b) Pathological Jaundice
• This type of jaundice appears within 24-48hrs of life and is not self-
limiting thus may persist for long (14-21 days if untreated).
• There is rapid rise in serum bilirubin.
• It includes both obstructive and hemolytic jaundice.
Causes of Pathological Jaundice
• They include pathological disorders that increase bilirubin
production, reduces transportation to and fro the liver or reduced rate
of conjugation. These are;
1. Increased haemolysis
 Rhesus and ABO incompatibility,
 G6PD enzyme deficiency,
 Bacterial septicaemia.
2. Non-haemolytic causes of increased unconjugated bilirubin
 CNS hemorrhage,
 Cephalo-haematoma,
 Polycythaemia,
 Exaggerated entero-hepatic circulation of
bilirubin due to functional ileus.
3. Decreased rate of conjugation;
 Criggler Nagar syndrome,
 Gilbert’s syndrome
4. Hepatotoxic drugs
5. Billiary obstruction that prevents transport of conjugated
bilirubin to GIT for excretion
6. Reduced bilirubin binding sites to the albumin.
7. Malnutrition
8. Increased reconversion of conjugated to unconjugated bilirubin
if it stays in the GIT for long.
 Nursing Management of Pathological Jaundice
• Assess the baby to determine the degree of jaundice.
• Do investigations on serum bilirubin levels and Hb.
• Start the baby on phototherapy.
• Order for blood exchange transfusion if necessary.
Complication of neonatal jaundice
• Retinal damage due to light used in treatment
• Anemia
• Hyperthermia associated with phototherapy.
• Hypocalcaemia
• Kernicterus
NB: Read more on obstructive and haemolytic jaundice
 Treatment Modalities of Neonatal Jaundice
• There are three main modalities namely;
I. Phototherapy
II. Blood exchange transfusion
III. Protoporphyrins
 I. Phototherapy
• Phototherapy prevents bilirubin levels from going high enough to
cross BBB and cause kernicterus
Mechanism of action
• Blue florescent light at a given wave length is absorbed by the
unconjugated bilirubin in the skin and superficial capillary and is
converted into conjugated bilirubin which is water soluble and can
be excreted in stool and urine.
 Indications for Phototherapy
• Pre term with jaundice appearing after 48 hrs and bilirubin levels
are 260-265 mmol/L
• Pre term with weight less than 1500g and bilirubin levels are 85 -
114 mmol/L
• Pre term with weight more than 1500g and bilirubin levels are
114-165 mmol/L
 Care of the baby on Phototherapy
• Expose the whole body of the baby to increase surface area
exposed to light
• Keep turning the baby 2hrly to expose all parts to the fluorescent
light.
• Ensure the airway of the baby is patent by extending the head.
• Cover the eyes of the baby to prevent damage by direct ray of
lights.
• When breastfeeding the eyes are unpadded to encourage eye
contact with the mother.
• Provide intermittent phototherapy i.e. 6 hours on and 6 hours off
but may be continuous.
• Give phototherapy for 2-3days and assess the serum bilirubin levels
twice or three times a day
• NB: Greatest reduction in bilirubin levels will be in the first 24 hrs
of phototherapy.
• Observe the eyes for weeping or discharge.
• If phototherapy is continuous, give extra fluids to prevent
dehydration and maintain accurate input output charts.
• Change linen frequently because opening of bowels is
increased(loose stool)
• Observe the feeding and sleeping behavior of the baby.
• Observations e.g. temperature to rule out hyperthermia and skin
colour to monitor the progress.
• Top tail the baby to maintain hygiene.
 Side effects of Phototherapy
• Loose stool due to rapid intestinal transit
• Dehydration
• Hyperthermia
• Visual deprivation
• Poor feeding
• Fragility
• Lethargy
• Irritability
• Hypocalcaemia
 Nursing Diagnosis of children undergoing Phototherapy
• Deficient fluid volume
• Imbalanced nutrition less than body requirements
• Impaired skin integrity
• Risk for injury
• Ineffective thermoregulation
 II. Blood Exchange Transfusion
• This is a treatment in which the baby’s blood is gradually removed
and replaced by donor’s blood.
• It is used as a definitive treatment when bilirubin concentrations are
approaching toxic levels.
• The baby has haemolytic disease or low Hb.
• The blood exchange transfusion has the following benefits;
 It helps in increasing the baby’s Hb
 Excessive bilirubin and unwanted antibodies
are washed from the baby’s circulation.
