BSC SEM 6 UNIT 6 MIDWIFERY / OBSTETRIC AND GYNECOLOGY NURSING- I

For Patients	For Families	For Healthcare Systems
Faster recovery	Improved satisfaction and trust	Lower re-hospitalization rates
Reduced stress and anxiety	Greater involvement and confidence	Improved efficiency of care
Better adherence to treatment	Emotional and psychological support	Better health outcomes

🌼 1. What is Respectful Care of Neonate and Family?

Respectful care refers to providing care that:

Honors the values and needs of the neonate and family.
Is free from neglect, abuse, discrimination, or coercion.
Involves the family as partners in decision-making.
Recognizes the newborn as a human being with rights.

🍼 2. Principles of Respectful Care for Neonates

Principle	Description
Dignity	Treating the neonate and family with kindness and worth, regardless of background or condition.
Privacy and Confidentiality	Ensuring that personal information is kept private and care is provided in a private setting when possible.
Informed Decision-Making	Providing complete, understandable information so families can make choices.
Non-Discrimination	Care is given equally to all babies and families regardless of gender, caste, religion, or economic status.
Compassionate Care	Addressing both physical and emotional needs with empathy.
Continuity of Care	Ensuring smooth transition between care levels (e.g., from delivery room to NICU to home).

💬 3. Respectful Communication with Neonate and Family

✅ With the Family:

Use of simple, non-technical language
→ Explain procedures, conditions, or treatments in ways that parents can understand.
Active listening
→ Let the family express their feelings, worries, or doubts without interruption.
Emotional support
→ Reassure, comfort, and validate the emotions of the family, especially in stressful or uncertain situations.
Cultural Sensitivity
→ Respect beliefs, customs, or practices related to childbirth, naming, or caregiving.
Shared Decision-Making
→ Involve parents in care plans and seek their consent before procedures.
Transparency
→ Keep families informed about the baby’s condition, progress, and any changes in care.
Respecting Parental Role
→ Encourage mother-father bonding, kangaroo care, and participation in feeding or bathing.

👶 With the Neonate:

Though neonates cannot verbally communicate, respectful interaction includes:

Handling gently during examinations or procedures.
Keeping the baby warm, clean, and comfortable.
Minimizing noise and light exposure.
Using soft voices and touch to soothe.
Avoiding unnecessary separation from the mother (promote rooming-in).
Practicing pain relief techniques during minor procedures (e.g., breastfeeding, sugar drops, skin-to-skin contact).

🏥 4. In Clinical Practice: Examples of Respectful Care

Situation	Respectful Action
Baby needs to be admitted to NICU	Explain reasons clearly, let parents see the baby, and visit regularly.
Procedure like heel prick or IV	Inform parents before, provide pain relief, handle baby gently.
Baby born with congenital anomaly	Speak with empathy, offer support, and avoid judgment.
Parents are anxious or crying	Sit with them, listen calmly, give reassurance.

👪 5. Why It Matters

Builds trust between healthcare workers and families.
Reduces parental stress, promotes bonding.
Enhances compliance with newborn care advice.
Improves health outcomes for the neonate.
Upholds human rights and ethical standards in care.

🧠 6. Key Skills for Providers

Empathy and Compassion
Cultural Competence
Patience and Active Listening
Clear and Honest Communication
Team Collaboration
Respect for Autonomy and Family Roles

Characteristics of a Normal Neonate:

A normal neonate is a newborn infant who is born at term (between 37 to 42 weeks of gestation), with no congenital anomalies or complications, and who adapts well to extrauterine life. Understanding the physical, physiological, and behavioral characteristics of a normal neonate is crucial for early identification of abnormalities and timely care.

🧒 1. General Physical Characteristics

Feature	Description
Weight	Average birth weight: 2.5 – 4.0 kg. Babies weighing <2.5 kg are considered low birth weight.
Length	Average: 48 – 53 cm from head to heel.
Head Circumference	33 – 35 cm. Head is larger in proportion to the rest of the body.
Chest Circumference	30 – 33 cm; usually 2–3 cm smaller than head circumference.
Body Proportion	Large head (~1/4th of body length), short neck, short limbs, and a relatively long trunk.
Posture	Flexed position (arms and legs bent) due to intrauterine positioning.

🧠 2. Neurological and Behavioral Characteristics

Aspect	Description
Reflexes	Present and important to assess neurological health. Include rooting, sucking, grasp, Moro (startle), Babinski, and tonic neck reflexes.
Tone and Activity	Active movement with good muscle tone. Hands usually clenched.
Crying	Strong and lusty cry is a sign of good respiratory and neurological status.
Sleep Pattern	Sleeps 16–18 hours a day in short intervals.
Senses	– Touch: Fully developed at birth. – Smell: Can recognize mother’s scent. – Taste: Prefers sweet taste. – Vision: Can see up to 8–10 inches, prefers human faces and high-contrast patterns. – Hearing: Fully functional and responsive to sound.

🫁 3. Respiratory Characteristics

Parameter	Normal Value
Respiratory Rate	40 – 60 breaths per minute (irregular but not labored).
Breathing Pattern	Abdominal (diaphragmatic) breathing is common. May show periodic breathing (brief pauses <10 sec).
Signs of Normality	No chest indrawing, grunting, nasal flaring, or cyanosis. Skin is pink and well-perfused.

❤️ 4. Cardiovascular Characteristics

Parameter	Normal Value/Feature
Heart Rate	120 – 160 beats per minute (can be higher during crying).
Color	Pink skin tone indicates good circulation; acrocyanosis (blue hands and feet) is normal initially.
Pulses	Peripheral pulses may be weaker but should be present.

🌡️ 5. Thermoregulation

Newborns lose heat rapidly due to:
- Large surface area to body weight ratio.
- Thin skin and little subcutaneous fat.
- Immature thermoregulation center.
Normal temperature: 36.5°C – 37.5°C (axillary).
Thermoregulation is supported by:
- Kangaroo care (skin-to-skin contact).
- Proper clothing and warm environment.
- Drying the baby immediately after birth.

🍽️ 6. Gastrointestinal Characteristics

Function	Observation
Feeding Reflexes	Rooting and sucking reflexes are present. Effective suck-swallow-breathe coordination develops gradually.
Stomach Capacity	Small at birth (~5–10 mL); increases over days.
First Stool (Meconium)	Thick, blackish-green, passed within 24–48 hours of life.
Subsequent Stool	Transition to yellow, seedy stools by day 4–5, especially in breastfed babies.

