Make sure your bladder is empty, then sit or lie down. Tighten your pelvic floor muscles. Hold tight and count 3 to 5 seconds. Relax the muscles and count 3 to 5 seconds. Repeat 10 times, 3 times a day (morning, afternoon, and night).

1. Unit IV
NEW BORN BABY

2. Newborn baby
A healthy new born at term (between 38 weeks
and 42 weeks) should have an average birth
weight (exceeds 2,500 g), cries immediately
following birth, establishes independent
rhythmic respiration and quickly adapts to the
changed environment.

3. • Average birth weight varies by country. In India, the
weight varies between 2.7 kg and 3.1 kg with a
mean of 2.9 kg
• The length (crown to foot) is 50–52 cm. (length
reliable criterion of gestational age than the
weight).
• Occipito-frontal circumference measures about 32–
37 cm
• Bi-parietal diameter measures about 9.5 cm.

4. IMMEDIATE CARE OF THE NEWBORN
Soon after the delivery of the baby,
• placed on a tray covered with clean dry linen with
the head slightly downward
• The tray is placed between the legs of the mother
and at a lower level than the uterus

5. • Air passage (oropharynx) should be cleared of
mucus and liquor by gentle suction.
• Apgar rating at 1 minute and at 5 minutes.
• Clamping and ligature of the cord:
• The cord is clamped by two Kocher’s forceps, the near one is
placed 5 cm away from the umbilicus and is cut in between.

6. • Delay in clamping for 2–3 minutes or till cessation
of the cord pulsation facilitates transfer of 80–100
mL blood from the compressed placenta to a baby
when placed below the level of uterus.
• early clamping should be done in cases of Rh-
incompatibility or babies born asphyxiated or one
of a diabetic mother.

7. • Quick check is made to detect any gross
abnormality
• the baby is wrapped with a dry warm towel.
• The identification tape is tied both on the wrist of
the baby and the mother.
• Once the management of third stage is over (usually
10–20 minutes), baby is given to the mother or to
the nurse.

8. Care in Nursery
• Admission in Nursery—All healthy newborns are kept in
the delivery room with their mother to promote
immediate breastfeeding and early bonding.
• Common indications for admission of the newborn in
the nursery are: prematurity, respiratory distress, poor
perfusion or presence of pallor or cyanosis,
malformation and need for O2 therapy.

9. • Routine Nursery Care—The newborn is examined
systematically and assessment of the gestational
age is done.

10. • Infant’s parameters are recorded
– weight,
– fronto-occipital circumference (FOC)
– length
• On these basis, the newborn is classified as
– average for gestational age (AGA),
– small for gestational age (SGA) or
– large for gestational age (LGA)

11. • The newborn must be kept under a neutral thermal
condition.
• The normal skin temperature in the neonate is
36.0–36.5°C (96.8–97.7°F).
• Normal core (rectal) temperature is 36.5–37.5°C
(97.7–99.5°F).
• Axillary temperature may be 0.5–1.0°C lower.

12. • The measures to prevent heat loss are:
(i) Place the baby under a preheated (36.5°C) radiant
warmer immediately following delivery,
(ii) Dry baby immediately after birth,
(iii) Cover baby (including the head) with a pre-warm
towel,
(iv) Put baby close to mother’s breast (Kangaroo
method),
(v) Wrap the mother and baby together,
(vi) Commence early breastfeeding

13. • DAILY OBSERVATION AND CARE
Rooming-in: Soon after birth, if mother is fit, baby
is kept in a cot by the bedside of mother. This
establishes mother-child relationship. Mother also
learns the art of baby care.

14. • Baby bath:
– Routine bath is delayed until the baby is able to maintain
the body temperature and has started breastfeeding.
– The excess vernix, blood or meconium are wiped off
from the skin using sterile moist swabs and then make
the skin dry by using a soft towel.
– The water for baby bath should be at body temperature
(> 97.5°F)

15. • Umbilical cord care:
• exposed to air and allowed to dry to promote
early detachment.
• Topical antiseptics or antibiotics such as triple
dye or neosporin powder applied to reduce
bacterial colonization.

16. • Routine medications:
–A single intramuscular dose of 0.5–1 mg of
vitamin K1 (phytonadione) is given to all
newborns within 6 hours of birth. This prevents
vitamin K deficient bleeding.

17. • Eyes
– kept clean with cotton wool soaked with sterile normal
saline as a prophylaxis against ophthalmia neonatorum
(chlamydia, gonococcus). Erythromycin ointment (0.5%)
bilaterally in the conjunctival sac or tetracycline (1%)
ointment may be used.

18. • Immunization and vaccines: Hepatitis B vaccine is
given at birth. Other vaccine information is given to
the parents

19. • Screening of the newborn:
– Commonly done screening tests are:
• Glucose screening and detect hypoglycemia
especially for infants of diabetic mothers, SGA
and LGA infants;
• Bilirubin screening;
• Other metabolic screen depending on need

20. • Assessment of vital signs:
– Respiratory rate,
– heart rate,
– axillary temperature
recorded every 6–8 hours in baby’s chart. Each
urine and stool output is recorded. Most of the newborns
pass urine by 24 hours and meconium by 48 hours of life.
• Daily weights are recorded. Weight loss in excess of
7% is often due to inadequate calorie intake.

21. • Feedings:
– The frequency, duration and volume of each feed is
important for newborn’s growth and development.
– The infant should be put to breast as soon as possible
after delivery in the delivery room. Feeding is allowed on
demand (demand feeding). Usually it is 8–12 times per
day.

22. • Discharge:
• Each infant is evaluated carefully to decide the
optimal time of discharge.
• early discharge of mother and infant may be done
to avoid overcrowding in the postnatal ward and in
the nursery.

23. The following infants may be discharged by 48 hours of
age:
– Vaginal delivery,
– gestational age > 38 weeks,
– singleton birth,
– birth weight—AGA,
– normal vital signs,
– passed urine and stool,
– initial immunization done,
– successful feedings and normal on physical examination.

24. Follow-up:
• Follow-up of newborns should be organized depending
upon the
• risks of feeding problems,
• infections,
• hyperbilirubinemia or other issues.
• During follow-up, the newborn is assessed for weight,
hydration, infection and for any new problem.
• Parental education and immunization schedule are
discussed

25. INFANT GROWTH ASSESSMENT:
• Serial measurement of weight, length and head
circumference allow for evaluation of infant growth.
– WEIGHT: There is weight loss of 7–10% in the first week of
life. Weight gain generally begins by the second week.
Average daily weight gain is 20–30 g/day. The infant should
be weighed daily.
– LENGTH: Normal weekly length gain is 0.8–1.0 cm for first 8–
12 weeks.
– HEAD CIRCUMFERENCE: Intrauterine growth is 0.5–0.8
cm/week.

