Ica presentation On postnatal care

Group members

Ashima Binti Ali (115123F)

Tengku Nurul Shahila ( 113308J)

Nurhakim Saine (111224E)

Sim Yan Xing (113430P)

Wang Ker (110193X)

INTRODUCTORY PAGE CONTENT PAGE CASE STUDY- 35YRS OLD, MRS AMY LEE NORMAL VAGINAL DELIVERY EPISIOTOMY SUBCUTICULAR SUTURES COMPLICATION POST NATAL UNIT AIMS OF POSTNATAL CARE POST DELIVERY ASSESSMENT ALL ABOUT BREASTFEEDING POTENTIAL COMPLICATIONS HOME CARE CARE OF EPISIOTOMY WOUND MAINTAINING HEALTHY BODY & MIND CONTINUITY OF EFFECTIVE BREASTFEEDING CARE OF NEWBORN

Mrs. Amy Lee 35 years Deliver full-term male infant Normal vaginal delivery Had an episiotomy repaired with subcuticular sutures. Estimated blood loss was 200mls. She and her baby have just been transferred to your postnatal ward. Informs that she wants

Lets watch a video on Normal Vaginal Delivery

Shahila

refers to the intentional incision of the vaginal opening to hasten delivery or to avoid or decrease potential tearing. is the most common procedure performed in modern day obstetrics reported benefits included preservation of the integrity of the pelvic floor and prevention of uterine prolapse and other vaginal trauma

Evidence of maternal or fetal distress (i.e. no time to allow perineum to stretch). The baby is premature or in breech position, and his/her head could be damaged by a tight perineum. The baby is too large to be delivered without causing extensive tearing. The delivery is being assisted by forceps or a vacuum extractor The mother is too tired or unable to push Existing trauma to the perineum Twin or multiple deliveries

Subcuticular sutures
Subcuticular suture is a method of skin closure involving placement of stitches in the subcuticular tissues parallel with the line of the wound.

Subcuticular suturing
Subcuticular suturing is a very useful and neat way of closing the skin. The suture runs continuously just under the cutis of the skin where the strength is. The epidermis, where regeneration of skin cells occurs, is not damaged by subcuticular sutures. This avoids the cross hatching scars of full thickness skin stitches.

POST NATAL UNIT

Aims of postnatal care

To check the mother returns to her pre pregnant state
To monitor and ensure healthy development of the baby. Help the mother (and family) to adapt and successfully fulfill the role and responsibilities of motherhood. To give the mother sufficient rest and support after the physical exertion of the labour itself.

Provide consistency of advice and support for recovery from pregnancy and the birth

Nursing Care
Directed by a knowledge of the stages of the puerperium Monitoring safety Intensive discharge planning Repetitive anticipatory guidance Increasing self care and self confidence Increasing independence with baby care Closing knowledge deficits Group Classes Nurses lead group classes on postpartum units Baby care Breastfeeding Group classes are not a substitute for individualized care planning

Post Delivery Assessment

Postpartum Check
Vital signs Fundus Bladder Bowel Lochia Perineum

Ashima

Vital Signs
Blood pressure Blood pressure is altered slightly but will either decrease if high and increase if low Temperature During first 24 hours may increase to 38 degree as a result off dehydrating of labor. After 24 hours , the women should be afebrile . Pulse Remains elevated for the first hour or so after birth . it then begins to decrease at an unknown rate. By 8 to 10 weeks after childbirth , the pulse has returned to a non-pregnant rate Respiration The respiration rate should decrease to with the

Inspect & Palpate The Breasts

Raise the head of the bed Ask the patient lower her gown so that her breasts can be examined Visually inspect and palpate each breast noting: Soft, filling or firm Engorged, reddened, or painful Nipples: Inverted , cracked, bleeding, bruised, presence of colostrum or breastmilk.

Palpate the Fundus

The fundus should be palpated until the 10th day postpartum. Since patients are usually discharged sooner, patients should be instructed in self-examination so that she can be alert to sudden changes in the uterus. Note: Fundal consistency and tone(Firm, Round, Smooth; Not Boggy) Fundal position in relationship to the midline. *Displacement to the left or right could be caused by a distended bladder. Fundal height measured in finger breadths from the umbilicus.