💦 7. Urinary Characteristics

Function	Observation
First Urine	Usually passed within 24 hours after birth.
Urine Output	6–8 wet diapers/day by end of first week.
Renal Function	Immature at birth; kidneys concentrate urine poorly.

🧬 8. Integumentary (Skin) Features

Skin Feature	Normal Observation
Color	Pink; may have acrocyanosis (bluish hands/feet) for first 1–2 days.
Vernix Caseosa	White, cheesy substance on skin; protective covering.
Lanugo	Fine hair on shoulders/back; more in preterm babies.
Milia	Small white spots on nose/face; harmless and self-resolving.
Peeling	Mild skin peeling is normal, especially on hands and feet.
Mongolian Spots	Bluish-gray patches over lower back/buttocks; common in darker-skinned infants.
Birthmarks	Some babies may have hemangiomas or other benign marks.

🧷 9. Umbilical Cord

Appearance: Bluish-white, jelly-like at birth with two arteries and one vein.
Care: Kept clean and dry. Usually falls off in 7–10 days.
Watch for: Redness, swelling, pus – signs of infection.

🧫 10. Immunity and Blood Profile

Aspect	Details
Immunity	Passive immunity from mother (IgG antibodies via placenta); begins to decline by 3–6 months.
White Blood Cell Count	High at birth (10,000–30,000/mm³).
Red Blood Cells	High hematocrit at birth; physiological jaundice may occur due to breakdown of excess RBCs.

🧠 11. Psychological Bonding and Communication

Newborns are capable of:
- Bonding with parents through touch, smell, and voice.
- Facial recognition within a few days.
- Responding to mother’s voice and heartbeat.
Skin-to-skin contact immediately after birth promotes attachment and emotional security.

✅ Summary Table: Vital Signs of Normal Neonate

Parameter	Normal Range
Heart Rate	120–160 bpm
Respiratory Rate	40–60/min
Temperature	36.5°C – 37.5°C (axillary)
Weight	2.5 – 4.0 kg
Length	48 – 53 cm
Head Circumference	33 – 35 cm

Physiological Adaptation of a Normal Neonate:

When a baby is born, they undergo several physiological adaptations to transition from life inside the womb (intrauterine) to the outside world (extrauterine). These adaptations are critical for survival, health, and growth. A normal neonate (term baby with no complications) adjusts to this new environment through a series of well-coordinated systemic changes.

🧠 1. Respiratory Adaptation

Before Birth:

The fetus receives oxygen through the placenta.
Lungs are filled with fluid and are non-functional for gas exchange.

After Birth:

The baby must breathe air on its own.
First breath: Initiated by physical, chemical, thermal, and sensory stimuli.
Lung expansion occurs, and the fluid in the alveoli is absorbed into the bloodstream and lymphatics.
Surfactant (a substance that keeps alveoli open) helps prevent lung collapse.

Key Adaptations:

Establishment of regular breathing (30–60 breaths/min).
Clearing of lung fluid.
Closure of fetal shunts (see below).

❤️ 2. Cardiovascular Adaptation

Fetal Circulation Includes:

Ductus venosus: Bypasses liver.
Foramen ovale: Bypasses lungs by shunting blood from right to left atrium.
Ductus arteriosus: Connects pulmonary artery to aorta.

After Birth:

Lungs begin oxygen exchange, increasing oxygen levels in blood.
Umbilical cord is clamped → placenta (oxygen source) is removed.
Pressure changes in the heart lead to:
- Closure of foramen ovale
- Closure of ductus arteriosus
- Closure of ductus venosus

Result:

Normal adult-like circulation is established.
Heart rate stabilizes around 120–160 bpm.

🌡️ 3. Thermoregulation

Before Birth:

Fetal temperature is regulated by maternal body.

After Birth:

Baby must regulate own body temperature.
Prone to heat loss due to:
- Large surface area.
- Thin skin and little fat.
- Inability to shiver efficiently.

Adaptation Mechanisms:

Non-shivering thermogenesis using brown adipose tissue (BAT).
Peripheral vasoconstriction to reduce heat loss.
Behavioral responses like flexing limbs to conserve heat.

Support Needed:

Immediate drying, skin-to-skin contact, warm environment, and proper clothing.

🧫 4. Hematologic Adaptation

At birth: Higher red blood cell (RBC) count and hemoglobin level (~17–20 g/dL) to carry oxygen.
After birth:
- Oxygen availability increases → reduced erythropoietin → gradual RBC breakdown.
- This leads to physiological jaundice (bilirubin build-up due to immature liver).
White blood cells are also elevated (10,000–30,000/mm³).
Vitamin K deficiency: Neonates are born with low levels of vitamin K → risk of bleeding → Vitamin K injection is given.

🧬 5. Gastrointestinal Adaptation

Before Birth:

Nutrients provided via placenta.
GI tract is sterile and inactive.

After Birth:

Gut becomes functional and colonized by bacteria (important for digestion and immunity).
Stomach capacity: 5–10 mL at birth → increases daily.
Enzymes: Enough for digestion of milk (lactase present; amylase is low initially).
First stool: Meconium (black-green, tarry) passed within 24–48 hrs.
Transitional stools turn yellow and seedy (especially in breastfed babies).

💦 6. Renal (Kidney) Adaptation

Characteristics:

Kidneys are immature at birth.
Poor ability to concentrate urine → risk of dehydration and electrolyte imbalance.
First urine is passed within 24 hours.
Urine output increases by the end of the first week (6–8 wet diapers/day).

🧠 7. Neurological Adaptation

Nervous system is immature but functional at birth.
Neonatal reflexes (primitive reflexes) are present:
- Rooting, sucking, Moro (startle), grasp, Babinski, tonic neck, etc.
Sensory perception:
- Touch and hearing are well-developed.
- Vision: Limited but can focus at ~20–25 cm.
- Taste: Prefers sweet flavors.
- Smell: Can recognize mother’s scent.

🧬 8. Immune System Adaptation

Neonate has an immature immune system.
Relies on passive immunity from:
- Maternal IgG antibodies (cross placenta during last trimester).
- IgA from breast milk provides mucosal protection.
Neonates are vulnerable to infections → proper hygiene and exclusive breastfeeding are critical.

