The trajectories of physical growth in 4 months postnatal corrected age among preterm infants discharged from neonatal intensive care units and associated factors: A prospective study

Objectives Growth retardation is a risk for premature infants.In addition to demographic and perinatal factors,preterm infants’physical growth may be affected by neonatal intensive care unit(NICU)stress,maternal postpartum depression,and mother-infant interaction.This study aimed to investigate the trajectories of physical growth in 4 months corrected age among preterm infants discharged from the NICU and the impactors on these trajectories.Methods A prospective study was conducted among 318 preterm infants from September 2019 to April 2021 in Shanghai,China.Latent growth modeling was applied to identify the weight,length,and head circumference growth trajectories in 4 months corrected age and explore the effects of demographic and medical characteristics,infant stress during NICU stay,maternal postpartum depression,and mother-infant interaction on each trajectory.Results Unconditional latent growth models showed curve trajectories with increasingly slower growth in weight,length,and head circumference until 4 months of corrected age.Conditional latent growth models showed that a longer length of stay in the NICU and more skin punctures were negatively associated with weight at 40 weeks corrected gestational age(β=−0.43 and−0.19,respectively,P<0.05).The maternal postpartum depression between 40 weeks corrected gestational age and 1 month corrected postnatal age was associated with a lower growth rate of length(β=−0.17,P=0.040),while between 2 and 3 months corrected postnatal age,there were lower growth rates of weight and head circumference(β=−0.15 and−0.19,respectively,P<0.05).The mother-infant interaction scores between 40 weeks corrected gestational age and 1 month corrected postnatal age negatively predicted the growth rate of weight(β=−0.19,P=0.020).Conclusion The physical growth trajectories of preterm infants discharged from the NICU were influenced by infant stress during the NICU stay,maternal postpartum depression and mother-infant interaction.

Liquid Chromatography-tandem Mass Spectrometry for Analysis of Acylcarnitines in Dried Blood Specimens Collected at Autopsy from Neonatal Intensive Care Unit

Objective To investigate the feasibility of analyzing acylcarnitine in dry filter-paper blood spots by liquid chromatography-tandem mass spectrometry(LC-MS/MS) which could be applied to detect inborn errors of metabolism in neonates.Methods We obtained filter-paper blood from 26 dead infants from a neonatal intensive care unit(NICU) between October 1,2008 and September 30,2009.Acylcarnitine and amino acid profiles were obtained with LC-MS/MS.Four infants underwent routine autopsy.The postmortem blood specimens were compared with newborn blood specimens,and with specimens obtained from older infants with metabolic disorders.Results Of all the 26 patients,5(19.2%) were diagnosed as having different kinds of diseases:3 with methylmalonic acidemia(the concentration of C3,and the ratio of C3/C16,C3/C2 increased),1 with maple syrup urine disease(the concentration of leucine and isoleucine increased),and 1 with isovaleric aci-demia(the concentration of C5 increased).Conclusions Postmortem metabolic test can explain infant deaths and provide estimates of deaths attributable to inborn errors of metabolism in NICU.LC-MS/MS is suitable for analysis of postmortem specimens and can be considered for routine application in NICU autopsy.

Prevalence and Spectrum of Complex Congenital Heart Disease in the Neonatal Intensive Care Unit at High Altitude in China

Background:Previous studies from high altitudes have reported significantly higher prevalence of congenital heart disease(CHD),consisting almost solely of simple CHD.Little is known about the occurrence of complex CHD.Neonates with complex CHD are likely admitted to NICU.We examined the prevalence and spectrum of complex CHD in NICU in order to depict a truer picture of CHD at high altitude.Methods:We reviewed charts of 4,214 neonates admitted to NICU in Qinghai province(average altitude 3,000 m).Echocardiography was performed in 1,943 babies when CHD was suspected based on clinical examinations.Results:CHD was diagnosed in 1,093(56.3%of echoed babies).Mild CHD in 96.8%(1058 babies).Moderate CHD in 0.8%(9)included 1(0.1%)large secundum atrial septal defect,3(0.3%)moderate pulmonary stenosis,2(0.2%)aortic stenosis and 3(0.3%)partial anomalous pulmonary venous connection.Severe CHD in 2.4%(26)included 6(0.5%)complete atrioventricular septal defect,5(0.5%)complete transposition of the great arteries,5(0.5%)hypoplastic right heart,3(0.3%)hypoplastic left heart,3(0.3%)double outlet right ventricle,3(0.3%)tetralogy of Fallot,2(0.2%)truncus arteriosus,2(0.2%)total anomalous pulmonary venous connection,2(0.2%)severe aortic stenosis,2(0.2%)interrupted aortic arch and 2(0.2%)severe pulmonary stenosis and 1(0.1%)single-ventricle abnormality.At two-years follow-up in 737(67.4%)patients,18(90%)with severe CHD and 38(5.3%)with mild and moderate CHD died,and 15 underwent cardiac surgery with 1 early death.Conclusions:At high altitude,a wide spectrum of CHD exists,with many heretofore unreported complex CHD.There is urgent need for routine echocardiography and early interventions in newborns particularly in NICU.