Palpate the Bladder

Assess for Bladder Distention: Uterine Atony UTI

Measure amount of urine voided

Bladder distention could displace the uterus Impeding involution Impeding the control of bleeding.

FIGURE 232

The uterus becomes displaced and dev iated to the right when the bladder is f ull.
2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 07458

Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Monitor Urinary Output

*Often times will be catheterized in LWD post delivery
Voiding pattern & amounts voided: Is it at least 30ml/hr? Pain: Is voiding painful, burning or itching? Distention: Is a distended bladder displacing the uterus? Recatheterize in 6 hours if not voided (Dr.)

Monitor Bowel Activity

Bowel movements: When was her last BM? Is she passing flatus? (gas) Hemorrhoids: Are there hemorrhoids present? Is there active bleeding Assessment for: Bowel Sounds & bloatedness Complaints of Gas Pains The need medication for gas pains, laxatives, stool softeners, enemas

Monitor Lochia
Detach the peripad from the front to the back to minimize the risk of contaminating the vagina with rectal discharge. Note: Type rubra (dark and red) 1-3 days -serosa (serous or brown)3-10 days -alba (white) 10-14 days Amount Estimate of Drainage Number of Pads Presence of odor could indicate

Episiotomy/Perineum
Instruct the client to assume a side-lying (Sims) position. Gently separate the buttocks & inspect the perineum for: Episiotomy, lacerations and hemorrhoids Bruising, hematoma, edema, discharge Intact Suture Line Signs of Infection

Patient Post Epidural

Assessment of Lower Extremities for: Sensation Movement The need of Bed rest / assistance

Emotional Status
Can have Mood Swings post delivery Observing Bonding Behavior & Ability to give Infant Care Willingness to cooperate

Clinical Assessment
Mrs Amy Lee
Vital Signs
Temperature: 37.3 (Normal) HR: 99 (Normal) RR: 19 (Normal) BP: 110/65 mmhg

UTERUS: Well contracted, midline at umbilicus LOCHIA: Normal ,moderate amount of lochia, nil presence
of odor & clots

EPISIOTOMY: Sutures intact, Slight edematous BLADDER: Not distended,Catherized in LWD (350mls Clear
Urine) BOWEL: Nil, bowel sounds present THROMBOPHLEBITIS: Nil seen POST EPIDURAL: Sensations present, ambulate

AAP Breastfeeding Recommendations

exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first six months of life Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child.

WHO Breastfeeding Recommendations

exclusive breastfeeding for six months is

the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to two years of age or beyond.

Breast Milk
Has a unique smell which enhances bonding between mum & baby and a taste that varies with mums diet (unlike formula milk). Contain easily absorbable fat such as omega fatty acids, which enhance babys brain & eye development. Meet the energy needs of the baby compared to formula milk. Is more digestible& easily absorbed. Contain antibodies It is always fresh and at just

Yan xing

Types and Composition of Human Breast Milk

Types of Breast Milk:
Colostrum or Early Milk Transitional Milk Mature Milk

Colostrum or Early Milk is produced in the late stage of pregnancy till 4 days after delivery and is rich in antibodies. Transitional Milk is produced from day 4 10 is lower in protein in comparison to Colostrum. Mature milk is produced from approximately ten days after delivery up until the termination of the breastfeeding.

Benefits of Breastfeeding
BABY Creates a special bond between mum & baby. Helps in Gastrointestinal development & function Helps in cognitive & immune system development Reduced risk of infections eg otitis media, Lower respiratory tract infection, Diarrheal MUMMY

Early suckling helps womb contract , reducing blood loss after childbirth. Aids involution of the uterus. Long term breastfeeding helps in loss of the excess weight acquired during pregnancy. It lower the risks

Let us proceed to share the various positioning for breastfeeding

Wang ke

Cradle hold

Cross-cradle Hold

Lying Down

Football

is not usually the best position for the first days of nursing

common position used by mothers

Infants head is supported in the elbow, the back and buttock is supported by the arm and lifted to the breast

Ideal for early breastfeedin g

The other hand is placed beneath the breast in a Ushaped to guide the baby's mouth to your breast

Mother holds the baby crosswise in the crook of the arm opposite the breast the infant is to be fed

The baby's trunk and head are supported with the

Good position after operative procedures

The infants is placed under the arm, like holding a football

Babys body is supported with the forearm and the head is supported with

Many mothers are not comfort able with this position

Good position after Caesare an section.