🎯 9. Endocrine and Metabolic Adaptation

Neonate must maintain glucose homeostasis independently.
At birth:
- Baby may experience transient hypoglycemia as maternal glucose supply ends.
- Glycogen stores in the liver are used until feeding is established.
Brown fat metabolism provides energy and heat.
Risk of hypoglycemia is higher in:
- Preterm babies.
- Small-for-gestational-age (SGA).
- Infants of diabetic mothers.

📌 Summary Table: Physiological Adaptations

System	Key Adaptation
Respiratory	Lungs inflate, surfactant functions, breathing begins
Cardiovascular	Fetal shunts close; independent circulation starts
Thermoregulation	Brown fat metabolism and vasoconstriction
Hematologic	RBC breakdown, bilirubin rise, vitamin K deficiency
Gastrointestinal	Digestion begins, meconium passage, stool pattern changes
Renal	Urine production starts; immature concentration ability
Neurological	Reflexes present, senses functioning
Immune	Passive immunity from mother; immature active immunity
Metabolic	Blood sugar regulation and brown fat metabolism

Newborn Assessment:

Newborn assessment is a comprehensive and systematic evaluation of a baby immediately after birth and during the early neonatal period (first 28 days of life). It helps in identifying normal adaptation to extrauterine life and detecting any immediate or underlying problems requiring medical intervention.

🩺 1. Timing of Newborn Assessment

Timing	Purpose
Immediate (at birth)	Assess need for resuscitation and evaluate general condition.
Within first hour	Assess vital signs, congenital anomalies, and reflexes.
Within 24 hours	Complete physical examination, screening tests, and initiate routine care.
Daily (during hospital stay)	Monitor feeding, jaundice, weight, elimination, and bonding.

🧩 2. Components of Newborn Assessment

📍 A. Immediate Assessment (At Birth)

Apgar Score (At 1 and 5 Minutes)

Scored out of 10, based on 5 criteria:

Component	Score 0	Score 1	Score 2
Appearance (Color)	Blue/pale	Pink body, blue extremities	Completely pink
Pulse (HR)	Absent	<100 bpm	>100 bpm
Grimace (Reflex)	No response	Grimace	Cry/pull away
Activity (Tone)	Limp	Some flexion	Active
Respiration	Absent	Weak cry	Strong cry

Score 7–10: Normal
Score 4–6: Moderate difficulty
Score 0–3: Severe distress, needs resuscitation

📍 B. Physical Examination (Head-to-Toe)

1. General Appearance

Alertness, tone, color, movement
Normal posture: Flexed limbs, active movement

2. Skin

Color: Pink (acrocyanosis may be normal)
Birthmarks: Mongolian spots, hemangiomas, vernix caseosa
Rashes, peeling, bruising

3. Head and Neck

Fontanelles: Anterior (diamond-shaped), Posterior (small and triangular)
Sutures: May be overriding or molded
Caput succedaneum vs. cephalohematoma
Neck masses, webbing, range of motion

4. Eyes

Placement, red reflex, discharge, strabismus
Subconjunctival hemorrhage may be normal

5. Ears and Nose

Position and shape of ears
Nasal patency, flaring (sign of respiratory distress)

6. Mouth

Palate (check for cleft), suck reflex
Epstein pearls (harmless cysts), natal teeth

7. Chest

Shape, symmetry, respiratory effort
Breath sounds, heart sounds, murmurs

8. Abdomen

Umbilical cord: 2 arteries, 1 vein
Soft, non-distended; liver/spleen edges may be felt

9. Genitalia

Male: Testes descended, urethral opening (rule out hypospadias)
Female: Labia majora covers minora; possible white or blood-stained discharge (normal)

10. Extremities

Movement, symmetry, clubfoot, polydactyly
Palmar creases (single crease may be a sign of Down syndrome)

11. Spine

Straight and intact
Look for dimples, tufts of hair, or sinus (may suggest spina bifida)

📍 C. Vital Signs

Vital Sign	Normal Range
Temperature	36.5°C – 37.5°C (axillary)
Heart Rate	120 – 160 bpm
Respiratory Rate	40 – 60 breaths/min
Blood Pressure	Not routinely measured unless ill

📍 D. Measurements

Parameter	Normal Range
Weight	2.5 – 4.0 kg
Length	48 – 53 cm
Head Circumference	33 – 35 cm
Chest Circumference	30 – 33 cm

📍 E. Neurological Assessment

Reflexes:
- Moro (startle): Arms extend and then flex
- Rooting: Turns head toward touch on cheek
- Sucking: Sucks when something touches the mouth
- Palmar grasp: Grasps finger placed in palm
- Tonic neck: “Fencing” posture
- Babinski: Toes fan outward

🧪 3. Newborn Screening Tests

✅ Metabolic Screening (Heel Prick Test)

Done within 24–72 hours after birth to detect:

Congenital hypothyroidism
Phenylketonuria (PKU)
Galactosemia
Sickle cell disease
G6PD deficiency (in some settings)

✅ Hearing Screening

Otoacoustic emissions (OAE) or Auditory Brainstem Response (ABR)

✅ Critical Congenital Heart Disease (CCHD) Screening

Pulse oximetry test on right hand and foot after 24 hours

🧷 4. Other Observations During Early Days

Area	What to Look For
Feeding	Breastfeeding/latching, sucking reflex, frequency
Elimination	Meconium passed within 24–48 hrs, urine output
Jaundice	Physiological jaundice peaks at day 3–5, must be monitored
Bonding	Parental interaction and attachment
Crying	Strong and clear cry is reassuring

📌 Summary: Quick Checklist for Newborn Assessment

✅ Apgar score
✅ Vital signs and measurements
✅ Skin color and condition
✅ Head, fontanelles, eyes, mouth
✅ Chest and abdominal exam
✅ Genitalia and anus
✅ Reflexes and tone
✅ Elimination and feeding
✅ Screening tests

🍼 Newborn Care:

Newborn care refers to all the practices and interventions provided to a baby during the first 28 days of life (neonatal period) to ensure a healthy start, promote growth and development, and prevent illness or complications. This period is critical as it lays the foundation for lifelong health.

🧸 1. Immediate Care at Birth (Within the First Hour)

Also called Essential Newborn Care, the steps include:

✅ a. Warmth (Preventing Hypothermia)

Dry the baby immediately after birth with a warm towel.
Skin-to-skin contact with mother (Kangaroo care).
Cover with a cap and blanket.
Maintain room temperature at 25–28°C.