26. Neonatal resuscitation
• Effective resuscitation at birth can prevent a large
proportion of the neonatal death due to birth
asphyxia
• (Birth asphyxia is defined simply as the failure to
initiate and sustain breathing at birth)

27. Indication for newborn resuscitation
• Who do not meet effective criteria for
healthy term newborn, (Clear amniotic fluid,
Adequate respiratory effort, Good muscle
tone) need additional steps in resuscitation

28. Resuscitation procedure
• Resuscitation includes
– initial stabilization( providing warmth,
positioning, clearing the airway, drying
stimulating and repositioning) with
ventilation, chest compression and
medication

29. Steps of neonatal resuscitation
• Step 1 ; Initial step
– Providing warmth
– Minimizing heat loss
– Clearing the airway
– Tactile stimulation for primary apnea
– Assessment of Oxygen Need and Administration of
Oxygen

30. Step 2; Positive pressure ventilation
• infant remains apneic or gasping, or if the heart rate
remains <100 per minute after administering the
initial steps, start PPV.
– Initiation of positive pressure ventilation for 30 seconds
before beginning chest compression
– Opening breaths with longer inspiratory times
– Ventilation bag with volume 200-750 ml

31. • Step 3; Assisted-Ventilation Devices
–Laryngeal Mask Airways
–Endotracheal Tube Placement

32. • Step 4; Chest Compressions
–Chest compressions are indicated for a heart
rate is <60 per minute at the femoral or brachial
pulse despite adequate ventilation with
supplementary oxygen for 30 seconds.
–Compressions delivered on the lower third of
the sternum to a depth of approximately one
third of the anterior-posterior diameter of the
chest approximately 4 cm / 1.5 inch

33. Techniques For Chest Compression
• compression with 2 thumbs with fingers encircling
the chest and supporting the back (the 2 thumb–
encircling hands technique) recommended newly
born infants
• compression with 2 fingers with a second hand
supporting the back.

34. compressions ratio
• 3:1 ratio of compressions to ventilations
• compression ratio applicable 15:2 or even 30:2 one
or two rescuer respectively. if the arrest is believed
to be of cardiac origin

35. Assessment
• Respirations, heart rate, and oxygenation should be
reassessed periodically, and coordinated chest
compressions and ventilations should continue until
the spontaneous heart rate is ≥60 per minute
• However, frequent interruptions of compressions
should be avoided,

36. Medications
• the heart rate remains <60 per minute despite
adequate ventilation (usually with endotracheal
intubation) with 100% oxygen and chest
compressions
• administration of epinephrine or volume expansion,
or both, may be indicated.
• Rarely, buffers, a narcotic antagonist, or
vasopressors may be useful after resuscitation,

37. epinephrine
• IV administration of 0.01 to 0.03 mg/kg per dose is
the preferred route.
• higher dose (0.05 to 0.1 mg/kg) through the
endotracheal tube may be considered,
• The concentration of epinephrine for either route
should be 1:10,000 (0.1 mg/mL).

38. Steps for chest compression to
ventilation
• Check the breathing <10 seconds
• Check brachial pulse with in 10 seconds
• Chest compression and ventilation
– Two finger technique
– 2 thumb encircling hands technique

39. Two finger technique
• Place the baby in flat and firm surface
• Place the 2 finger in the center of the infants chest, just below
the nipple line
• Provide compression 30;2 and 15;2 according one and two
rescuer respectively with depth of 4 cm
• At the end of each compression completely release the
pressure on the breast bone and allow the chest to recoil
• compressions and ventilations should continue until the
spontaneous heart rate is ≥60 per minute
• Respirations, heart rate, and oxygenation should be
reassessed periodically
• However, frequent interruptions of compressions should be
avoided

40. 2 thumb encircling hands technique
• Place the baby in flat and firm surface
• Place the both thumb side by side the center of the infant
chest, on the lower half of the chest bone. Encircle the infant
chest and support the infant’s back with the fingers of both
hands
• Provide compression 30;2 and 15;2 according one and two
rescuer respectively with depth of 4 cm
• At the end of each compression completely release the
pressure on the breast bone and allow the chest to recoil
• compressions and ventilations should continue until the
spontaneous heart rate is ≥60 per minute Respirations, heart
rate, and oxygenation should be reassessed periodically
• However, frequent interruptions of compressions should be
avoided

41. Post resuscitation care
• Maintenance of airway and ventilation
• Fluid and electrolyte management
• Continuous monitoring
• Preparation for transport

42. Maintenance of airway and ventilation
• Stabilize the airway and ensure oxygenation and
ventilation
• Avoiding over distension
• Mechanical ventilation initiated

43. Fluid and electrolyte management
• Normal intermittent supply of glucose and other
fluids that in characteristics of extra uterine life
• Fluid and electrolytes support to maintain an
appropriate intravascular volume and to achieve
glucose homeostasis and electrolyte balance
• Glucose determination and glucose infusion started
at the rate of 4-6mg/kg /min, if required

44. Continuous monitoring
–Monitor weight, clinical hydration status ,
urine output, and serum sodium
concentration
–Monitor for fluid overload

45. • Preparation for transport
Prepare newborn transfer to an advanced nursery
care followed by complete routine care with complete
documentation of subsequent therapies and secure
all lines, tubes, catheters for transport

47. FEEDING
The rate of growth of the infants during the first
6 months of life is greater and faster than any other
period of life. Its weight is doubled by the age of 5
months and tripled by the end of one year. Due to
exclusive breast feeding

48. NUTRITIONAL REQUIREMENTS IN THE
NEONATE
• Fluid intake should be 150–175 mL/kg body weight
per day
• A term healthy infant needs 100–110 kcal/kg of
body weight per day.
• Low birth weight infant needs about 105–130
kcal/kg/day.
• protein (2–4 g/kg/day),
• fat (4–6 g/kg/day),
• carbohydrate (10–15 g/kg/day),

49. TYPES OF FEEDING
• Breastfeeding
• Artificial feeding

50. • All the babies, regardless of the type of delivery,
should be given early and exclusive breastfeeding
up to 6 months of age.
• Exclusive breastfeeding means giving nothing orally
other than colostrum and breast milk. Medicines
and vitamins are allowed.
• Breastfeeding is the “Gold standard” for infant
feeding.