The mother lies on her side propping up her head and shoulder with pillows.

Allows the new mother some rest.

The infant is also lying down facing the mother.

Most mothers are scared of crushing the baby

Ashima

Proper identification of the newborn

Image of baby when ready to latch on

Offering Your Breast to Baby

Fingers underneath, thumb on top of breast Fingers well behind areola Hold your breast like a C Hold

Rooting Reflex and Latch-On

Position baby correctly at breast with mouth directly in front of nipple Use nipple to tickle babys lips until mouth opens wide Support babys head

Babys mouth is open wide enough to take in nipple and most of areola

Open wide

Signs of good latch

Babys upper and lower lips flare out to form a good seal on the breast Babys chin is touching the breast and the nose is slightly away from the breast The areola is drawn into your babys mouth Babys check is round You may feel the initial tug on the nipple when baby suckles but you should not have nipple pain or discomfort You can observe your babys sucking rhythm to ensure good milk transfer. Suck > swallow > Breathe (pause) rhythm.

Coming Off The Breast

Watch baby for cues that he is finished
May spontaneously come off the breast May fall asleep Allow baby to determine when he is done Foremilk and hindmilk If you need to stop the feeding early, break suction by inserting finger into corner of babys mouth

LET US SHARE WITH YOU POST

PARTUM POTENTIAL COMPLICATIONS

Nurhakim

HEMORRHAGE
Most common cause of excessive bleeding during childbearing cycle. Loss of blood of more than 500 ml following uncomplicated vaginal birth First 24 hour is the most critical time. Early pp Hemorrhage -1st 24hour caused by uterine atony & laceration. Later pp Hemorrhage -from 24hour to 6weeks caused by retained placenta fragments& hematomas & subinvolution of uterus.

Common Causes
A. B. C. D. E. primigravida birth retained placenta uterine atony uterine rupture lacerations of the cervix

Risk Factors
Prolonged 3rd stage of labor Fibroids, placenta previa Previous PPH Overdistended uterus

HEMATOMAS
Vulvar hematoma is a localized collection of blood in the connective tissue beneath the skin covering the external genitalia or vaginal mucosa. It generally forms as a result of injury to the perineal blood vessels during the delivery process.

Causes of Hematomas Rapid, spontaneous delivery.

Perineal varicosities. Episiotomy repairs. Laceration of perineal tissues.

Signs and Symptoms

Severe, sharp perineal pain. Appearance of a tense, sensitive mass of varying size covered by discoloured skin. Swelling in the perineal wall. Often seen on the opposite side of the episiotomy. Inability to void due to pressure/ edema on or around the urethra. Complaint of fullness or pressure in the vagina.

Medical Treatment.
This is consists of analgesics given for discomfort, opening the hematoma so blood clots can be evacuated and the bleeders can be ligated, and packing for pressure.

Nursing Interventions.
Apply ice to area of hematoma. Observe for evidence of enlarged hematoma.

Wang Ke

Infections

 Uterus & Vagina open after vaginal delivery provide easy access to microorganism Therefore it increases the risks of : Reproductive System Infections Peurperal Infection Bacterial Infections of the Genital Tracts Sites other than genital tracts include : Mastitis UTI

MASTITIS
is inflammation of the breast tissue, usually unilateral after the milk flow is established. caused by streptococcal or staphylococcal invasion of the breast tissue through cracks or fissures around the nipple. may be obtained from the infant's nose or throat. The infant probably acquired it while in the nursery. Signs and Symptoms Erythema over the infected breast. Marked breast engorgement. Acute breast pain, tenderness. Fever and chills. Ancillary lymph gland enlargement

Medical Treatment

Antibiotic therapy and analgesic therapy. Periodic cultures of breast milk. Intravenous fluids. Possible I&D, if abscesses. Discontinued breast-feeding for a short time depending on antibiotic used and closeness of abscess site to nipple. Nursing Care

Apply ice or heat to painful, swollen breast depending on the stage of infection. Ice should be avoided if the mother plans to resume or continue breast-feeding. Encourage increased fluids. Inform mother to wear a support bra. Have the mother pump her breast until nursing resumes. Pumping the breast should be avoided if the mother plans to bottle-feed.

Yan Xing

Depression

Psychological problems

Postpartum Blues. Postpartum Depression. Postpartum Psychosis.