✅ b. Airway and Breathing

Ensure the baby is breathing or crying.
Clear secretions only if needed.
If not breathing: Start neonatal resuscitation.

✅ c. Umbilical Cord Care

Clamp and cut the cord using sterile equipment.
Keep stump clean and dry.
Do not apply powders, oils, or bandages.

✅ d. Early Initiation of Breastfeeding

Begin within 1 hour of birth.
Encourage colostrum feeding (rich in antibodies).
Avoid prelacteal feeds (honey, water, etc.).

🧼 2. Daily Newborn Care

🟡 a. Feeding

Exclusive breastfeeding for the first 6 months.
Feed on demand (every 2–3 hours or 8–12 times/day).
Watch for hunger cues: rooting, sucking, restlessness.
Proper latch and position are essential.

🟡 b. Hygiene and Bathing

Sponge bath until umbilical cord falls off.
Use mild baby soap, warm water.
Clean eyes, face, and diaper area daily.
Wash hands before handling the baby.

🟡 c. Skin and Cord Care

Leave vernix (white creamy coating) on skin after birth.
No antiseptics or powders on the cord stump.
Watch for signs of infection: redness, swelling, discharge.

🟡 d. Sleep and Positioning

Newborns sleep ~16–18 hours a day.
Place baby on back to sleep (prevents SIDS).
Avoid soft bedding, pillows, or stuffed toys in the crib.
Practice safe co-sleeping if needed (baby on a firm surface).

👶 3. Monitoring Baby’s Health

✅ a. Urine and Stool

First urine within 24 hours; meconium (first stool) within 48 hours.
By day 5: 6–8 wet diapers and 3–4 stools daily (especially in breastfed infants).

✅ b. Weight Monitoring

Normal to lose up to 10% of birth weight in first week.
Regains birth weight by day 10–14.
Regular checkups to monitor growth.

✅ c. Jaundice

Physiological jaundice is common after day 2–3.
Observe skin and eyes for yellowing.
Ensure frequent feeding to promote bilirubin excretion.

💉 4. Immunization at Birth

Vaccine	When	Purpose
BCG	At birth	Protection against tuberculosis
OPV (0 dose)	At birth	Protection against polio
Hepatitis B (1st dose)	Within 24 hours	Prevents perinatal hepatitis B infection
Vitamin K injection	At birth	Prevents bleeding disorders

🧠 5. Development and Bonding

Talk, sing, and make eye contact with the baby.
Practice skin-to-skin contact and gentle touch.
Respond to the baby’s cries promptly to build trust.
Encourage family members to participate in care.

🧩 6. Warning Signs in Newborn (Refer Immediately)

Sign	Possible Concern
Poor feeding or refusal to feed	Infection, lethargy
Fast or difficult breathing	Pneumonia, respiratory distress
Fever or low temperature	Sepsis or environment-related
Yellow skin (especially before 24 hrs or worsening)	Pathological jaundice
Convulsions	Neurological issues
Vomiting (green or persistent)	Intestinal blockage
Redness or pus from cord stump	Umbilical infection
Drowsy, limp, or unresponsive	Emergency! Needs urgent care

👪 7. Parental Education and Support

Teach about breastfeeding, hygiene, sleep safety, and signs of illness.
Encourage mothers and fathers to participate equally in care.
Provide emotional support to first-time or anxious parents.
Promote immunization and scheduled follow-ups.

🧬 Screening for Conggenital Anomalies in Newborns:

Congenital anomalies (also known as birth defects) are structural or functional abnormalities present at birth that can affect almost any part of the body. Early screening and detection are essential to ensure timely intervention, reduce complications, and improve long-term outcomes.

📌 What is Screening for Congenital Anomalies?

Screening refers to the early identification of babies who may have hidden (silent or asymptomatic) congenital conditions through physical examination, tests, or imaging. It is ideally performed within the first 72 hours of life, but some tests continue into the first few weeks.

🔍 1. Types of Congenital Anomalies to Screen For

Type	Examples
Structural	Cleft lip/palate, clubfoot, congenital heart defects, spina bifida
Genetic/Metabolic	Down syndrome, hypothyroidism, phenylketonuria (PKU), G6PD deficiency
Neurological	Microcephaly, hydrocephalus
Sensory	Congenital deafness, cataracts
Genitourinary	Undescended testes, hypospadias, renal agenesis

🧪 2. Key Screening Components and Methods

✅ A. Physical Examination (Head-to-Toe)

Conducted within 24 hours of birth and repeated before discharge.
Assesses for:
- Facial anomalies (e.g. cleft lip)
- Limb abnormalities (e.g. clubfoot)
- Genital abnormalities (e.g. hypospadias, ambiguous genitalia)
- Spinal defects (e.g. spina bifida, sacral dimple)
- Cranial size and shape (microcephaly, hydrocephalus)

✅ B. Newborn Metabolic Screening (“Heel Prick Test”)

Usually performed after 24–48 hours of feeding.

Condition Screened	Test Type
Congenital Hypothyroidism	TSH/T4
Phenylketonuria (PKU)	Phenylalanine level
Galactosemia	Enzyme assay
Congenital Adrenal Hyperplasia	17-hydroxyprogesterone
G6PD Deficiency	Enzyme screening
Sickle Cell Disease	Hemoglobin electrophoresis
Cystic Fibrosis (in some countries)	Immunoreactive trypsinogen (IRT)

📌 In India, this screening is increasingly included in hospital protocols and government newborn programs.

✅ C. Hearing Screening

Timing: Before discharge or within first month.

Tests Used:

Otoacoustic Emissions (OAE) – sound response from inner ear
Auditory Brainstem Response (ABR) – measures auditory nerve response

Purpose: Detect congenital hearing loss, which affects 1–3 per 1,000 babies.

✅ D. Eye Screening

Red reflex test: Performed at birth to check for cataracts or retinoblastoma.
Retinopathy of Prematurity (ROP) screening: In preterm or low birth weight babies, usually done at 4–6 weeks of age.

✅ E. Pulse Oximetry Screening

When: After 24 hours of birth

Where: Right hand and either foot

Purpose: To detect Critical Congenital Heart Disease (CCHD) by identifying low oxygen saturation levels.