51. BABY FRIENDLY HOSPITAL INITIATIVE
• Baby Friendly Hospital Initiative with ten steps to
successful breastfeeding
(WHO/UNICEF 1992: Protecting, Promoting and
Supporting breastfeeding).
• (i) There must be a written breastfeeding policy;
• (ii) All health care staff must be trained to
implement this policy;

52. • (iii) All pregnant women must be informed about
the benefits of breastfeeding;
• (iv) Mothers should be helped to initiate
breastfeeding within half an hour of birth;
• (v) Mothers are shown the best way to breastfeed;
• (vi) Unless medically indicated, the newborn should
be given no food or drink other than breast milk;

53. • (vii) To practice ‘rooming-in’ by allowing mothers
and babies to remain together 24 hours a day;
• (viii) To encourage demand breastfeeding;
• (ix) No artificial teats to babies should be given;
and
• (x) Breastfeeding support groups are established
and mothers are referred to them on discharge.

54. ADVANTAGES OF BREASTFEEDING:
Composition:
• ideal food with easy digestion and low osmotic
load.
• Carbohydrate: Mainly lactose, stimulates growth of
intestinal flora, produces organic acids needed for
synthesis of vitamin B

55. • Fat: Smaller fat globules, better emulsified and
digested
• Protein: Rich in lactalbumin and lactoglobulin, less
in casein
• Minerals: Low osmotic load (K+ , Ca2+, Na+ , Cl– ),
less burden on the kidney.

56. • Protection against infection and deficiency states:
– 1. Vitamin D promotes bone growth, protects the baby
against rickets
– 2. Leukocytes, lactoperoxidase prevents growth of infective
agents
– 3. Lysozyme, lactoferrin, interferon protect against infection
– 4. Long-chain omega-3 fatty acids essential for neurological
development
– 5. Immunoglobulins IgA (secretory), IgM, IgG protect against
infection
– 6. Supply of nutrients and vitamins.

57. • Breast milk is a readily available food to the
newborn at body temperature and without any
cost.
• Breastfeeding acts as a natural contraception to the
mother

58. • Additional advantages are:
– (i) It has laxative action;
– (ii) No risk of allergy;
– (iii) Psychological benefit of mother-child bonding;
– (iv) Helps involution of the uterus
– (v) Lessens the incidence of sore buttocks,
gastrointestinal infection and atopic eczema.
• The incidence of scurvy and rickets is
significantly reduced.

59. • PREPARATIONS FOR BREASTFEEDING:
– The preparations started from the middle of pregnancy.
– abnormality in the nipple, like cracked or depressed
nipple should be adequately treated.
• Massaging the breasts, expression of the
colostrum and maintenance of cleanliness

60. MANAGEMENT OF BREAST FEEDING:
– The modern practice is to reduce nipple cleansing to a
minimum and to wash the breasts once daily. A clean,
soft supporting brassiere should be worn. The mother
should wash her hands prior to feeding. Mother and the
baby should be in a comfortable position during feeding.
• Frequent feedings, 8–12 feeds/24 hours are
encouraged.

61. • First feed—In the absence of anatomical or medical
complications, a healthy baby is put to the breast
immediately or at most 1/2–1 hour following
normal delivery. Following cesarean delivery a
period of 4–6 hours may be sufficient for the
mother to feed her baby.

62. • Milk transfer
– Milk transfer to infant is a physiological process.
• It starts with good latch on the nipple is tilted
slightly downward using a “C-hold”.
• The milk is extracted by peristaltic action from the
tip of the tongue to the base.

63. Frequency of feeding:
– Time schedule—During the first 24 hours, the mother
should feed the baby at an interval of 2–3 hours.
– Gradually, the regularity becomes established at 3–4
hours pattern by the end of first week. Baby should be
fed more on demand.

64. • Demand feeding—
– The baby is put to the breast as soon as the baby
becomes hungry. There is no restriction of the number
of feeds and duration of suckling time.

65. • Duration of feed
– The initial feeding should last for 5–10 minutes at each
breast. Thereafter, the time spent is gradually increased.
– Baby is fed from one breast completely so that baby gets
both the foremilk and the hind milk. Then the baby is
put to the other breast if required. Hind milk is richer in
fat and supplies more calories

66. • Night feed
– In the initial period, a night feed is required to avoid long
interval between feeds of over 5 hours.
– It not only eliminates excessive filling and hardening of
the breasts but also ensures sound sleep for the baby.

67. • Amount of food—
– The average requirement of milk is about 60 mL/kg/24
hours on the first day,
– 100 mL/kg/24 hours on the third day and I
– 150 mL/kg/24 hours on the 10th day.
– However, the baby can take as much as he wants.

68. Technique
• The mother and the baby should be in a
comfortable position.
• Feeding in the sitting position, the mother holds the
baby in an inclined upright position on her lap;
• baby’s head on her forearm on the same side close
to her breasts,
• neck is slightly extended.
• The mother should guide the nipple and areola into
the baby’s mouth for effective milk transfer.
• milk transfer to the infant begins with good latch on
and by a peristaltic action

69. • The proper position for milk transfer is chest to
chest contact of the infant and mother.
• The infant’s ear, shoulder and hip are in one line
• Baby sucks the areola (lactiferous sinuses) and the
• nipple holding between the tongue and the palate.
• Feeding in lateral position following cesarean
delivery or with painful perineum is carried out by
placing the baby along her side between the trunk
and the arm.

70. • The failure to develop good milk transfer is the major
cause of
– lactation failure and
– breast pain.
• Inhibition of let down reflex and failure to
– empty breasts leads to ductal distortion,
– parenchymal swelling and
– breast engorgement.
• Normally breast is washed with clean water and
allowed to air dry.

71. • Nipple confusion: If the baby is fed with an artificial
nipple of a bottle, he cannot suck the mother’s
nipple effectively due to nipple confusion.
• artificial nipple is strictly discouraged. If at all
needed, the artificial feed is given by spoon

72. • Breaking the wind (Burping)
• All babies swallow varied amount of air during
sucking.
• To breakup the wind, the baby should be held
upright against the chest and the back is gently
patted till the baby belches out the air. It is better
baby to take more food and at the end of sucking to
prevent hiccough and abdominal colic.