• The donor’s blood used for the transfusion should be Rhesus
negative so that it does not alter the baby’s blood group and to
ensure that no antigen is introduced into the baby’s circulation that
may lead to antibodies production.
• It should also be fresh and ABO compatible.
 Indications for Blood Exchange
Transfusion
• Infants with haemolytic disease.
• Preterms with bilirubin levels of 300-400 mol/l
• Babies whose birth weight was less than 1500g and have bilirubin
levels of 255mol/l
• Term babies with bilirubin levels above 100 mol/l at birth or later
400-500 mol/l
 Care of the baby Post Transfusion
• Put the baby back to phototherapy to continue with it.
• Closely observe the baby for bleeding from the umbilical cord.
• If the baby was on infusion, continue for some time.
• Reassure the mother and involve her in the care of the baby.
Complications of Blood Exchange Transfusion
• Circulatory collapse
• Incompatibility reactions
• Acquired infections e.g. HIV, Hepatitis B.
[Link]
• These are haeme oxygenase inhibitors which are administered to
inhibit the breakdown of haeme thus reduce bilirubin production.
• They are usually used in combination with phototherapy and/or
blood exchange transfusion.
 HAEMORRHAGIC DISEASE OF THE
NEWBORN (HDN)
• This refers to bleeding that occurs during the first few days of life
due to vitamin K deficiency.
• Vitamin K is synthesized by the bowel normal flora and its role is to
convert clotting factors such as prothombin, thrombokinase,
thromboplastin.
• To prevent HDN, all neonates are given Vitamin K 0.5mg - 1mg i.m
at birth
 (Vit. K 0.5mg for Preterm babies and 1 mg for term babies).
 Predisposing factors to HDN
• Hereditary factors; clotting factor defect e.g. haemophilia
• Prematurity
• Birth trauma
• Treatment with antibiotics
• Respiratory Distress Syndrome
• Disseminated intravascular coagulopathy (DIC)
• Birth asphyxia
• Mothers who are on drug such as warfarin, heparin and
phenobarbital
 Clinical features of HDN
• Continuous oozing of blood from the umbilical cord
• There is spontaneous bleeding from various parts of the body
• Bleeding in the mucous membrane of GIT and may present with
maleana stool or haematemesis
• Continuous bleeding from any punctured blood vessel or injection
site thus when looking for venous access avoid puncturing femoral
or jugular veins which are the largest veins in the body
• Haematuria or omphalorrhagia
 Nursing Management of HDN
• Upon admission into NBU, administer vitamin K 0.5mg-1mg I.M,
• Preserve all linen soiled by blood for estimation of blood loss
• Administer vitamin K 1-2 mg to arrest bleeding immediately
• Observe vital signs TPR ¼ hrly
• If bleeding is severe, transfuse fresh blood or frozen plasma at
20mls/kg of body weight
• Observe for signs of shock and if present transfuse with packed cells
and fresh whole blood at 75 -100mls/kg of body weight if the baby
is term
• General management is like any other baby in the unit
 Complications of HDN
• Anaemia
• Hypovolaemic shock
• Brain damage
 BIRTH INJURIES
• Birth injuries refer to trauma that a foetus sustains during birth. The
structures commonly involved are muscles, nerves, bones, visceral
organs and skin.
Types of Birth Injuries 
1) Internal organ injuries – spleen, liver, adrenal glands
2) Nerve injury–mostly brachial plexus leading to Erb’s palsy
3) Soft tissue injury-genitalia, eyes.
4) Intracranial injuries e.g. haemorrhages, skull fractures
5) Extracranial injuries e.g. cephalo-haematoma, caput
succedaneum.
 Predisposing factors to Birth Injuries
• Prematurity
• Large for dates babies
• Cephalo pelvic disproportion
• Malpresentation
• Congenital malformation e.g. hydrocephalus
 a) Caput Succadenium and Cephalohaematoma
• Caput succadenium is an oedematous swelling due to
accumulation of serum fluid under the foetal scalp. It
results from pressure between the foetal skull and
pelvic bones during delivery that leads to reduced
venous blood and lymphatic drainage and part of the
serum escapes into the tissues. The swelling is self-
limiting and disappears within 36hours of life.
• Cephalohaematoma is accumulation of blood
between the periosternum and the skull bone. It is
caused by friction between the foetal skull bones and
the pelvic bones e.g. in CPD
Caput succadenium Cephalohaematoma
Present at birth Appears after 12 hrs of life
Disappears within 36 hours May persist for weeks

