CASE PROBLEMS
CASE 1
An infant is delivered by spontaneous vertex delivery at term. Immediately after birth the cord is clamped and cut and the infant is dried. The infant cries well and appears normal. The infant has a lot of vernix and a blue mark is noticed over the lower back. The infant passes urine after delivery but does not pass urine again for 24 hours.
- When should the infant be given to the mother?
As soon as the infant is dried, the cord cut, the Apgar score determined and a brief examination indicates that the infant is a normal, healthy term infant. The father should also be present to share this exciting moment.
- What is the blue mark over the infant's back?
A "mongolian spot", which is normal. It is important to explain to the mother that it is not a bruise. It disappears over a few years.
- Should the vernix be washed off immediately after delivery?
Infants should not be bathed straight after delivery, as they often get cold, while vernix should not be removed as it helps protect the infant's skin from infection. It would be better to bath the infant the following day, in the mother's presence, when most of the vernix will have cleared.
- Should the infant stay with the mother after delivery?
Yes, if possible the mother and her infant should not be separated after delivery.
- Does it matter if the infant only passes urine once in the first 24 hours?
No. During the first few days a normal infant often does not pass urine frequently. However, after day 5, an infant should have at least 6 wet nappies a day.
CASE 2
Starch powder is sprinkled onto the umbilical cord of a newborn infant twice a day to hasten drying. The cord is then covered with a linen binder. The mother is worried that the infant has enlarged breasts. As the ward is cold at night, she puts the infant into her bed.
- What do you think of the method of cord care in this infant?
The cord should be dried with surgical spirits and not covered with starch powder. Covering the umbilical cord with a binder is incorrect as it prevents the cord drying out.
- What treatment is needed for the infant's enlarged breasts?
No treatment is needed and the mother must not squeeze the breasts. The mother must be reassured that breast enlargement resolves spontaneously in a few months.
- What would you advise the mother about sleeping with her infant?
If the ward is cold and there is no simple way of keeping the infant warm, then the infant should sleep with the mother. It is important that infants do not get cold. Kangaroo mother care is a very effective method of keeping the infant warm.
CASE 3
A normal infant weighs 3000 g at birth. By day 4 the infant appears well but the weight has dropped to 2850 and it is suggested that formula be started. The next day the mother has painful, engorged breasts. The policy in the hospital is to keep all normal infants in the nursery where the mothers can visit at feeding time.
- Is the weight loss of 150 g normal for this infant?
Yes. An infant may normally lose up to 10% of the birth weight in the first 5 days after delivery.
- Should formula feeds be started?
No. Within a day or two the mother should have enough milk and the infant will start to gain weight.
- How should the mother's engorged breasts be managed?
Stop formula feeds and allow the infant to breast feed frequently.
- What do you think of normal infants being kept in the nursery?
Normal infants should room-in with their mothers.
CASE 4
A well newborn infant is given clear feeds of 5% dextrose for the first day. As the mother is tired after the delivery, the infant is immediately sent to the nursery. On day 3 the mother is advised to bottle feed as her milk appears to be too weak. She is a poor women who plans to return to a rural district. It is suggested that the infant start solids at 1 month.
- Should clear feeds be used in a healthy newborn infant?
No. Feeds should be started with breast milk or full strength formula.
- Why should the infant not be sent immediately to the nursery?
It is important for the mother to hold her infant after the delivery. This promotes breast feeding and bonding. It is best if mother and infant be kept together.
- Why is it incorrect to advise formula feeds if the breast milk appears to be weak?
Both foremilk and colostrum often appear weak. This is normal and never an indication for formula feeds.
- What are the dangers of a poor rural woman giving bottle feeds?
She may not be able to clean the bottle and teat correctly. Cup feeds would be safer if formula is used as a cup is easier to clean. This mother should be encouraged to breast feed.
- Why is it important that this woman breast feed her infant?
She will not be able to buy formula as she is poor and probably does not live close to a shop. As a result the infant is at high risk of gastroenteritis and malnutrition. These problems can usually be prevented by breast feeding.
- When should the infant be given solids?
This mother should breast feed for as long as possible. It would probably be best if solids were only started at 6 months