73. • FACTORS FOR SUCCESSFUL LACTATION:
• (i) Positioning
• (ii) Attachment to breast
• (iii) Nursing technique (to avoid breast pain, nipple
trauma, incomplete emptying), and
• (iv) A rotation of positions is helpful to reduce focal
pressure on the nipple and to ensure complete
emptying.

74. • DIFFICULTIES IN Breastfeeding AND THE
MANAGEMENT:
– At times, breastfeeding poses some problems and if it is
not promptly detected and rectified, it may lead to
adverse consequences. The causes may be classified as
those:
– Due to mother
– Due to infant

75. CONTRAINDICATIONS OF BREASTFEEDING
Contraindications are classified as
–Temporary Contraindications
–Permanent Contraindications
• In cases of temporary contraindications, the baby
should be put to the breasts as soon as the condition
permits.
• HIV positive mothers are counseled as regard the risks
and benefits. She is helped to make an informed
choice.

77. DRUGS AND BREASTFEEDING
• drugs appear in the breast milk.
• drug level in the breastfed infant ranges from
0.001% to 5% of the therapeutic doses.
• Contraindicated drugs are
Eg; anticancer drugs, chloramphenicol, radioactive
materials, phenylbutazone and atropine.

78. MATERNAL NUTRITION DURING LACTATION
• produce about 500–900 mL breast milk per day.
• Provide baby about 75 kcal/dL.
• 750 kcal/day for the mother additional required.
• drink at least 1 extra liter of fluid per day

79. ASSESSMENT OF WELL-BEING OF THE NEWBORN
• General condition—The baby is happy, sleeps
between feeds and at night,
• passes urine at least six times in 24 hours;
• good movements of the limbs and cry
• no weight loss and weight gain as per growth chart
• appearance of yellow seedy stools

80. UNDERFEEDING
• seen in artificially–fed babies
• Failure in weight gain
• dissatisfied feeds evidenced by cry in between feeds
and sleep disturbences
• Constipation
• dimnished urinary output
• Management: substituted by artificial milk

81. CARE OF THE BREASTS
• Clean with water before and after each feed.
• Provide Breast binders
• maintain supine position

82. FEEDING DIFFICULTIES DUE TO NIPPLE
ABNORMALITIES
• Breast engorgement
Management:
– Gentle hand expression of milk to make the breasts soft
– Application of moist heat and cold compress to relieve
edema
– Gentle breast massage
– Medication for inflammation and pain

83. • Long nipples and Inverted or flat nipples
• Management:
– lactation is initiated by expression.
– corrected by suction with a syringe or breast pump

84. • Expression of breast milk or artificial removal of
breast milk
Indication
• baby is separated from the mother due to
prematurity or illness;
• difficulties in breastfeeding; cleft palate.

85. Methods of milk expression:
• Manual expression by mechanical pumping.
• Breast pumps may be electrical or manually
controlled.

86. • Donor Breast Milk: Historically, it has been used for
centuries. Currently its use is limited. Transmission of
infection (HIV, CMV, Hepatitis B, TB) is the concern for
its safety. If the donor breast milk or milk banks are
used, donor screening, pasteurization of milk and
parental counseling are recommended. Breast milk can
be stored frozen at – 20°C for up to 6 months,
refrigerated at 4°C for 24 hours and at room
temperature for 4 hours. Fresh, unrefrigerated milk can
be used within 4 hours of expression.

87. • METHODS OF ESTABLISHMENT OF LACTATION
For babies
• Stop bottle feedings;
• put the baby to the breast at frequent intervals
• suck in a well-attached manner.
For the mothers
• To encourage plenty of fluid (1 L extra) and milk
• Drugs like metoclopramide or oxytocin

88. • ARTIFICIAL FEEDING
When the infant is fed by any preparation other than
human milk or drug or vitamin, it is called artificial
feeding. also called as bottle feeding.

89. Indications
• Contraindications of breastfeeding either temporary
or permanent
• Changing lifestyle of women or pressurized under
changed socioeconomic conditions

90. Complication
• diarrhea
• Type I diabetes;
• Sudden infant death
• Adult type 2 diabetes
• Childhood obesity
• Adult obesity
• Crohn’s disease
• Ulcerative colitis
• Atopic dermatitis
• Reduced Intelligence Quotient (IQ).

91. FOOD USED
• no perfect substitute for breast milk.
• In general, boiled diluted cow milk, various dried
milk formulas are commonly used as artificial feeds.
• In some countries, goat milk or buffalo milk is used.

93. Low birth weight baby
Low birth weight (LBW) infant is defined as one
whose birth weight is less than 2500 g irrespective of
the gestational age.
Very-low birth weight (VLBW) infants weigh 1500 g or
less
extremely-low birth weight (ELBW) infants weigh
1000 g or less (WHO)

94. Preterm—Preterm Birth (PTB) is defined as one
when birth occurs before completion of 37 menstrual
weeks of gestation regardless of birth weight.
The growth potential may be normal and appropriate
for the gestational period (10 th to 90th percentile).

95. Small for gestational age (SGA)— About 70% of
infants with a birth weight below the 10th
percentile are found normally grown.

96. The factors influencing the low birth
weight of the baby
• socioeconomic status,
• nutritional and intrauterine environment.
• Ethnic background and genetic control

97. • Definition: A baby born before 37 completed
weeks of gestation calculating from the first
day of last menstrual period is arbitrarily
defined as preterm baby.

98. • Preterm baby constitutes two-thirds of low
birth weight babies. The incidence of low birth
weight baby is about 30–40% in the
developing countries

99. etiology
• In about 50%, the cause of preterm labor is
not known. Often it is multifactorial.
• Risk factors are;
– History of preterm birth , ART, UTI

100. • Complications in present pregnancy
– Maternal:
• Preeclampsia,
• antepartum hemorrhage,
• premature rupture of the membranes,
• polyhydramnios;
• Uterine anomalies: Cervical incompetence,
malformation of uterus;
• Medical and surgical illness:
• Acute fever,

101. • acute pyelonephritis,
• diarrhea,
• acute appendicitis,
• toxoplasmosis and abdominal operation.
• Chronic diseases: Hypertension, nephritis,
diabetes, decompensated heart lesion, severe
anemia, low body mass index (LBMI);
• Genital tract infection

102. • Fetal:
– Multiple pregnancy, congenital malformations and
intrauterine death
• Placental:
– Infarction, thrombosis, placenta previa or abruption.