Mothers’experiences of neonatal intensive care:A systematic review and implications for clinical practice

BACKGROUND Preterm birth is on the rise worldwide.Neonatal intensive care units(NICUs)have enabled many critically ill newborns to survive.When a premature baby is admitted to the NICU,the mother–infant relationship may be interrupted,affecting the mother's mental health.AIM To examine the maternal emotions associated with having a child in the NICU and provide suggestions for clinical practice.METHODS MEDLINE,CINAHL,PsychARTICLES,and PsychINFO were searched for relevant articles between 2005 to 2019,and six qualitative articles were chosen that explored the experiences of mothers who had a preterm infant in the NICU.The thematic analysis method was used to identify the most common themes.RESULTS Four main themes of the experience of mothers who had a preterm infant in the NICU were identified:Negative emotional impacts on the mother,support,barriers to parenting,and establishment of a loving relationship.CONCLUSION NICU environment is not conducive to mother-child bonding,but we stipulate steps that health care professionals can take to reduce the negative emotional toll on mothers of NICU babies.

Use of antenatal corticosteroids among infants with gestational age at 24 to 31 weeks in 57 neonatal intensive care units of China: a cross-sectional study

Background:Antenatal corticosteroids(ACS)can significantly improve the outcomes of preterm infants.This study aimed to describe the ACS use rates among preterm infants admitted to Chinese neonatal intensive care units(NICU)and to explore perinatal factors associated with ACS use,using the largest contemporary cohort of very preterm infants in China.Methods:This cross-sectional study enrolled all infants born at 24^(+0)to 31^(+6)weeks and admitted to 57 NICUs of the Chinese Neonatal Network from January 1st,2019 to December 30th,2019.The ACS administration was defined as at least one dose of dexamethasone and betamethasone given before delivery.Multiple logistic regressions were applied to determine the association between perinatal factors and ACS usage.Results:A total of 7828 infants were enrolled,among which 6103(78.0%)infants received ACS.ACS use rates increased with increasing gestational age(GA),from 177/259(68.3%)at 24 to 25 weeks’gestation to 3120/3960(78.8%)at 30 to 31 weeks’gestation.Among infants exposed to ACS,2999 of 6103(49.1%)infants received a single complete course,and 33.4%(2039/6103)infants received a partial course.ACS use rates varied from 30.2%to 100%among different hospitals.Multivariate regression showed that increasing GA,born in hospital(inborn),increasing maternal age,maternal hypertension and premature rupture of membranes were associated with higher likelihood to receive ACS.Conclusions:The use rate of ACS remained low for infants at 24 to 31 weeks’gestation admitted to Chinese NICUs,with fewer infants receiving a complete course.The use rates varied significantly among different hospitals.Efforts are urgently needed to propose improvement measures and thus improve the usage of ACS.

Categorization and Frequency of Indications for Packed Cell Transfusion in the Preterm Newborn during the Initial Hospital Stay at a Tertiary Care Hospital: A Cross-Sectional Study