Feeling blue when your baby is brand-new

Having a baby can be both exhilarating and exhausting. It can bring much joy, but it can also challenge you in ways you never expected. Soon after giving birth, many women feel weepy and moody. You may be blessed with a beautiful baby

Postpartum Blues
Complicates 50% of deliveries Mild, transient, selflimited disorder. Mode swings, with change in appetite and sleep. Onset at 3rd or 4th day postdelivery. Often resolves within few

Risk Factors for PPB

Hormonal rebalancing after delivery History of depression or premenstrual mood changes Depressive symptoms during pregnancy Family history of depression Concern about child care Psychosocial impairment

Why?
After pregnancy, hormonal changes in a woman's body may trigger symptoms of depression. During pregnancy, the amount of two female hormones, estrogen and progesterone, in a woman's body increases greatly. In the first 24 hours after childbirth, the amount of these hormones rapidly drops back down to their normal nonpregnant levels. Researchers think the fast change in hormone levels may lead to depression, just as smaller changes in hormones can affect a woman's moods before she gets her menstrual period.

Other Contributing Factors

Feeling tired after delivery, broken sleep patterns, and not enough rest often keeps a new mother from regaining her full strength for weeks. Feeling overwhelmed with a new, or another, baby to take care of and doubting your ability to be a good mother. Feeling stress from changes in work and home routines. Sometimes, women think they have to be "super mom" or perfect, which is not realistic and can add stress. Having feelings of loss loss of identity of who you are, or were,

Symptoms:
Sadness, anxiety, irritability
Uncontrollable tearfulness Wide mood swings

Decreased concentration
Insomnia constant worry about minor problems

Occasional negative thoughts

Primary Treatment:
Supportive care and reassurance about the condition

Touch is an essential part of bonding even when there are complications

Your baby will be the most miraculous thing you

G U I D A N C E

HOMECARE

G U I D A N C E

Care Of Episiotomy Wound

Shahila

Avoid touching the open wound. Cleaning the area at least twice a day, with local dilute antiseptic solution like Chlorhexidine or Dettol Remember, always wash from front to back, never the other are to prevent infection. While youway, urinating, squirt lukewarm water with a peri-bottle. Take a warm sitz bath. Walking can be good exercise to increase blood flow and speed healing. Purchase a donut-shaped pillow to sit on after you give birth as is allows you to sit

Kegel exercises are very beneficial for strengthening the weakened muscles in this area .
Oral medications such as pain killer tablets (paraceptamol, ibuprofen, etc. ) should only be taken as advised by your doctor.

Most doctor use stitches, which dissolve on their own and / or fall off after a few days. Ask your doctor if you need to come back to show the stitches.

Ashima

A Healthy Mind

Getting organised
Planning to have additional support in the first few months can make the transition to motherhood less stressful. Try not to make major life changes like moving house or changing jobs late in pregnancy or in the first few months after you have your baby.

Getting support
Develop a support system of friends, family and/or health professionals, including parent groups, that give you the opportunity to share stories and experiences and meet new people who are in a similar situation.

Learning to manage stress

Keep a diary of feelings and every now and then take time to look through it and note any progress made. Doing breathing and muscle-relaxation exercises, as well as learning to let people know how youre feeling,

Staying healthy
Try to eat healthy meals, exercise regularly and avoid drugs and alcohol. Having a good night's sleep is also important for maintaining good health, but can be almost impossible with a new baby. Taking every available opportunity to nap can not only help you stay physically fit, but also mentally healthy. Do this when the baby is Taking when partners, asleep ortime out family members and friends are able to time for Organise your routine so you get some look after the baby. yourself. Arrange for a . It can also be helpful to try to get the baby into look childcare service, friends or family members to a good sleeping pattern as after the children early as possible. occasionally.

Being good to yourself

It can take time to adjust to becoming a parent. Don't be too harsh on yourself. Acknowledge the many things you have achieved and are doing well. Don't just focus on the

Nurhakim

A HEALTHY BODY

Healthy Diet
Increase of Fluid Intake
Drinking sufficient amount of water, is the first rule of breastfeeding diet, therefore it is advised to drink lots of water. Keep a glass of water with you while feeding baby. Juices, milk are the recommended fluids.