103. • Iatrogenic:
– Indicated preterm delivery due to medical or obstetric
complications.
• Idiopathic:
– Premature effacement of the cervix with irritable uterus
– early engagement of the head

104. Clinical manifestation
Anatomical
• The weight is 2500 g or less
• length less than 44 cm.
• Disproportion in head and chest
circumference.
• Pinnae of ears are soft and flat.
• eyes closed

105. • red thin and shiny skin
• Poor Muscle tone .
• testicles are undescended; the labia minora
are exposed because the labia majora are not
in contact.
• Nails not developed

106. COMPLICATIONS
• Asphyxia
• Hypothermia
• Cerebral hemorrhage
• Pulmonary syndrome
• Fetal shock
• Hypoglycemia
• Heart failure
• Oliguria, anuria

107. • Infection
• Jaundice
• Patent Ductus Arteriosus (PDA)
• Dehydration and acidemia
• Anemia
• Apnea and Sudden Infant Death Syndrome (SIDS)
• Retinopathy of prematurity
• Length of stay

108. IMMEDIATE MANAGEMENT FOLLOWING BIRTH
–Early cord clamp
–cord length is kept long (about 10–12 cm)
–Oro-phrangeal suction
–Oxygen supply mask or nasal catheter
–wrapped with warm towel
–vitamin K 1 mg is to be injection

109. INTENSIVE CARE PROTOCOL:
• Inability to suckle the breast and to swallow.
• Incapacity to regulate the temperature within
limited range from 96°–99°F (35.6°–37.2°C
• Inability to control the cardiorespiratory function
without cyanotic attacks.

110. principles taken for the babies requiring special care
• To maintain thermo neutral condition—keep
delivery room warm and dry
• wrap the baby with a warm towel,
• baby with mother—skin-to-skin contact.
• Oxygen therapy and adequate ventilation.
• maintain nutrition and adequate nursing care.

111. Management in intensive care unit
• To maintain body temperature:
• Fluid Electrolytes: IV fluid 50–70 mL/kg/day when
baby incubator. Monitor electrolytes
• Respiratory support
• Serum bilirubin should be maintained < 10mg/dl
• prevent or minimize infection.
• Prophylactic antibiotic therapy
• Nutrition

112. nursing care:
• temperature monitoring twice daily and
weigh daily
• Constant supervision first 48 hours
• Mother allowed to care baby in the
nursery

113. FAVORABLE SIGNS OF PROGRESS
• The color of the skin remains pink all the time.
• Smooth and regular breathing.
• movements of the limbs and cry.
• Progressive gain in weight.

114. • ADVICES ON DISCHARGE
• Continues supervision at home by public health
nurses.
• Parental education is given for care of the baby at
home. about feeding schedule. — Prescribe a
suitable multivitamin and oral iron preparation as
mentioned earlier. — To attend the well baby clinic
for subsequent check up, immunization and
guidance

115. Fetal Growth Restriction (FGR)
DEFINITION:
Fetal Growth Restriction (FGR) is said to be
present in those babies whose birth weight is below
the 10th percentile of the average for the gestational
age. Growth restriction can occur in preterm, term or
post-term babies.

116. • NCIDENCE: FGR comprises about one-third of low
birth weight babies.
• overall incidence is about 2–8%.
• The incidence among the term babies 5%
• Among post-term babies is about 15%

117. classification
• clinical evaluation and ultrasound
examination the small fetuses are divided
into:
–small and healthy
–pathological or true IUGR

118. small and healthy
• The birth weight is less than 10th percentile for
their gestational age. normal
• subcutaneous fat and usually have uneventful
neonatal course.

119. pathological or true IUGR
• Depending upon the relative size of their head,
abdomen and femur,
• the fetuses are subdivided into:
– Symmetrical or Type I
– Asymmetrical or Type II

120. • Symmetrical (20%):
• The fetus is affected from the noxious effect very
early in the phase of cellular hyperplasia.
• The total cell number is less.
• caused by structural or chromosomal abnormalities
or congenital infection (TORCH).
• The pathological process is intrinsic to the fetus and
involves all the organs including the head

121. Asymmetrical (80%):
• affected in later months during the phase of cellular
hypertrophy.
• The total cell number remains the same but size is
smaller than normal.
• often result in maternal diseases extrinsic to the fetus.
• reducing uteroplacental blood flow or by restricting the
oxygen and nutrient transfer or by reducing the
placental size.

123. ETIOLOGY:
• The causes of fetal growth restriction can be divided
into four groups:
• Maternal
• Fetal
• Placental
• Unknown

124. Maternal:
• Constitutional—
– Small women,
– slim, low body mass index,
– maternal genetic and racial background are associated
with small babies.
• Maternal nutrition before and during pregnancy
• Maternal diseases: Anemia, hypertension,
thrombotic diseases, heart disease, chronic renal
disease, collagen vascular disease
• Toxins—Alcohol, smoking, cocaine, heroin, drugs.

125. Fetal:
• Structural anomaly either cardiovascular, renal or
others.
• Chromosomal abnormality is associated with 8–12%
of growth retarded infants.
• Infection
• Multiple pregnancy

126. Placental:
• poor uterine blood flow
• placental pathology
• Placenta previa, Abruption, Circumvallate, Infarction
and Mosaicism.
Unknown:
The cause remains unknown in about 40%

127. DIAGNOSIS
• Clinical:
–Clinical palpation of the uterus for the fundal
height, liquor volume and fetal mass
–Symphysis Fundal Height(SFH) measurement
–Maternal weight gain
–Measurement of the abdominal

128. • Biophysical:
–Sonographic predictive values used
–Head circumference (HC)
–abdominal circumference (AC) ratios
–Femur length (FL)
–The FL/AC ratio
–Amniotic fluid volume
–Anatomical survey

129. • COMPLICATIONS:
• Fetal:
–(a) Antenatal—Chronic fetal distress, fetal death
–(b) Intranatal—Hypoxia and acidosis

130. After birth
– Immediate:
–Asphyxia, bronchopulmonary dysplasia and RDS.
–Hypoglycemia
–Meconium aspiration syndrome
–Microcoagulation leading to DIC.
– Hypothermia.
–Pulmonary hemorrhage
– Polycythemia, anemia, thrombocytopenia.