Diffuse and pits on pressure Circumscribed; doesn’t pit

on pressure
May cross a suture line Never crosses a suture line

Double caput is unilateral Double cephalohaematoma is

bilateral
Tends to grow less with Tends to grow larger with
time time
b) Intracranial Injuries And Haemorrhage
• This refer to the damage of structures within the cerebral
hemispheres of the brain.
• Various structures may be injured leading to different types of
haemorrhage e.g.;
 Cerebral tissue–injury to cerebrum leading to cerebral haemorrhage
 Cerebral hemisphere and basal ganglia–supra tentorial haemorrhage
 Veins of gallen and tentorium–subarachnoid haemorrhage
 Falx cerebri (fold of dura mater and tentorium cerebelli)–subdural
haemorrhage
 Predisposing Factors to Birth Injuries
• Prematurity
• Excessive moulding
• Instrumental delivery
• Hypoxia that leads to engorgement of blood vessels
• Precipitate labour
• Prolonged labour
• Large babies
 Clinical Features of Birth Injuries
• Dyspnoea
• Asphyxia
• Rolling of the eyes
• Pallor of the skin and mucous membranes
• Bulging of the anterior fontanelle due to increased ICP
• Shock due to circulatory collapse
• Twitching of the facial muscles if facial nerve is affected
• Cyanosis
• Grunting respirations
• High pitched cry
• Rigidity of limbs
 General Management of Birth Injuries
• Intrapartally, predisposing factors should be diagnosed and managed
early e.g. preterm labour, malpresentation, prolonged labour.
• Observe the baby closely for skin colour, twitching, rolling of the
eyes, convulsions
• Keep the baby warm
• Administer Vitamin K 0.5 -1 mg i.m for they are predisposed to
haemorrhage
• Maintain 2 hrly turning of the baby
• Provide intermittent oxygen therapy PRN
• Give IV fluids e.g. 10% dextrose for the first 24 hours then
introduce oral feeds if the condition improves
• Give symptomatic management
• Have resuscitative equipment ready in case of an emergency
• Administer anticonvulsants e.g. Phenobarbital prophylactically
 Complications of Birth Injuries
• Musculoskeletal deformities
• Brain damage
• Respiratory distress
• Hyperbilirubineamia (jaundice)
• Hypoglycaemia
 HYDROCEPHALUS
• This is a condition where there is accumulation of CSF within the
ventricles of the brain with resultant increased ICP and
enlargement of the cerebral ventricles.
• It can be detected prenatally by ultrasound and in labour they
present by breech, fontanelles and sutures are very wide on VE
 Formation and flow of CSF
• CSF is secreted by the choroid plexus into the lateral ventricles. It
then passes to the third ventricle from where it flows to the fourth
ventricle through the aqueduct. From the fourth ventricle, it flows
through the median and lateral foramina of the fourth ventricle into
the subarachnoid space. It is then absorbed into the venous sinuses
of dura matter through arachnoid granulations.
• Hydrocephalus occurs when there is increased formation or
decreased absorption of CSF.
 Causes of Hydrocephalus
• Congenital Malformations
• Infections e.g. meningitis
• Cerebral trauma
• Space occupying lesions
• Intracranial haemorrhage
• Haematomas
 Types of Hydrocephalus
• Communicating Hydrocephalus – occurs when CSF is
inadequately absorbed into subarachnoid space due to aqueductal
stenosis or chiari malformation (brainstem, cerebellum and the
fourth ventricle are displaced downwards into foramen magnum).
• Non-communicating Hydrocephalus – occurs when there is
obstruction of CSF outflow from the fourth ventricle due to atresia
of the foramina
• Post-inflammatory Hydrocephalus – occurs secondary to
meningeal inflammation or subarachnoid haemorrhage which
cause ventricular obstruction or formation of fibrous tissue in
subarachnoid space.
 Clinical Features of Hydrocephalus
• Prominent forehead Headache
• Bulging fontanelles
• Distended scalp veins High pitched cry
• Setting sun eyes (downward rotation) Lethargy
• Failure of muscle co-ordination (ataxia)
• Separated cranial sutures Poor feeding
• Increased head circumference Irritability
• Alteration in consciousness
Papilloedema
Seizures
Vomiting
 Management of Hydrocephalus
a) Treatment;
• Surgery to remove the lesion, mass, adhesion, within CSF system
• Creating a divert (shunt) from the ventricles to another body
compartment e.g. into the right atrium of the heart via the superior
vena cava (VA shunt) or into peritoneum (VP shunt)
• Diuretics e.g. acetazolamide and furosemide are occasionally used
to control the head enlargement.
 Nursing Management
• Take head circumference daily to know the progress
• Palpate for cranial suture’s separation
• Observe fontanels for bulging
• Monitor neurological status to detect signs of Increased ICP
• Administer analgesics to relieve pain
• Postoperatively, pay more attention to the shunt
• Observe the operation site for bleeding and draining
• Give the baby small frequent feeds for it has feeding difficulty
• Observe for swelling which may indicate obstruction of the shunt
• Monitor the vitals signs quarter hourly until the baby stabilizes
• Administer antibiotics prophylactically to combat infection
• Maintain fluid input output charts to avoid overhydration
• Reassure the mother and family
 Resuscitation of a Newborn
• Resuscitation is an emergency measure taken to sustain life or to
revive when life has just ceased.
• The aim is to establish the heart and lung function following
cardio-pulmonary arrest.
Meconium Aspiration Syndrome (MAS).
Definition:
-This respiratory disorder is caused by meconium aspiration
by the fetus in utero or by the newborn during labor and
delivery.
- MAS is often a sign that the neonate has suffered asphyxia
before or during birth.
- The mortality rate can be as high as 50% and survivors
may suffer long-term complications related to neurological
damage..
 Causes and Pathophysiology:
1. Fetalis hypoxia; e.g. cord prolapse that comes around the neck of
the fetus many days before delivery.
2. Babies born breech presentation.
In both cases;
-----intrauterine hypoxia----vagal nerve stimulation ---relaxation of
the sphincter muscle --------releasing of the first stool (meconium) in
the intrauterine life and becomes mixed with the amniotic fluid, with
the first breath the baby can inhale meconium.
The aspirated meconium can cause airway obstruction,clinical
manifestations of RDS, and an intense inflammatory reaction.
  Management of MAS:

A)Suctioning of the oropharynx by obstetricians before delivery

of the shoulders.
Immediate insertion of an ET tube and tracheal suctioning
before ambu agging (Maintain a neutral thermal environment).
B)Gastric lavage, and emptying of the stomach contents to avoid
further aspiration.
C) Postural drainage and chest vibration followed by frequent
suctioning
D) Pulmonary toilet to remove residual meconuim if intubated.
E) Antibiotic coverage .
F) Oxygenation ( maintain a high saturation > 95%)
G) Mechanical ventilation to avoid hypercapnia & respiratory
acidosis.
 Management of a Neonate Born to a Mother
with HIV

• This could include prevention of mother to child transmission (PMTCT) by

the use of anti retroviral drugs (nevirapine), which are administered to the
mother during labour and to the infant within 72 hours of birth.
Nursing care
[Link] breaking/bruising the baby’s skin.
2. Wipe the baby dry with particular attention to the face.
3. Feed the baby within half an hour to one hour.
4. Sleep and rest should be adequate. Ensure that medical/surgical procedures
are coordinated, so that they do not interfere with the rest and sleep
requirements of the infant.
5. Skin integrity should be maintained. The skin should remain intact, as it is
prone to fungal, viral and bacterial infection.
6. Observe the body temperature frequently as this may be elevated where
there is an infected skin condition and may be an indicator to the possible
developmentother infections.
7. Observe both baby and environmental hygiene at all times.
 There are different levels of resuscitation:
• First level resuscitation includes wiping of the face and body and
flicking the soles of the feet to stimulate the baby
• Second level resuscitation involves:
• Clearing the airways
• Oxygen administration
• Mouth to mouth/bag and mask
• Intubation, that is, intermittent positive pressure ventilation (IPPV)
• Cardiac massage
• Drug administration
Essential requirements both in the labor ward and in the newborn unit:

• A source of heat, for example, a radiant warmer or resuscitaire

with bed
• At least two resuscitation trays, that is, one drug tray and one
for catheters of various uses.
• Warm dry linen, stethoscope, and a wall clock are essential for
the procedure
 The drug tray should contain the following items:

• Sodium bicarbonate 8.4% or 7.5% for correction of metabolic acidosis.