Introduction: Packed cell transfusion is a lifesaving procedure in premature babies as they have more complications as compared to babies who are born at term. Complications related to prematurity increase as gestational age decreases and anemia is one of the complications of prematurity which needs packed cell transfusions. To date, when to transfuse preterm babies and what would be the threshold for hemoglobin and hematocrit is still a point of argument as well as liberal versus restrictive transfusion protocols have been developed but what should be followed still needs more data. In our study, we have observed frequencies of different indications of packed cell transfusion in the neonatal intensive care unit of a tertiary care hospital. This endeavor will help in the establishment of guidelines regarding transfusion and the threshold on which any intervention should be done also it would be a step towards the identification of preventable causes that lead to transfusion and transfusion-related risks and hazards. Objective: To determine the indication of packed cell transfusion and their frequencies in preterm neonates. Study Design: This was a cross-sectional study. Setting: The study was carried out in the neonatal intensive care unit (NICU). Study Duration: The duration of the study was 1 year. Material and Methods: A total of 246 preterm neonates admitted to Aga Khan University Hospital (AKUH) neonatal intensive care unit in the tenure of 1 year, fulfilling the inclusion criteria and requiring packed cell transfusion were included. After the approval from ethical review committee, charts were reviewed for gestational age, birth weight, mode of delivery (normal vaginal or Cesarean-section) were recorded. Indications of packed cell transfusion (intraventricular hemorrhage, infection or sepsis, anemia of prematurity, phlebotomy losses, increase oxygen requirement, hematological causes, other causes of hemorrhage and other causes) were observed and recorded. Pre-transfusion hemoglobin levels (g/dL) and hematocrit levels were also recorded. Other information like number and volume of transfusion and day of life on which transfusion was administered was also documented. Results: A total of 246 critically ill children were enrolled in this study. Of the total, 52.8% were baby boys and 47.2% were baby girls. 57% of babies were born via cesarean section and 43% were born via vaginal delivery. Out of total preterm newborns admitted in NICU, 22.8% were extremely preterm, 35.4% were very preterm and 41.9% were late preterm. Mean gestational age was observed to be 31 (±4) weeks and the mean birth weight of newborns was 1500 (±600) grams. Indications of packed cell transfusion observed in our study are intraventricular hemorrhage 10%, 26% sepsis/infection, 4% hematological disorders, 12.8% anemia of prematurity, 25.2% was related to increase in oxygen requirement, 13% other hematological causes and 9.3% other causes. Conclusion: An increase in oxygen requirement and anemia of prematurity were the indications that were observed in the extremely preterm and very preterm groups. Sepsis and increase oxygen requirement are some of the major causes of transfusions observed in the late preterm group. Preventable indications can be one of the areas that can be worked on and will reduce the need for transfusion in preterm babies with subsequent prevention of transfusion-associated risks.

Nurses’ Perception of Privacy in the NICU and GCU: A Qualitative Descriptive Study

Purpose: The purpose of this study was to identify the perceptions that determine the nursing practices of nurses working in NICU and GCU to protect the privacy of the affected children and their families, and the perceptions that arise in relation to their practices. Further to obtain information on current issues and future suggestions for nursing practice. Method: Semi-structured interviews were conducted with six nurses of Clinical Ladder I or higher currently working in the NICU and GCU, and content analysis was conducted. Result: The study identified five categories, 16 subcategories, and 63 codes: “keeping in mind to act in accordance with the characteristics of the NICU and GCU”, “trying to secure a space only for the affected children and families depending on the situation”, “feeling the need for consideration for the affected children and families”, “feeling puzzled and frustrated through the relationship with families”, “having a dilemma between the environment they want to realize for the affected children and families and the fact that it cannot be realized”. Conclusion: In considering nursing care in NICU and GCU, including consideration for privacy, the need to reflect on daily nursing care and share it with other staff members was suggested.

Thermoregulation,incubator humidity,and skincare practices in appropriate for gestational age ultra-low birth weight infants:need for more evidence

Background Although not universal,active care is being offered to infants weighing<500 g at birth,referred to as ultra-low birth weight(ULBW)infants appropriate for gestational age.These infants have the greatest risk of dying or developing major morbidities.ULBW infants face challenges related to fluid and heat loss as well as skin injury in the initial days of life from extreme anatomical and physiological immaturity of the skin.Although there is an emerging literature on the outcomes of ULBW infants,there is a paucity of evidence to inform practice guidelines for delivering optimal care to this cohort of infants.Data sources A comprehensive review of the literature was performed using the PubMed and Embase databases.Searched keywords included“thermoregulation or body temperature regulation”,“incubator humidity”,“skin care”,“infant,extremely low birth weight”and“ultra-low birth weight infants”.Results Evidences for thermoregulation,incubator humidity,and skincare practices are available for preterm infants weighing<1500 g at birth but not specifically for ULBW infants.Studies on thermoregulation,incubator humidity,or skincare practices had a small sample size and did not include a sub-group analysis for ULBW infants.Current practice recommendations in ULBW infants are adopted from research in very and/or extremely low birth weight infants.Conclusions This narrative review focuses on challenges in thermoregulation,incubator humidity,and skincare practices in ULBW infants,highlights current research gaps and suggests potential developments for informing practices for improving health outcomes in ULBW infants.