131. –Hyperviscosity-thrombosis.
–Necrotizing enterocolitis
–Intraventricular hemorrhage (IVH).
–Electrolyte abnormalities: hypocalcemia,
hypokalemia due to impaired renal function.
– Multiorgan failure.
– Increased perinatal morbidity and mortality.

132. Late:
• retarded neurological and intellectual development in
infancy.
• obesity, hypertension, diabetes and coronary heart
disease
• congenital infection, congenital abnormalities and
chromosomal defects.
• increased appetite and reduced satiety.
• Reduced number of nephrons—causes renal vascular
hypertension

133. Maternal
• does not cause any harm to the mother.
• underlying disease process like preeclampsia, heart
disease, malnutrition may be life threatening.
• for a woman with a growth retarded infant, risk of
having another is two-fold.

134. • Fetuses that are constitutionally small require no
intervention.
• symmetrically growth restricted fetus, investigated
to exclude fetal anomalies, infections and genetic
syndromes.

135. General management
• Adequate bed rest in left lateral position
• correct malnutrition by balanced diet: 300 extra
calories per day
• appropriate therapy for the associated complicating
factors
• Avoidance of smoking, tobacco and alcohol
• Maternal hyperoxygenation at the rate of 2.5 L/ min
• Low dose aspirin (50 mg daily) with history of
thrombotic disease, hypertension, preeclampsia, or
recurrent IUGR
• Maternal hyperalimentation by amino acids
• Maternal volume expansion

136. • Antenatal fetal well being evaluation
– Ultrasound examination done at an interval of 3–4
weeks for the assessment of BPD, HC/AC, fetal weight
and AFI
– Fetal well-being is assessed by Kick count, NST,
biophysical profile, amniotic fluid volume and
cordocentesis for blood gases
– Doppler ultrasound parameters

137. DELIVERY MANAGEMENT
• The factors to be considered are:
– Presence of fetal abnormality
– Duration of pregnancy
– Degree of FGR;
– Associated complicating factor
– Underlying pathology (if known)
– Results of antenatal fetal surveillance
– Availability of neonatal intensive care unit (NICU).

138. Optimum time of delivery for a growth
restricted fetus may be between 34 weeks and 37
weeks depending upon the presence of any additional
risk
• Pregnancy ≥ 37 weeks
• Pregnancy < 37 weeks

139. Pregnancy ≥ 37 weeks
Delivery should be done

140. Pregnancy < 37 weeks
– Uncomplicated mild IUGR
– Severe degree of IUGR

141. Uncomplicated mild IUGR:
• treatment as outlined
• to improve the placental function.
• Pregnancy is continued at least 37 weeks.
Thereafter delivery is done.

142. Severe degree of IUGR
• Delivery basis of fetal surveillance
• delivery is done when lung maturation evident
• Betamethasone therapy gestational age is <34 weeks.
• Corticosteroids reduce the risk of neonatal HMD and
intraventricular hemorrhage
• Delivery to be done at 34 0/7 weeks of gestation in
cases of FGR with additional risk factors for adverse
perinatal outcome
• delivery is to be done before 32 weeks, magnesium
sulfate should be given to the mother for fetal and
neonatal neuroprotection.

143. Methods of delivery
• Vaginal delivery pregnancy beyond 34 weeks with
favorable cervix and the head is deep in the pelvis
– With oxytocin and ARM
– Prostaglandin (PGE2 ) gel, cervix is unfavorable.
– Intrapartum monitoring
• Cesarean delivery when the risks for vaginal
delivery

144. INTENSIVE CARE OF THE
NEWBORN

145. • Intensive care unit also known as intensive care
nursery
• The concept of separate intensive care unit is
specialized care reduce infection
• The care of newborn is according to the level of
complexity of care provided

146. Level of care
• India has a 3 tier sys
• tem based on weight and gestational age of
neonate
– Level I care
– Level II care
– Level IIIcare

147. Level I care
• Neonate weighing more than 1800g or having
gestational maturity of 34 weeks or more
• Consist of basic care at birth , provision of warmth,
maintaining asepsis and promotion of breast
feeding

148. Level II care
• Neonate weighing 1200g - 1800g or having
gestational maturity of 30-34 weeks are categarized
level II
• Trained nurse and intensive neonatologist available
24/7
• Equipments are avilable for resusitation , maintain of
thermo nutral environment, intra venous infusion,
gavage feeding, photo therapy and exchange
transfusion

149. • Location : Close to labour room, adequate
ventilation and sunlight required
• Space: 500-600gross square feet per bed , it
includes storage area, space for doctors and nurses
office area seminar room laboratory area, space fro
families

150. • Floor plan: open area, automatic door closing
system, washing area with elbow or floor operated
tapes
• Ventilation : effective air ventilation with central air
conditioning
• Lighting: well illuminated with white paint
• Environmental temperature and humidity:
temperature maintained at 28oc, humidity >50%

151. • Acoustic characters: sound limit to 15 decibels
• Communication system: direct and outside telephone
line
• Staff: full time neonatologist, nures 1:1 for intensive
care; intermediate care 1:3 with minimum experience
of 3 years .
• Other staff: respiratory therapist, laboratory technician,
public health nurse/ social worker, biomedical engineer,
clerk, housekeeping staff, dietician

152. • Bed strength: 1-2 % of hospital bed
• Equipment required:
– Resuscitation set
– Open care system
– Incubators
– Infusion pump
– Positive pressure ventilators
– Oxygen hood
– Oxygen analyser

153. • Heart rate apnea monitor
• Phototherapy unit
• Electronic weighing scale
• Pulse oximeter
• ECG monitor
• Blood gas analyzer
• Intra cranial pressure monitor

154. MECONIUM ASPIRATION SYNDROME
(MAS)
• The meconium stained liquor may be aspirated by
the fetus-in-utero or during first breath.
• Meconium aspiration syndrome (MAS) usually
occurs in term or post-term babies who are small
for gestational age (IUGR).

155. • incidence of meconium stained amniotic fluid
(MSAF) varies between 8% and 20%.
• Chronic placental insufficiency leads to
intrauterine hypoxia with passage of
meconium.

156. Pathophysiology
• causing hypoxia and increased pulmonary vascular
resistance (PVR)
• chemical pneumonitis
• pulmonary inflammation due to release of
cytokines.
• causes airway edema and hypoxia
• surfactant dysfunction
• development of persistent pulmonary hypertension
(PPHN).