✅ F. Imaging Studies (If indicated)

Ultrasound skull/spine: If head circumference abnormal or spinal anomaly suspected
Echocardiogram: For murmur or suspected heart defect
Abdominal Ultrasound: In case of ambiguous genitalia or abdominal mass

🧠 3. Antenatal Screening and Its Role

Some congenital anomalies can be detected before birth:

Ultrasound (USG) at 18–20 weeks: Neural tube defects, heart anomalies, cleft lip, renal anomalies
Maternal serum markers: AFP, hCG, estriol – for Down syndrome risk
Non-Invasive Prenatal Testing (NIPT): Cell-free fetal DNA test for chromosomal disorders
Amniocentesis: Confirms genetic/chromosomal disorders (e.g. Down syndrome, thalassemia)

🏥 4. National Programs in India for Congenital Anomaly Screening

🇮🇳 Rashtriya Bal Swasthya Karyakram (RBSK)

A government initiative under NHM.
Focuses on early identification of 4Ds:
- Defects at birth
- Deficiencies
- Diseases
- Developmental delays and disabilities
Mobile Health Teams screen children from birth to 18 years.
Covers congenital heart defects, cleft lip/palate, Down syndrome, hearing loss, etc.

⚠️ 5. Follow-Up and Referral

If a congenital anomaly is suspected or confirmed:

Immediate referral to pediatrician/specialist.
Counseling for parents about prognosis and treatment.
Long-term monitoring, early intervention, and support services (speech therapy, physiotherapy, surgery).

🍼 Care of Newborn from 72 Hours to 6 Weeks After Delivery (Routine Newborn Care):

The period from 72 hours to 6 weeks after birth is a critical time for growth, adaptation, bonding, and prevention of illness. This is the postnatal period where the newborn continues to adjust to life outside the womb. Routine care during this time is aimed at monitoring development, ensuring proper nutrition, preventing infections, and promoting family bonding.

📆 1. Schedule of Postnatal Visits (Recommended by WHO and National Guidelines)

Visit Number	Time
1st Visit	Within 24 hours of birth
2nd Visit	On Day 3 (72 hours)
3rd Visit	Between Days 7–14
4th Visit	At 6 weeks of age

🌼 2. Key Components of Routine Care (72 Hours – 6 Weeks)

✅ A. Feeding and Nutrition

Exclusive breastfeeding is essential.
- Feed every 2–3 hours (8–12 times/day).
- Ensure proper latch and positioning.
- Monitor signs of adequate feeding: content baby, good weight gain, 6–8 wet diapers/day.
Avoid prelacteal feeds, water, honey, or formula unless prescribed.
Burp the baby after each feed to prevent gas and vomiting.

✅ B. Growth Monitoring

Parameter	Expected Trends
Weight	Initial loss (up to 10%) is normal. Should regain birth weight by 10–14 days. Then, gain ~20–30g/day.
Length	Increases ~2.5–4 cm in first 6 weeks.
Head Circumference	Increases by ~1.5–2 cm in the first month.

Regular weight checks during visits help detect growth faltering early.

✅ C. Umbilical Cord Care

Usually falls off by 7–10 days.
Keep the stump clean and dry.
No need to apply antiseptics unless signs of infection.
Watch for redness, swelling, discharge, or foul smell.

✅ D. Bathing and Hygiene

Can bathe the baby once the cord has fallen off and dried.
Use lukewarm water and mild baby soap.
Clean eyes, ears, and diaper area daily.
Change diapers frequently to prevent diaper rash.

✅ E. Thermoregulation

Keep baby warm using appropriate clothing.
Avoid over-wrapping or overheating.
Continue kangaroo mother care if baby is preterm or low birth weight.

✅ F. Sleep and Environment

Newborns sleep ~16–18 hours/day in short intervals.
Place the baby on their back to sleep to prevent Sudden Infant Death Syndrome (SIDS).
Keep the crib clean, with a firm mattress and no pillows or soft toys.

✅ G. Immunization

At birth:

BCG
OPV-0
Hepatitis B (1st dose)

At 6 weeks (as per National Immunization Schedule):

Pentavalent-1 (DPT + Hep B + Hib)
OPV-1
PCV-1 (Pneumococcal)
RVV-1 (Rotavirus)
IPV-1 (Inactivated polio, if available)

Ensure timely vaccination and educate parents about vaccine schedules and common side effects.

✅ H. Developmental Surveillance and Stimulation

Respond to baby’s cues (crying, cooing, facial expressions).
Talk to, sing, and cuddle the baby.
Allow tummy time for short periods to strengthen neck and muscles (always under supervision).
Monitor for:
- Eye contact by 4–6 weeks.
- Smiling in response to caregiver.
- Sucking, grasping, and movement reflexes.

✅ I. Screening and Follow-up Tests

Newborn Metabolic Screening (if not done before 72 hours): For thyroid, PKU, G6PD, etc.
Hearing Screening: Before 1 month.
CCHD Screening: Using pulse oximetry if not done earlier.

✅ J. Common Minor Issues and Their Care

Condition	Routine Care
Cradle cap	Gentle washing and brushing
Milia	Small white spots; no treatment needed
Neonatal jaundice	Monitor; feed frequently; refer if worsening
Colic	Soothing, tummy massage, warm compresses
Hiccups or sneezing	Usually normal; no treatment required

⚠️ 3. Danger Signs – Refer Immediately

Poor feeding or refusal to feed
Lethargy or low activity
Convulsions
Fast or difficult breathing
Fever or hypothermia
Yellowing of eyes/skin before 24 hours or after day 7
Umbilical infection signs
Persistent vomiting or diarrhea
Bleeding from any site

👪 4. Parent and Family Support

Educate about:
- Breastfeeding techniques
- Danger signs
- Immunization schedule
- Hygiene and safe sleep practices
Encourage both parents to participate in newborn care.
Provide mental health support to mothers (monitor for postpartum depression).

🤱 Skin-to-Skin Contact of Newborn:

Skin-to-skin contact (SSC), also known as kangaroo mother care (especially for preterm or low birth weight babies), is the practice of placing a naked newborn (wearing only a diaper and cap) directly on the mother’s or father’s bare chest. This simple yet powerful practice promotes bonding, regulates the baby’s vital signs, and improves health outcomes.

🌟 1. What is Skin-to-Skin Contact?

It involves immediate and continuous placement of the newborn on the parent’s bare chest, ideally within the first few minutes to hours after birth, and continued regularly during the postnatal period.

🕐 2. When Should It Be Done?

Time	Details
Immediately after birth (within 1–5 minutes)	Initiated after drying the baby. Helps stabilize temperature, breathing, and heartbeat.
During the first hour (Golden Hour)	Supports breastfeeding initiation and bonding.
Postnatal period (up to 6 weeks and beyond)	Especially for preterm/LBW babies. Done regularly at home.