Reliability and validity of the Chinese version of the Readiness for Hospital Discharge Scale-Parent Form in parents of preterm infants

Background: The Readiness for Hospital Discharge Scale (RHDS)-Parent Form shows satisfactory reli-ability and validity to assess the readiness of parents to take care of their children discharged from hospitals in Western countries. However, the reliability and validity of this instrument has not been evaluated in Chinese populations.Objectives: Evaluate the psychometric features of the RHDS-Parent Form among Chinese parents of preterm infants. Methods: The RHDS-Parent Form was translated into a Chinese version following an international in-strument translation guideline. A total of 168 parents with preterm infants were recruited from the neonatal intensive care units of two tertiary-level hospitals in China. The internal consistency of this measure was assessed using the Cronbach's a coefficient;confirmatory factor analysis was conducted to evaluate the construct validity;and Pearson correlation coefficient was used to report the convergent validity. Results: The Chinese version of RHDS (C-RHDS)-Parent Form included 22 items with 4 subscales, ac-counting for 56.71% of the total variance. The C-RHDS-Parent Form and its subscales showed good reliability (Cronbach's a values 0.78-0.92). This measure and its subscales showed positive correlations with the score of Quality of Discharge Teaching Scale. Conclusion: The factor structure of C-RHDS-Parent Form is partially consistent with the original English version. Future studies are needed to explore the factors within this measure before it is widely used in Chinese clinical care settings.

Study on the Relationship between Nursing Staffing and Nosocomial Infection in Very Low Birth Weight Infants

Background: At present, there is no domestic research on the relationship between nurse staffing and hospital infection in very low birth weight infants. In this paper, we will explore the relationship between nurses of very low birth weight (VLBW) infants in neonatal intensive care unit (NICU) and nosocomial infections. Methods: The clinical data of 280 very low birth weight infants born in our hospital from January 2010 to January 2020 were collected, and the chi-square test and multiple logistic regression analysis were used to study the nursing staff of each very low birth weight infant who was admitted to the NICU The relationship between the number of infections and hospital infections. Results: On average, each nurse needs to care for 4.3 very low birth weight infants (lowest to highest: 2.50 - 8.42). In the univariate analysis, the higher the incidence of urinary tract infection (P < 0.05), the multivariate logistic regression analysis of neonatal nosocomial infection showed that nurse staffing was significantly related to the incidence of urinary tract infection (OR = 1.78;95% confidence interval, 1.17 - 2.35, P < 0.05). However, there was no significant correlation between nurse staffing and bloodstream infection (OR = 0.91;95% confidence interval, 0.74 - 1.06, P > 0.05) or Ventilator associated pneumonia (VAP) infection (OR = 1.17;95% confidence interval, 0.94 - 1.47, P > 0.05). Conclusion: Our research shows that in the neonatal intensive care unit, the reasonable deployment of nursing staff is an important factor in preventing urinary tract infections in very low birth weight infants. It is important for improving the survival rate of very low birth weight infants and reducing the occurrence of sequelae.