157. Clinical manifestation
–tachypnea,
–nasal flaring,
–intercostal retractions
–cyanosis.

158. Diagnosis
• Aspiration of meconium from the trachea at birth
• Signs of respiratory distress
• Radiologically hyper inflated lung fields, flattened
diaphragm
• Cyanosis.

159. Management
• Proper intrapartum monitoring and care
• Amnio infusion in oligohydramnios
• Maintenance of Thermo neutral environment
• To correct metabolic abnormalities
• Circulatory support
• Airway and oral suctioning may be needed
• Liberal oxygen supply
• Antibiotic therapy
• arterial blood gas analysis
• Inhaled nitric oxide or surfactant therapy may be
beneficial

160. General management
• includes correction of hypoxia, acidosis,
hypoglycemia and hypocalcemia.
• Mechanical ventilation is required where PO2 is less
than 50 mm Hg and PCO2 is above 50 mm of Hg.

161. Complications
Air leak (pneumothorax),
PPHN (persistant pulmonary hypertension )
bronchopulmonary dysplasia or chronic lung diseases

162. Prognosis:
MAS may be associated with
• neurodevelopmental delay,
• cerebral palsy and
• mental retardation.
• Infants need long-term follow-up.

163. JAUNDICE OF THE NEWBORN
• Yellow discoloration of the skin and the mucosa is
caused by accumulation of excess of bilirubin in the
tissue and plasma
• (serum bilirubin level should be in excess 7 mg/dL).
• A value > 15 mg/dL is considered severe.
• About 80% of term newborn and most of preterm
newborns develop clinical jaundice.

164. CAUSES OF NEONATAL JAUNDICE
–Physiological
–Nonphysiological/ PATHOLOGICAL

165. PHYSIOLOGICAL
• appears on 2nd and 3rd day and disappears by 7th–
10th day, a little later in premature neonates.
• In a term infant the level may be 6–8 mg/dL on 3rd day.
• unconjugated serum bilirubin up to 12 mg/dL is in the
physiological range.
• In a premature infant the peak level of 12–15 mg/dL in
the 1st week may be without any abnormality.

166. Causes of excessive bilirubin production are:
–Increased red cell volume per kg and increased
red cell destruction
–Transient decreased conjugation of bilirubin
–Increased enterohepatic circulation
–Decreased hepatic excretion of bilirubin
–Decreased liver cell uptake of bilirubin

167. Treatment
–No specific treatment.
–frequent feeds.
–careful observation In premature babies,
–critical level need exchange transfusion.
–Medication ; phenobarbitone
–phototherapy

168. PATHOLOGICAL/ NONPHYSIOLOGIC
CAUSES
Excessive red cell hemolysis
• Hemolytic disease of the newborn
– Fetomaternal blood group incompatibilities
– Increased red cell fragility
– Deficient red cell enzyme
• Sepsis: Intrauterine
• Blood extravasation

169. • Defective conjugation of bilirubin
– Congenital deficiency of glucuronyl transferase
• Breast milk jaundice:
• Metabolic and endocrine disorders: Galactosemia,
hypothyroidism
• Increased enterohepatic circulation
• Substances and disorders that affect binding of bilirubin
to albumin
• Miscellaneous: Congenital obstruction, asphyxia,
polycythemia and thalassemia.

170. HYPERBILIRUBINEMIA OF THE NEWBORN

171. Definition:
When the bilirubin (unconjugated) level rises
more than the arbitrary cut-off point of 12 mg/dL, in
a term infant the condition is called
“hyperbilirubinemia of the newborn”.
The face and chest of the infant are stained
yellow at this level of serum bilirubin.

172. DIAGNOSIS OF NEONATAL HYPERBILIRUBINEMIA
• Clinical:
–Evaluation of jaundice is done by blanching
the skin with digital pressure.
–Clinical jaundice in a neonate indicates
serum bilirubin of more than 5 mg/dL.

173. On physical examination
• Abnormal neurologic signs are:
– lethargy,
–poor feeding,
–vomiting,
–hypotonia
–seizures.

174. Laboratory studies
• Serum bilirubin level > 12 mg/dL,
• Blood group (ABO, Rh)
• Direct Coombs’ test
• Total bilirubin, conjugated bilirubin and
unconjugated bilirubin.
• Complete hemogram including reticulocyte count
• Serum albumin
• culture for infection
• Hemoglobin electrophoresis
• Osmotic fragility tests
• Thyroid and liver function tests

175. Radiology and Ultrasonography
• to detect intestinal obstruction, intraventricular
hemorrhage and tumor.

176. COMPLICATION (unconjugated)
• Kernicterus is more often fatal, if not promptly
detected and adequately treated.

177. Kernicterus
Kernicterus is a pathological condition
characterized by yellow staining of the brain by
unconjugated bilirubin resulting, in neuronal
injury. Basal ganglia, cranial nerve nuclei,
hippocampus, brainstem nuclei and anterior
horn cells of the spinal cord are commonly
affected.

178. • The critical level of bilirubin causing kernicterus in a
term infant is more than 20 mg/dL (340 µmol/L).
Bilirubin enters the brain in free form.
• Risk of bilirubin encephalopathy is unlikely, if the
total bilirubin level is < 20 mg/dL.

179. Risk factors
–Hypoxia,
–acidosis,
–hypoglycemia,
–hypothermia,
–sepsis or prematurity

180. Clinical manifestation
–lethargy,
–hypotonia,
–poor feeding
–loss of neonatal reflexes.

181. severe illness
– hypertonia,
– prostration, respiratory distress
– Opisthotonos ( spasm of the muscles causing
backward arching of the head, neck, and spine )
– hyperpyrexia,
– convulsions,
– enlarged liver, spleen and chronic bilirubin
encephalopathy.
– anemia in babies of hemolytic disease.

182. Prevention and management:
• Regular estimation of serum bilirubin level in
susceptible babies
• double surface phototherapy
• exchange transfusion.
• barbiturate therapy

183. MANAGEMENT OF JAUNDICE IN THE NEWBORN
Three methods of treatment are used to reduce
the level of unconjugated bilirubin
• Phototherapy
• Pharmacologic therapy
• Exchange transfusion.

184. • Phototherapy: Phototherapy degrades bilirubin by
photooxidation and structural isomerization
(lumibilirubin).
• blue or blue green light of 420–470 nm wavelength
• Bilirubin is converted to less toxic polar isomer.
These products are water soluble and therefore
readily excreted in the bile and urine.
• he baby’s eyes shoul
• Phototherapy is discontinued when serum bilirubin

185. • Phototherapy started early,
• exposing the maximum surface area
• Provide shielding the eyes.
• increased insensible fluid loss of the neonate.
• Oral hydration with frequent breast milk is
encouraged. IV fluid therapy or nasogastric feeding
may be needed.
• Phototherapy blankets protect the infants.