🧸 3. How to Perform Skin-to-Skin Contact

Mother or father removes clothing from chest.
Baby is naked except for diaper and cap.
Baby is placed upright between the breasts (or on chest).
Covered with a warm blanket or mother’s gown.
Maintain this position for at least 1 hour.
Can be done several times a day.

🌡️ 4. Benefits of Skin-to-Skin Contact

🔵 For the Baby:

Regulates body temperature (acts as natural warmer).
Stabilizes heart rate and breathing rate.
Maintains blood sugar levels.
Reduces crying and stress.
Promotes exclusive breastfeeding and better latch.
Enhances brain development and immunity.
Reduces risk of infections, hypothermia, and SIDS.
Supports healthy weight gain and sleep cycles.

🟢 For the Mother:

Promotes bonding and attachment.
Stimulates oxytocin release, aiding in milk letdown and uterine contraction.
Boosts breastfeeding success.
Reduces postpartum depression and anxiety.

🟠 For the Father:

Enhances emotional bonding.
Gives confidence in caring for the baby.
Supports shared parenting.

🩺 5. Especially Recommended For:

All term babies, immediately after birth.
Low birth weight (LBW) or preterm babies who are stable.
Babies born via cesarean section, after mother is stable.
During illness recovery, in both baby and mother.

⚠️ 6. When to Delay or Avoid Skin-to-Skin Contact

In case of medical emergencies in mother or baby.
If the baby has severe respiratory distress or needs resuscitation.
If the mother is unconscious, under general anesthesia, or unwell.

In such cases, skin-to-skin can be provided by the father or another family member until the mother recovers.

📌 7. WHO & UNICEF Recommendations

Initiate skin-to-skin contact immediately after birth and continue for at least 1 hour.
Encourage Kangaroo Mother Care (KMC) for preterm and LBW babies.
Promote continued SSC at home as part of daily care.

🌡️ Thermoregulation in Newborns:

Thermoregulation is the ability of a newborn to maintain a stable body temperature despite environmental changes. It is a critical physiological function immediately after birth, as newborns are particularly vulnerable to heat loss and cannot regulate temperature as effectively as adults.

🧠 1. Why Is Thermoregulation Important in Newborns?

Maintains normal metabolic function.
Prevents cold stress, which can lead to hypoglycemia, respiratory distress, acidosis, and even death.
Ensures optimal growth, oxygenation, and immunity.
Supports brain development and energy balance.

📏 2. Normal Body Temperature in Newborns

Site	Normal Range
Axillary (underarm)	36.5°C – 37.5°C
Below 36.5°C	Hypothermia
Above 37.5°C	Hyperthermia (fever)

❄️🔥 3. Why Newborns Are Prone to Heat Loss

Large surface area relative to body weight
Thin skin and low subcutaneous fat
Poor shivering ability
Immature hypothalamic thermoregulatory center
Exposure to cold delivery rooms, wet surfaces, and inadequate clothing

🧊 4. Mechanisms of Heat Loss in Newborns

Mode	Explanation	Example
Evaporation	Loss of heat when moisture on skin evaporates	Wet baby after birth
Conduction	Direct transfer of heat to colder surface	Placing baby on cold tray
Convection	Loss to surrounding air	Fan or AC blowing air on baby
Radiation	Loss to nearby cold objects	Cold walls, windows near the crib

🔥 5. Mechanisms of Heat Production

Since babies can’t shiver well, they generate heat mainly by:

✅ Non-shivering Thermogenesis:

Utilizes brown adipose tissue (BAT) located around the neck, back, kidneys, and armpits.
Releases energy as heat to warm the blood.

Preterm and LBW babies have less brown fat, making them more prone to hypothermia.

🧺 6. Methods to Maintain Thermoregulation in Newborns

🟡 A. Immediately After Birth

Dry the baby thoroughly with a warm towel.
Remove wet linen and cover with warm blanket.
Start skin-to-skin contact (Kangaroo care).
Ensure warm delivery room (25–28°C).

🟢 B. Ongoing in Hospital or Home

Use warm, dry clothing and caps.
Avoid exposing baby during examinations or bathing.
Room temperature should be comfortably warm.
Use radiant warmers or incubators if necessary.
Cover the head: Babies lose most heat through the head.

🔵 C. Special Measures for Preterm or LBW Babies

Continuous Kangaroo Mother Care (KMC).
Warm room or thermal mattress.
Delay bathing (until 24–48 hrs).
Use plastic wrap or thermal caps in NICU settings.

📉 7. Signs of Hypothermia in Newborn

Temperature	Severity	Signs
36.0–36.4°C	Mild	Cold skin, acrocyanosis
32.0–35.9°C	Moderate	Lethargy, poor feeding, weak cry
<32°C	Severe	Apnea, bradycardia, shock, unconsciousness

💊 8. Management of Hypothermia

Mild: Rewarm with skin-to-skin contact, warm room.
Moderate–Severe:
- Place under radiant warmer or in incubator.
- Monitor vital signs, blood glucose.
- Treat underlying causes (e.g., infection).

🔁 9. Thermoneutral Zone

The thermoneutral zone is the range of ambient temperature in which a baby can maintain normal body temperature without using extra oxygen or energy.

Neonate Type	Temperature Range
Term baby	32–34°C (ambient)
Preterm baby	34–36°C (ambient)

🌬️ Mechanism of Heat Loss in Newborns:

Newborns, especially preterm and low birth weight babies, are highly vulnerable to heat loss. Immediately after birth, they face a sudden drop in environmental temperature, which can lead to hypothermia if not managed. Understanding the mechanisms of heat loss is crucial to prevent cold stress and related complications.

❄️ Four Main Mechanisms of Heat Loss

Mechanism	Definition	Example	Prevention
1. Evaporation	Loss of heat as water on the skin evaporates	Baby wet after birth or bath loses heat as the moisture evaporates	Dry the baby immediately with a warm towel after birth or bathing
2. Conduction	Direct loss of heat when baby comes in contact with a cold surface	Placing baby on a cold weighing scale or cold bed	Use warm blankets and pre-warmed surfaces
3. Convection	Loss of heat to cool air or breeze moving over the baby	Fan or open window causes cool air to move across the baby’s skin	Keep the baby covered and the room free from drafts or fans
4. Radiation	Loss of heat to cooler objects not in direct contact, but nearby	Baby placed near cold wall, window, or metal object	Keep baby away from cold walls/windows and use incubators if needed

🧠 Why Are Newborns More Prone to Heat Loss?