Calories are Good

Calories are good for lactating mothers, and thus are an integral part of the diet for breastfeeding mothers. A lactating mother spends 500 calories per day, to produce milk for her child. Maintain a calorie intake of 2500, spread over 5 meals in a day. The body is continuously producing No Coffee-No Soda milk, which is why it needs a regular caloric intake.

Eat in Variety

Thinking from the baby's nutrition point of view, experiment with your food to get adequate diet. Have lots

In the diet during breastfeeding, a mother has to avoid caffeine contained

Alcohol and Tobacco: A Strict No

Alcohol passes in the breast milk in about less than an hour. Alcohol can retard baby's growth, and is best when avoided. Tobacco is harmful not only for the baby, but you as well. Tobacco reduces appetite and increases nicotine levels in the body. Nicotine passage through milk likely to cause respiratory ailments, fast heartbeat, restlessness and vomiting.

Iron and Folic Acid

Consuming foods high in iron and vitamin B9 is an essential part of the diet.Folic acid is vital nutrient for development of baby's nervous system. Eating a lot of spinach, corn, cabbage, fenugreek, asparagus, chickpeas and beet root will give you the daily dose of iron and folic acids.

Body Relaxations
Post Natal Massage
After giving birth the body craves nurturing touch to assist with the integration of this amazing transition into motherhood. Massage will ease away any aches and pains, melt away tension and tiredness. The stress from childbirth and time spent caring for your newborn is taxing on our body. Therefore post-natal massage not only gives nurturing and emotional support to help mothers gain back their lost energy, it also brings body back to its pre-pregnancy condition by retaining muscles and connective tissue.

 Post Natal Yoga

Yoga is nurturing and relaxing, and will support you during this transition. Post natal yoga is essential for the first six months following birth. Yoga will assist you to gradually regain physical strength and muscle tone. It will help with balancing energy, emotions and preserving vitality. A specially designed series of exercises and passive poses will aid recovery and help get you back to your pre-birth condition.

 Naturopathy
Herbs can be gentle and effective in supporting both mother and baby after birth. It is not always possible to have the time to recover fully from the physical stress of childbirth so herbs can aid in a rapid recovery. Some mothers may need help with sleep patterns, adequate lactation, emotional support or later on, a normal menstrual cycle . Herbs can be useful for babies with common ailments such as colic, skin rashes or poor sleep patterns.

Continuity of Breastfeeding

Shahila

Nursing
Let baby nurse as long as he wants Do not watch the clock, watch the infant Generally, 10-30 minutes, longer or shorter ok Active nursing from first breast Stimulate infant if sleepy When done, burp, check diaper and offer 2 nd He may or may not take 2nd Alternate the starting breast each feeding

Signs of Effective Breastfeeding

Weight loss less than seven percent of birth weight. Three or more bowel movements per day after day one. Seedy, yellow bowel movements by day five. At least six wet diapers per day by day four. Satisfied baby. Audible swallowing. No weight loss after day three ; gaining weight by day five. Back to birth weight by day 10.

Signs of Effective Breastfeeding

Noticeable increase in firmness, weight, and size of breast and noticeable increase in milk volume by day five. Nipples not damaged. Breast fullness relieved by breastfeeding. Refer to lactation consultant or other knowledgeable helper if neither baby nor mother shows signs of effective breastfeeding.

Engorgement

Wang ke

Occurs 2-5 days after delivery Lasts 24-48 hours Swelling of the breast by increase blood & lymph fluid as milk comes in

Prevention of Engorgement
Nurse frequently Correct latch Skin to skin contact No supplements Pump only for comfort Engorgement care plan

Various Ways Of Pumping

How to Store Breast Milk

Always wash hands with soap and hot water before expressing or handling breast milk. Use a clean storage bottles and caps. Fill bottles or milk storage bags. Leave space at the top for expansion of the liquid if freezing bottles. Fill bottles in the portion size needed for feedings. Tightly cap bottles or double bag milk storage bags to avoid spills.

Yan Xing

Date all bottles and bags. Store in properly working refrigerator or freezer. Do NOT store milk in the door of the refrigerator. If a refrigerator or freezer is not available, store milk in a cooler packed with ice or an ice gel pack until you get home. Use the milk with the oldest date first.