Nurses’experiences of caring for preterm infants in pain:A metaethnography

Objective:Preterm infants are subjected to numerous painful procedures during their neonatal intensive care unit(NICU)hospitalization.Despite advancements in pain alleviation,nurses remain challenged to provide timely and effective pain management for preterm infants.Greater understanding of the lived experience of nurses caring for preterm infants in pain could provide novel insights to improve pain management for this vulnerable population.The aim of this meta-ethnography was to synthesize and interpret qualitative findings of nurses’experiences of taking care of preterm infants in pain.Methods:An extensive literature search in PubMed,CINAHL,PsycINFO,Scopus,BIOSIS and ProQuest Dissertation and Theses Database was conducted,including studies within the past 10 years.Two nursing researchers conducted data extraction and analysis independently.Inclusion criteria were applied to search for qualitative studies of nurse participants who worked in the NICU taking care of preterm infants.Studies published in a language other than English,articles that did not include qualitative data and qualitative data that could not be extracted from the findings or did not discuss nurses’experiences were excluded.Critical Appraisal Skills Programme was used for literature quality evaluation.Results:Eight studies remained after further screening according to inclusion and exclusion criteria.These eight studies were conducted from 2013 to 2018 and totally enrolled 205 nurses from Iran,Canada,the United States,Finland,Sweden,Switzerland,and Australia.Five themes emerged on the nurses’perspectives of taking care of preterm infants in pain:1)They sense the neonatal pain;2)Adverse consequences of unrelieved pain;3)Barriers of managing pain;4)Concerns of available approaches for pain relief;5)Failure to work with parents.Conclusions:This meta-ethnography identified nurses’understanding of pain in preterm infants that can be assessed,and they acknowledged that unrelieved pain could cause developmental deficits in infants.The barriers are lack of training and support on pain assessment and intervention in preterm infants.Optimizing workload and environment,developing age-specified pain assessment and intervention,receiving emotional support and training,and building up a rapport with parents are urgent needs for nurses to provide better care to infants having pain.

Current Situation and Influencing Factors of Preterm Infants Breastfeeding in Jingzhou 3A Hospital

Background: Breast milk is the best source of nutrition for premature infants and a “good medicine” for disease treatment. However, the rate of exclusive breastfeeding of premature infants in China still needs to be improved at present, and the factors affecting breastfeeding are different in different places. Objective: To investigate the current status and influencing factors of preterm infants breastfeeding in Jingzhou 3A hospitals. Methods: A cross-sectional study was conducted to collect breastfeeding information of premature infants in neonatal intensive care unit (NICU) from May to August in 2019 in Jingzhou 3A Hospital, and 152 premature infants’ related information were collected. A questionnaire survey was conducted among the mothers who failed to breastfeed. Results: The rate of exclusive breastfeeding among premature infants in NICU was 9.87%. The rates of first breastfeeding and exclusive breastfeeding at discharge were 13.16% and 32.89% respectively. Not producing enough milk and knowing the right way to pump breast milk contributed a lot to the failure of exclusive breastfeeding. Conclusion: More attention should be paid to the health education and management to improve the rate of breastfeeding in NICU.

Global variation in skin injures and skincare practices in extremely preterm infants

Background Globally,are skincare practices and skin injuries in extremely preterm infants comparable?This study describes skin injuries,variation in skincare practices and investigates any association between them.Methods A web-based survey was conducted between February 2019 and August 2021.Quantifying skin injuries and describing skincare practices in extremely preterm infants were the main outcomes.The association between skin injuries and skincare practices was established using binary multivariable logistic regression adjusted for regions.Results Responses from 848 neonatal intensive care units,representing all geographic regions and income status groups were received.Diaper dermatitis(331/840,39%)and medical adhesive-related skin injuries(319/838,38%)were the most common injuries.Following a local skincare guideline reduced skin injuries[medical adhesive-related injuries:adjusted odds ratios(aOR)=0.63,95%confidence interval(CI)=0.45–0.88;perineal injuries:aOR=0.66,95%CI=0.45–0.96;local skin infections:OR=0.41,95%CI=0.26–0.65;chemical burns:OR=0.46,95%CI=0.26–0.83;thermal burns:OR=0.51,95%CI=0.27–0.96].Performing skin assessments at least every four hours reduced skin injuries(abrasion:aOR=0.48,95%CI=0.33–0.67;pressure:aOR=0.51,95%CI=0.34–0.78;diaper dermatitis:aOR=0.71,95%CI=0.51–0.99;perineal:aOR=0.52,95%CI=0.36–0.75).Regional and resource settings-based variations in skin injuries and skincare practices were observed.Conclusions Skin injuries were common in extremely preterm infants.Consistency in practice and improved surveillance appears to reduce the occurrence of these injuries.Better evidence regarding optimal practices is needed to reduce skin injuries and minimize practice variations.