Large surface area compared to body weight
Thin skin and limited subcutaneous fat
Poor ability to generate heat through shivering
Immature temperature regulation in the hypothalamus
Less brown fat in preterm or sick babies (used for non-shivering thermogenesis)

🧺 Simple Measures to Prevent Heat Loss

Dry and wrap baby immediately after birth
Skin-to-skin contact (Kangaroo care)
Keep baby warm and clothed, including cap and socks
Ensure warm environment (room temperature 25–28°C)
Delay bathing until 24–48 hours after birth

🦠 Infection Prevention in Newborns:

Newborns are highly susceptible to infections due to their immature immune system. Infections during the neonatal period (first 28 days of life) can lead to serious illness, complications, or death if not prevented or treated early. Therefore, infection prevention is a critical part of newborn care.

👶 1. Why Are Newborns at High Risk of Infection?

Immature immune system
Thin, delicate skin and mucous membranes
Exposure to unclean environments or instruments
Birth-related exposures (e.g., through birth canal)
Close contact with infected caregivers
Poor hygiene practices

🛡️ 2. Key Principles of Infection Prevention in Newborns

✅ A. Clean Birth Practices (“Five Cleans”)

Clean hands of birth attendant
Clean surface for delivery
Clean cord-cutting instrument
Clean cord tie
Clean cloth to dry and wrap baby

✅ B. Umbilical Cord Care

Keep cord stump clean and dry
Do not apply powder, oil, ash, or antiseptics
Fold diaper below stump to avoid contamination
Watch for signs of infection: redness, swelling, pus, foul smell

✅ C. Hand Hygiene

Anyone handling the baby must wash hands with soap and water or use hand sanitizer
Especially before feeding, diapering, and cord care

✅ D. Exclusive Breastfeeding

Breast milk provides natural antibodies (IgA) that protect against infections
Avoid bottle feeding or prelacteal feeds
Ensure clean nipples and breastfeeding practices

✅ E. Avoiding Crowds and Sick Visitors

Limit visitors in the newborn period
Keep baby away from people with cold, cough, or infections
Ensure siblings or caregivers are clean and healthy

✅ F. Immunization

Vaccine	Given at Birth
BCG	Prevents tuberculosis
OPV-0	Oral polio vaccine
Hepatitis B (1st dose)	Prevents vertical transmission from mother

Continue vaccines as per the national schedule

✅ G. Proper Bathing and Diaper Hygiene

Bathe only after cord falls off
Use clean, warm water and mild baby soap
Clean diaper area thoroughly and change frequently
Prevent diaper rash and skin infections

✅ H. Clean Clothing and Bedding

Use washed, soft, and clean clothes
Avoid tight clothing that may cause rashes or injuries
Wash baby items separately and dry in sun

✅ I. Safe Handling of Baby

Support the baby’s head and neck properly
Don’t kiss newborn on the face or hands (to avoid germ transfer)
Clean pacifiers, spoons, etc. if used (preferably avoid them)

⚠️ 3. Early Signs of Infection in Newborn

Watch for the following danger signs and refer immediately:

Signs	Possible Indication
Poor feeding or refusal to feed	Sepsis, lethargy
Fever (>37.5°C) or Hypothermia (<36.5°C)	Infection
Fast or difficult breathing	Pneumonia
Umbilical redness, swelling, or pus	Umbilical infection
Skin boils, rashes, or pus	Localized bacterial infection
Lethargy, weak cry, irritability	CNS involvement or sepsis
Vomiting, diarrhea	GI infection
Convulsions	Severe systemic infection

🏥 4. Hospital/NICU Infection Prevention (For Healthcare Settings)

Sterile delivery and resuscitation equipment
Strict aseptic technique in procedures
Handwashing stations and PPE for staff
Regular cleaning of NICU surfaces and instruments
Avoid overcrowding in newborn units

💉 Immunization: Full Detailed Overview (with Focus on Newborns and Infants)

Immunization is the process of administering vaccines to protect individuals—especially children—from infectious diseases by stimulating their immune system to develop resistance (immunity). Vaccination is one of the most cost-effective public health interventions that prevents illness, disability, and death.

🌼 1. What is Immunization?

It involves giving vaccines (biological preparations) that stimulate the body’s immune system to recognize and fight pathogens like bacteria and viruses.
Some vaccines provide lifelong immunity (e.g., measles), while others require booster doses.

👶 2. Importance of Immunization in Newborns and Infants

Newborns are highly vulnerable to infections due to immature immunity.
Maternal antibodies offer only temporary and partial protection.
Vaccination helps:
- Prevent life-threatening diseases (e.g., TB, polio, hepatitis B).
- Build herd immunity in the community.
- Reduce infant and child mortality.
- Prevent long-term disabilities.

📅 3. National Immunization Schedule (India)

This schedule is recommended by the Government of India under the Universal Immunization Programme (UIP) and includes free vaccines for all eligible children.

🍼 At Birth

Vaccine	Route	Site	Purpose
BCG (0.05 mL)	Intradermal	Left upper arm	Prevents tuberculosis
OPV-0 (2 drops)	Oral	Mouth	Prevents polio
Hepatitis B-1 (0.5 mL)	Intramuscular	Anterolateral thigh	Prevents hepatitis B

📅 At 6 Weeks

Vaccine	Purpose
Pentavalent-1 (DPT + Hep B + Hib)
OPV-1
IPV-1 (if available)
PCV-1 (Pneumococcal)
RVV-1 (Rotavirus)

📅 At 10 Weeks

Vaccine	Purpose
Pentavalent-2
OPV-2
RVV-2

📅 At 14 Weeks

Vaccine	Purpose
Pentavalent-3
OPV-3
IPV-2
PCV-2
RVV-3

📅 At 9 Months

Vaccine	Purpose
Measles-Rubella (MR-1)
JE-1 (in endemic areas)
PCV Booster (in some areas)
Vitamin A (1st dose)

📅 At 16–24 Months

Vaccine	Purpose
DPT Booster-1
OPV Booster
MR-2
JE-2 (in endemic areas)
Vitamin A (2nd–9th doses every 6 months)

📅 At 5–6 Years

Vaccine	Purpose
DPT Booster-2

📅 At 10 & 16 Years

Vaccine	Purpose
Tetanus and diphtheria (Td)**	School-age booster

🔄 4. Types of Vaccines

Type	Examples
Live attenuated vaccines	BCG, OPV, Measles
Inactivated vaccines	IPV, Hepatitis B
Toxoids (inactivated toxins)	Tetanus, Diphtheria
Conjugate vaccines	Hib, PCV
Subunit vaccines	Hepatitis B

🧪 5. Adverse Events Following Immunization (AEFI)

Common Reactions	Management
Fever	Paracetamol, tepid sponging
Pain/swelling at site	Cold compress, analgesic
Mild rash (after measles)	Self-limiting
Anaphylaxis (rare)	Immediate emergency care

All vaccine reactions should be documented and reported under the AEFI surveillance system.