186. Complications
–Watery diarrhea,
–skin rashes,
–dehydration,
–bronze baby syndrome (dark brown discoloration
of the skin),
–low calcium levels and
–retinal damage.

187. • Phenobarbital therapy induces hepatic microsomal
enzymes and increases bilirubin conjugation and
excretion.
• Phenobarbital is used to treat indirect
hyperbilirubinemia
• A loading dose of 10 mg/kg on day 1 and maintenance
dose of 5–8 mg/kg/day for next 4 days is given.
• used in the mother for 2 weeks prior to delivery in the
dose of 90 mg/day.

188. Exchange transfusion is used to prevent kernicterus.
Double-volume exchange replaces 85% of circulating
red blood cells and reduces bilirubin level by 50%.

189. Indication
• When phototherapy fails to prevent the rise in
bilirubin to toxic levels.
• When there is progressive rise of bilirubin (>1
mg/dL/hour) in spite of phototherapy „
• Rate of bilirubin rise >0.5mg/dL/hour despite
phototherapy when Hb is between 11–13 g/dL

190. Complications
– Air embolism,
– thrombosis,
– hypervolemia,
– RDS,
– hypothermia,
– acidosis,
– infection,
– hyperkalemia,
– hypocalcemia,
– hypoglycemia,
– cardiac arrhythmias,
– thrombocytopenia,
– coagulopathies and necrotizing enterocolitis.

191. • ANEMIA IN THE NEWBORN

192. • At birth normal values of hemoglobin (central
venous) in infants > 34 weeks gestation are
14–20 g/dL with an average value of 17 g/dL.

193. • DEFINITION: Central venous hemoglobin level
< 13 g/dL in an infant of > 34 weeks gestation
is considered anemia.

194. • CAUSES:
• Hemorrhagic anemia:
– Obstetric causes
• Abruptio placenta
• Placenta previa
• Traumatic rupture of umbilical cord
• Obstetric trauma
• Twintwin transfusion
• Delivery of the baby by cesarean section in anterior placenta
previa
• Ruptured vasa previa
• Excessive fetomaternal bleed
• Anemia of prematurity
• Hereditary RBC disorders—hemoglobinopathies.

195. • Neonatal causes:(a) Caput succedaneum; (b)
Cephalhematoma; (c) Intracranial hemorrhage; (d)
Visceral hemorrhage (spleen, kidneys and adrenals);
(e) DIC; (f ) Thrombocytopenia and (g) Hemorrhage
due to deficient vitamin K dependent factors (II, VII,
IX and X). (

196. • 2) Hemolytic anemia (see p. 554). (3) Under
production of RBCs: (a) Congenital hypoplastic
anemia, (b) Leukemia and (c) Infections
(Rubella, Syphilis).

197. Hemolytic disease in newborn
• Hemolytic disease of the new born major
cause of fetal loss or death
• Also called as erythroblastosisfetalis
• The condition due to incompatibility between
the blood types of mother and fetus

198. • “hemolitic” means breaking down for the red blood
cells
• Erythroblastosis refers to making of immature red
blood cells
• Fetalis refers to fetus

199. • Definition: Hemolytic disease defined as the
hemolysis of the fetal red blood cells (RBCs) due to
passively acquired maternal antibodies, these
Hemolysis is manifested by a decreased hematocrit,
increased reticulocyte count and an increased
bilirubin level.

200. • Common causes are
– Immune hemolysis
• Rh incompatibility,
• ABO incompatibility
• Other blood group incompatibility (C, E, Kell, Duffy)
• Maternal diseases (lupus); drugs
– Inherited RBC disorders
• RBC membrane defects
• Metabolic: G6PD
• deficiency „Systemic diseases (Galactosemia)
• Hemoglobinopathies (a- and b-thalassemia syndrome)
– Acquired hemolysis
• Infection: bacterial, viral, parasitic (Rubella, syphilis)
• DIC „
• Acute transfusion hemolysis
• Vitamin E deficiency „
• Drugs (Vitamin K, nitrofurantoin)

201. Pathogenesis
• Feto-maternal Hemorrhage
• Maternal antibodies formed against fetus derived
antigens
• During subsequent pregnancy, placental passage of
maternal IgG antibodies
• Maternal antibody attaches to fetal red blood cells
• Fetal red blood cell hemolysis

202. Signs and symptoms
• Jaundice
• Pain in the upper abdomen
• Leg ulcer and pain
• A severe reaction to a blood transfusion

203. Diagnosis
• Indirect coombs test for rh negative mothers and
test positivity indicates the antibody titer valuation
• Antenatal ultrasound for hydropsfetalis
• Fetal blood sampling
• Complete blood studies ; red blood cell count,
reticulocyte count,
• Biochemical studies for blood glucose

204. Treatment for hemolytic disease
• In newborns Treatment for HDN based on
baby’s gestational age, Health, medical history
• During pregnancy, intra uterine blood
transfusion,
• Early delivery induced if fetus develop
complication

205. • After birth treatment
• Blood transfusion for severe anaemia
• Iv fluids for low blood pressure
• Oxygen or mechanical breathing in case of
respiratory distress
• Exchange transfusion

206. Prevention
Anti D immunoglobulin prophylaxis given for all
Rh negative women not sensitized before, it can be
provide soon after the delivery and antenatally at 28th
week and 32nd week, after abortion or miscarriage, in
case of amniocentesis, ectopic pregnancy and
abdominal truma

207. Neonatal hypoglycemia
• Hypoglycemia is condition in which the
amount of blood glucose in the blood is lower
than normal

208. • Definition
• Neonatal hypoglycemia defined as the plasma
glucose level is less than 30mg/dLin the first
24 hours of life and less than 45mg/dL

209. • Causes
• Inadequate maternal nutrition in pregnancy
• Excess insulin produced in a baby of diabetic
mother
• Severe hemolytic disease of newborn
• Birth defect and congenital metabolic disease
• Birth asphyxia
• Cold stress
• Liver disease

210. • Signs and symptoms
• Asymptomatic during the first few days of life
and threatening to central nervous system
and cardiopulmonary disturbances