Parenting the NICU infant: A meta-ethnographic synthesis

Parenting the infant in the neonatal intensive care unit(NICU)comes with a multitude of unique challenges,and NICU parents are often unprepared and ill equipped for the challenges.Moreover,a gap in the literature still exists concerning a full understanding of the breadth of the process parents of NICU infants undergo from the time of admission to discharge.This study utilized Noblit and Hare's meta-ethnography synthesis method for literature extraction and data analysis to illuminate the NICU parenting process by metaphorically comparing the process to Patricia Benner's novice to expert theory.Fourteen studies including 12 published qualitative research articles and 2 dissertations from the nursing discipline were included in the analysis.Findings illuminated the process of becoming a NICU parent more fully and revealed the most salient and effective facilitators of the process from being a novice and advanced beginner to becoming a competent,proficient,even expert NICU parent.In addition,this paper discusses four influencing factors in a NICU parent's progression:contact with and proximity to their infant,relationship with the nurse,having information,and social support.Nurses must engage with NICU parents in such a way as to maximize the likelihood that these parents will reach at minimum the proficient and at maximum the expert parenting stage by discharge.

Neonatal and Young Infant Sepsis in a Regional Hospital in Ghana

Background: Neonatal sepsis is a global health problem that mainly affects low- and middle-income countries. We have previously shown that early neonatal mortality is high at the Ho Teaching Hospital (HTH) of Ghana. We sought to determine the prevalence of neonatal sepsis, sepsis-related mortality, and bacterial species patterns in neonatal and young infant sepsis in this hospital. Methods: A hospital-based study was conducted in the hospital’s neonatal intensive care unit (NICU) from March to June 2018. Blood samples from 96 babies clinically diagnosed with or at risk of sepsis were cultured using the BACTEC 9050® machine. Clinical data including gravida, parity and antibiotic medication before delivery of mother and delivery type, gestation, birth weight and antibiotic medication status were collected for analysis. MALDI-TOF MS identified bacterial isolates, and their identities were confirmed via tuf gene sequence typing. The data were analyzed using GraphPad Prism 8.0.2. Results: Blood cultures were positive in 28 of the babies, with 14 and 12 representing early-onset and late-onset neonatal sepsis, respectively, and two cases of unknown sepsis type. Of the bacterial species that caused sepsis in the babies, coagulase-negative staphylococcus (CoNS) was the most prevalent isolate in 22 cases, followed by Klebsiella pneumoniae in two and Staphylococcus aureus, Streptococcus agalactiae, the Acinetobacter species, and Escherichia coli in the rest (one each). Of the CoNS, S. haemolyticus and S. epidermidis were the most prevalent species, found in eight and six cases, respectively. Thirteen neonates died, of whom seven had positive blood cultures, and two were referred. A case fatality rate of 7/26 was estimated. Neonatal mortality caused by Gram-negative bacterial infection was higher than that caused by Gram-positive bacteria. Conclusions: These data suggest a significant burden of sepsis among neonates and young infants and are associated with substantial morbidity and mortality at the HTH. There is a need to investigate risk factors associated with the increased sepsis rate in this hospital to inform measures to reduce the neonatal sepsis rate.

Risk Factors for Perinatal Asphyxia in Newborns Delivered at Term

Perinatal asphyxia is defined as harm to the fetus or the newborn caused by hypoxia and/or ischemia of various organs with intensity to produce biochemical and/or functional changes. Understanding the risk factors for this clinical condition allows the identification of vulnerable groups, enabling an improvement in care planning in the perinatal period in neonatal intensive care units. In this sense, this research aimed to identify risk factors for perinatal asphyxia present in newborns term that showed record for this clinical condition. This was a cross-sectional, retrospective documentary, quantitative and descriptive, conducted from data from medical records of 55 infants admitted to a neonatal intensive care unit. As for maternal characteristics (78.0%) had between 16 and 35 years, only one child (53.0%) and (76.0%) had no prior history of miscarriage. As for pre-existing diseases or pregnancy (38.0%) developed by Hypertensive Pregnancy Specific disease (02.0%) were suffering from Hypertension and (02.0%) of Diabetes Mellitus. As for newborns, most infants had birth weight (43.6%) and correlation with gestational age (78.2%) compatible for good conditions of birth. Only (20.0%) of the infants had a difficult labor. It stood out although there was a slight predominance of severe asphyxia (50.9%) in the first minute and (45.5%) of the infants had record release intrauterine meconium. It was concluded that most mothers and newborns did not have risk factors for perinatal asphyxia, thus, this fact could be attributed to the structural conditions of service, especially in the care during labor, delivery and immediate assistance newborn.