Ashima

Home Care Of Baby

Decoding The Tears

A crying baby is trying to tell you something. Your job is to figure out why your baby is crying and what if anything you can do about it. Consider what your baby could be thinking

 I'm hungry. Most newborns eat every few hours round-the-clock. Some babies become frantic when hunger strikes. I need to burp. During and after each feeding, take time to burp your baby. I'm wet. For some babies, a wet or soiled diaper is a sure way to trigger tears. I'm tired. Tired babies are often fussy .Newborns often sleep up to 16 hours a day. I'd rather be bundled. Some babies feel most secure in a swaddle wrap. I want to move. Sometimes a rocking session or walk through the house is enough to soothe a crying baby. I want to suck on something. Sucking is a natural reflex. For many babies, it's a comforting, soothing activity.

Every day care

1. Breastfeeding
Support exclusive breastfeeding on demand day and night Infant should have minimum of 3-4 bowel movements every 24 hours. Infant should have about 68 wet diapers in a 24 hour period Average daily weight gain of 15 -30g. Infant has regained birth weight by day 10 of life.

2. Ensuring warmth
Wrap in soft dry clean cloth, cover head with cap Keep the room warm; if room not warm cover baby with a blanket or use skinto-skin Keep room warm for baby During the day, dress or wrap baby At night, let baby sleep with mother

3. Cord care
Wash hands before and after cord care Keep the cord stump clean & dry Fold diaper below stump If the stump is soiled, wash with alcohol swabs or clean water and soap Cord stump usually dries and fall within 7 to 10 days Ask mother to visit health facility, if umbilicus is red or draining pus / blood or adjoining skin is red.

4. Hygiene
Wipe the face, neck, underarms DAILY Wipe the buttocks when soiled Give bath when necessary: Use lukewarm water for bathing Dry the baby thoroughly , dress & cover after bath Wash hands after disposing soiled items DO NOT put anything in babys eyes or ears

Early recognition and treatment

Not feeding well Less active than before Fast breathing (>60/ min) Moderate or severe chest in-drawing Grunting Convulsions

Floppy or stiff Temperature >37.50C or <35.50C Umbilicus draining pus or umbilical redness extending to skin. >10 skin pustules Bleeding from umbilical Stump

Assessment Of Jaundice
Jaundice is common in the first week of life and may be missed in dark skinned babies Blanch the tip of the nose or hold baby up and gently tip forward and backward to get the eyes to open. Teach mother to do the same at home in the first week and report to hospital if significant jaundice is observed.

Blanching the tip of the nose

Follow up visit
Assessment of growth & development Ensure immunization Early diagnosis and management of illness

Health education
Exclusive breastfeeding for 6 months Complementary feeds after 6 months

Spacing of family

Ensure immunization
Age
At birth 1 month 3 months 4 months 5 months 5-6 months

Vaccine
BCG Hepatitis B 1st dose Hepatitis B -2nd dose DPT/DT 1st dose Oral Sabin -2nd dose DPT/DT 2nd dose Oral Sabin 2nd dose DPT/DT 3rd dose Oral Sabin -3rd dose Hepatitis B 3rd dose

1-2 Years
18 months 6-7 years (Primary 1) 10-11 years (Primary 5)

MMR- Primary dose(1st dose) DTPT/DT 1st booster Oral Sabin 1st booster Oral Sabin 2nd booster MMR Booster(2nd dose)
DT-containing vaccine- 2nd booster
rd

Frader, D. and Cooper, M. (Eds.). (2009). Myles textbook for midwives (15th ed). Edinburgh: Churchill Livingstone. Murray, S.S. & Mckinney, E.S (2010). Foundation of maternal newborn nursing (5th ed). St. Louis : Elsevier Saunders. Chao, V.T.T.(1993) . Breastfeeding. The Journal of Singapore Paediatric Society 35 ( 1 & 2), 77-91 Lowdermilk, D. L. & Perry, S.E.(Eds.).(2012). Maternity & Womens Health Care (10th ed) St. Louis Mosby Towie , M. A. (2009). Maternal-newborn nursing care. New Jersey: Prentice Hall From http://www.youtube.com/watch?v=pHLgva3PLuk . http://www.nlm.nih.gov/medlineplus/ency/article/002920.htm (assessed on 20 December 2011) http://www.babycenter.com.sg/baby/health/immunisationchart/ (assessed on 20 December 2011) http://www.drugs.com/cg/episiotomy.html (assessed on 20 December 2011) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004481/ (27 December 2011)