⚠️ 6. Contraindications to Vaccination

Severe allergic reaction (anaphylaxis) to a previous dose
Severe illness or high fever (delay, not avoid)
Immunosuppressed children (avoid live vaccines)

🏥 7. Cold Chain and Vaccine Storage

Vaccines must be stored at 2–8°C to maintain potency. Common equipment:

Ice-lined refrigerators
Cold boxes
Vaccine carriers

Cold chain maintenance is essential for vaccine effectiveness.

✅ 8. Role of Nurses and Health Workers in Immunization

Educate parents on vaccine importance and schedules
Screen child for eligibility and contraindications
Maintain safe injection practices
Observe and manage AEFI
Record-keeping and follow-up for next doses
Support public immunization drives and pulse polio campaigns

📌 9. Key Messages for Parents

Carry the Mother-Child Protection (MCP) card to every visit
Do not skip or delay any vaccine dose
Mild fever or cold is not a reason to delay vaccination
Report any unusual symptoms after vaccination

🧸 Minor Disorders of Newborn and Their Management:

During the early neonatal period (first 28 days of life), many newborns exhibit minor, self-limiting conditions that may look alarming to new parents but are generally harmless. These are part of the baby’s normal physiological adaptation to life outside the womb.

Here is a detailed list of common minor disorders in newborns along with their causes, signs, and management.

📋 1. Neonatal Jaundice (Physiological Jaundice)

🔹 Cause:

Immature liver cannot efficiently process bilirubin.
Common after 2–3 days of life, peaks at day 4–5, resolves by day 10.

🔹 Signs:

Yellowing of skin, eyes, and mucous membranes.

🔹 Management:

Frequent breastfeeding to promote bilirubin excretion.
Expose baby to indirect sunlight for short periods.
Monitor bilirubin levels.
Phototherapy if levels are high or if it appears <24 hours after birth (may indicate pathology).

📋 2. Milia

🔹 Cause:

Blocked sebaceous glands.

🔹 Signs:

Tiny white/yellow spots on nose, chin, or cheeks.

🔹 Management:

No treatment needed.
Do not squeeze or apply creams.
Disappears on its own in 1–2 weeks.

📋 3. Neonatal Acne (Baby Acne)

🔹 Cause:

Maternal hormones affecting baby’s oil glands.

🔹 Signs:

Red pimples on baby’s face, usually between 2–6 weeks of age.

🔹 Management:

Keep skin clean and dry.
Avoid using oils or lotions.
No medications needed; resolves naturally.

📋 4. Epstein Pearls

🔹 Cause:

Retention cysts in the gums or roof of the mouth.

🔹 Signs:

Small, white nodules inside the mouth.

🔹 Management:

No treatment needed.
Resolves spontaneously in a few weeks.

📋 5. Cradle Cap (Seborrheic Dermatitis)

🔹 Cause:

Hormonal changes affecting oil production in the scalp.

🔹 Signs:

Greasy, yellowish scales or crusts on the scalp.

🔹 Management:

Apply baby oil, wait 10–15 minutes, then gently brush.
Wash with mild baby shampoo.
Usually clears in weeks or months.

📋 6. Umbilical Cord Stump Issues

🔹 Normal:

Cord dries, turns black, and falls off in 7–10 days.

🔹 Minor Issue:

Mild bleeding or oozing after cord falls.

🔹 Management:

Keep clean and dry.
Fold diaper below cord to keep area exposed.
No antiseptics unless signs of infection.

⚠️ Refer if redness, pus, foul smell, or delayed stump fall (>3 weeks).

📋 7. Breast Engorgement in Newborns

🔹 Cause:

Maternal hormones passed during pregnancy.

🔹 Signs:

Swelling and sometimes a milky discharge from the baby’s breasts (both genders).

🔹 Management:

Do not squeeze or massage.
Leave it alone; resolves in 1–2 weeks.

📋 8. Vaginal Discharge or Pseudo-menstruation (in Female Babies)

🔹 Cause:

Withdrawal of maternal estrogen after birth.

🔹 Signs:

White or blood-stained vaginal discharge.

🔹 Management:

No treatment needed.
Keep the area clean and dry.
Resolves in a few days.

📋 9. Hiccups

🔹 Cause:

Normal immature diaphragm activity.

🔹 Signs:

Sudden, repeated hiccup sounds.

🔹 Management:

No treatment needed.
Feed baby calmly and burp after feeding.
Disappears over time.

📋 10. Sneezing or Nasal Congestion

🔹 Cause:

Normal response to clear nasal passages or environmental irritants.

🔹 Signs:

Sneezing occasionally, mild nasal stuffiness.

🔹 Management:

Use saline nasal drops if needed.
Keep the room dust- and smoke-free.
Ensure baby is feeding well and not in distress.

📋 11. Diaper Rash

🔹 Cause:

Prolonged exposure to wet or soiled diapers.

🔹 Signs:

Red, irritated skin in diaper area.

🔹 Management:

Change diapers frequently.
Wash with warm water; avoid harsh wipes.
Use zinc oxide-based diaper cream.
Expose area to air (diaper-free time).

📋 12. Regurgitation / Spitting Up

🔹 Cause:

Immature lower esophageal sphincter.

🔹 Signs:

Small amount of milk spit up after feeding.

🔹 Management:

Burp baby after every feed.
Keep baby upright for 20–30 mins post feeding.
Feed smaller amounts more frequently.

⚠️ Refer if projectile vomiting, green vomit, or poor weight gain.

Published March 28, 2025By mynursingapp

Categorized as BSC SEM 6 MIDWIFERY / OBSTETRIC AND GYNECOLOGY NURSING- I, Uncategorised

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