• Fifty percent dextrose for correction of hypoglacaemia
• Adrenaline if the heart rate is falling after several minutes of vigorous
resuscitative efforts;
• Vitamin K helps in the prevention of bleeding
• Aminophylline in small doses is given to aid in respiration if distress
is present (3mg kg/body weight intravenously). This drug is a vaso-
dilator and also stimulates the respiratory centre.
• Lorfan 0.25mg as an antidote to pethidine.
• Calcium gluconate can be administered intravenously and slowly to a
baby who displays tetany due to calcium deficiency. It is also a
cardiac muscle stabliliser.
• Source of oxygen to be administered after clearing the airway.
 Principles of Resuscitation
• Airway should be cleared either by suction or positioning the
infant.
• Breathing, that is, establish respiration if not breathing.
• Circulation should be noted through pulse,colour of mucus
membrane and heart beat. Start cardiac massage if there is no
heart beat or pulse.
• Drugs
• Observations to make a diagnosis.
 STEPS OF RESUSCITATION
1. Immediately after delivery, the infant should be placed under a radiant warmer or
wrapped in warm blankets.
2. The next step will depend on the condition of the neonate. All infants should be dried
well to prevent hypothermia.
3. Clear the airway by removing the remaining upper airway secretions via suctioning.
4. Administer oxygen by using a baby funnel or mask (not closely applied to the face) at
two litres per minute. A stream of oxygen directed on the baby’s face will stimulate
respiration and provide high oxygen for the baby’s first breaths
5. Bagging with oxygen, if properly done, may be the only required form of resuscitation.
The infant should lie flat on their back with shoulders slightly elevated and neck slightly
extended.
• Insert the airway above the tongue and place mask around the mouth and nose, making
certain that the mask fits tightly and that the neck remains extended during bagging.
• Rate of bagging should be 40 - 60 per minute.
6. In a severely depressed infant, proceed immediately with endo-tracheal intubation
and/or umbilical vessel catheterisation.
7. External cardiac massage should be commenced if the heartbeat has not returned after
three or four insufflations.
 Ct..
• Alternate the two manoeuvres. The heart should be compressed
two or three times (approximately 120 times per minute) after
which a breath of oxygen is given.
• The two procedures must not be performed together
(simultaneously).
The 'do nots' of neonatal resuscitation:
1. Hold the baby upside down
2. Perform routine aspiration of the airway
3. Perform gastric suction
4. Use sodium bicarbonate routinely
 BBA(BORN BEFORE ARRIVAL)
Problems that face infants who are delivered on the way to the hospital or at
home.
• Infections like pneumonia or tetanus depending on what was used to cut the cord
• Hypothermia if born on the way, without proper baby clothes
• Asphyxia due to inadequate resuscitation
• Injuries due to inexperienced hands conducting the delivery
Management of Babies Born Before Arrival
• On admission, take the proper history (both obstetric and mode of delivery).
Keep the infant warm.
• Provide nutrition for the infant.
• They should be started on antibiotics for both prophylacsis and for treatment.
• Check the cord, which may not have been handled properly by the person
conducting the delivery.
• Measure the weight and conduct a first examination to exclude any
abnormalities.
 Abandoned Infants

• You may also come across infants who are abandoned, either
in or outside the hospital.
• There are many reasons for individuals to abandon their
newborns. These include:
• Economic pressures
• Unwanted pregnancy
• Babies born of incest
• Congenital malformations on the baby
• Sick mother, for example, psychiatric disorders
• Orphans (especially when the mother dies during delivery)
• Other social cultural and religious factors
 MANAGEMENT OF ABANDONED INFANTS
• Basic/preliminary investigations like blood tests for
HIV, HBV and/or a full haemogram should be carried
out to rule out any infections.
• These infants should be cared for like any normal infant,
while attempts are made to trace their relatives through a
social worker.
• Arrangements for adoption, fostering or placement in
children’s homes should be made as soon as possible.
 REFERENCES
• Barbara F. Weller (2000) Bailliere’s Nurses Dictionary, 23rd
edition.
• Myles Margaret Textbook for Midwifery
• Odanga O. A, (2004). Baby at Risk. Covering Conditions in the
Newborn Unit, Nambale, Kenya.
• Waugh A. and Grant A. (2001). Ross and Wilson Anatomy and
Physiology in health and illness, 12th edition.
• WHO (2000) Integrated Management of Pregnancy and Child
birth, guidelines for midwives and doctors.
• MOPHS and MOMS (2012). National Guidelines for Quality
Obstetrics and Perinatal Care.