Vitamin K Deficiency

The Water Birth and Hospitalization of Amanda Woods
Part 1

Amanda's Birth

Sandra: I met Rebecca when she was five months pregnant. She was a psychology major at the local university. She related that she wanted a more supported birthing experience than she had with her first child, Aricka. Her husband, Joey, was in the military during her first pregnancy and birth. During that time they experienced some marital strife that ultimately led to divorce a short time after Aricka's birth. They were back together and were working through important issues. She told me that her birth was a painful frightening experience. She had an epidural and spontaneous vaginal delivery without overt complications.
Rebecca: I chose the hospital that I ultimately gave birth in because they advertised that they were not a "baby factory". "Women were not shipped in, delivered, and then shipped out" they said. However, shipped in and shipped out was exactly how I felt.
Sandra: Complicating matters was that Rebecca had no extended family to help her adjust to becoming a mother. That is a monumental transition, and it's very lonely when the only person you have a trusting and dependent relationship with is in a position of betraying you.
Rebecca: The military supplied a midwife who provided child birth preparation classes, and I took breast feeding classes after Aricka's birth. The midwife noticed that I was depressed, but she didn't make an effort to assist me in healing. I felt disoriented in the post partum. In fact, a nurse walked in to my room the day after delivery and asked if I had changed Aricka's diaper. I didn't realize that I was responsible for those sort of things. I felt like I was existing in another dimension. I wanted to take care of my baby, but I realized that I wasn't sure where to begin. I felt disorganized and unsure of myself. The midwife did say to call her if the depression didn't let up. It finally went away, but it took me a long time to bond with my first child.
Sandra: Wanting to learn all that she could, Rebecca signed up for the first Doula class that I was preparing to teach that spring. We met every other Friday for six months discussing pregnancy, breast feeding, post partum , and labor issues. We also practiced hands on techniques for labor support. At some point during our prenatal relationship, Rebecca decided she wanted to consider water birth. Even passed her due date, we discussed the pros and cons with the birth happening in her mother's home in the large oval shaped tub, verses a probable dry birth in her small campus apartment, or at the hospital. Her mother's home was rural, and 10 or 15 minutes from town, whereas her apartment was three blocks from the hospital. We stayed open to what Rebecca would ultimately want during the birth.
Rebecca: I was very unsure about what I wanted for Amanda's birth. I wasn't even sure whether or not I wanted to deliver at home. I kept the hospital option open for myself by getting standard prenatal care at the local hospital based midwifery clinic. I had as many visits with the clinic as I did with Sandra. When the time came for birth, I trusted Sandra to handle the birth in a more loving and attentive way.
Sandra: Rebecca's labor began in the evening. After midnight on June 30th, she called to tell me she was in labor. We sat in her apartment in the candle light. Her contractions were every five minutes. At one am, Moonbeam, her doula arrived, and Rebecca firmly said " I want to go to my mother's". That was it, she had made her decision about where she would give birth.
When we arrived, Rebecca headed straight for the large oval bath tub. If I were guessing dilation, I would have thought Rebecca was close to 5 centimeters by her furrowed brow and manner of breathing during the contractions. Between contractions she had a radiant smile that lit up the room. After an hour in the water she asked me to check her. I was quite surprised to find that her cervix was posterior, firm and still long. She was 2 centimeters. If I told Rebecca she was only two centimeters and that we were still in latent labor she would be very discouraged. She knew something was up because she readily complied when I said she needed to get out of the bath and walk. I told Moonbeam that I thought the baby wouldn't be born until day light, maybe even as far away as noon time. She needed to emotionally prepare and conserve her energy for a long birth.
It was three thirty am when we went for a walk in the garden. I wanted the Earth's heart beat to vibrate through Rebecca. After all it is God's heart beat. I knew from other women who have birthed outside that nature is a powerful aid during birth. More importantly it was Rebecca's choice to go outside and walk in the star light. She had told me at one of our prenatal visits that she felt comforted by the darkness when she looked out the window into her mother's yard. Her mother lived in a very rural area of the deep piney woods.
For an hour we walked outside. During the contractions we stopped to let Rebecca position herself. Rebecca held on to Joey and squatted. He supported her out-stretched arms, and upper back. During contractions Moonbeam would place both of her hands on Rebecca's lower back, allowing Reiki energy to comfort Rebecca. When I wasn't listening to baby's heart beat, I too focused Reiki energy on Rebecca by placing my hands on her head. Reiki is a powerful labor relaxant. I believe it is prayer in it's highest form. Reiki is a way of opening oneself to God and allowing the healing energy that is present for all of humanity to flow through an open non-judgmental heart to a another person. During Reiki the practitioner asks God to provide the highest good for the recipient. Not human judgment of what that is, but God's all knowing wisdom.
Rebecca: Being able to look at the sky and the stars comforted me. It was during the time outside that my training as a doula benefited me most. I realized that I had been holding back and focusing on the pain. I decided to allow my body to open up and I focused on what my body was telling me. Moon beam helped immensely. So did Joey; this birth really brought us closer together. I was able to take my focus inward. Labor progressed. I later related to Sandra, who I had explicitly told "do not sing at my birth" after a doula class where she tried to teach us birth songs, that one of those songs " I am feeling very open" kept coming in to my head. Later when I told this to Moonbeam and Sandra, they said that the same song came to mind during my contractions. No one sang out loud, no one said anything at the time, but our hearts were actually singing together.
Sandra: Just after four am she felt a gush of fluid. We headed in doors shortly after that. For a little while Rebecca and Joey laid on the bed. Moon beam and I continued the Reiki. Rebecca changed positions frequently, getting on her hands and knee's laying on her side, kneeling, whatever helped. The baby's heart beat stayed beautiful and healthy sounding. No decelerations during or after a contraction. An occasional acceleration of the baby's heart beat was noticed. Somewhere just before five Rebecca wanted back in the tub of water.
Rebecca: I knew the contractions could hurt worse than they were ; I remember them being much worse at Aricka's birth. I kept saying to myself, I can handle this, but please don't hurt any worse. They never did.
Sandra: At five minutes after five Rebecca had the urge to push. Her second vaginal exam revealed she was complete. Over the next 22 minutes at 5:27 am she pushed out a healthy vigorous baby girl whom she named Amanda. 9/9 apgars. Amanda peacefully floated in the water for ten minutes or so just drinking in her mother's face. Like Rebecca herself, Amanda's water birth was gentle, peaceful and Beautiful.
Rebecca: So peaceful, I don't even remember if Amanda cried.

Part Two
Amanda's Decline and Hospitalization

When Amanda was 23 days, Rebecca called concerned that Amanda had thrush. The week Rebecca gave birth she was taking a prescription for a painful bladder infection. Since she was half way through the antibiotic, I had reminded her to finish the prescription. Which she did. Rebecca was also taking probiotics. I had hoped that would prevent a thrush infection. Rebecca related that she had taken Amanda to the clinic 4 or 5 days prior and was told to treat Amanda by painting her mouth with gentian violet. Since she had waited a day or two to do the actual treatment, perhaps, she thought, it didn't work, because the thrush plaques were still bleeding several days later. At this point Rebecca wasn't worried, thrush is relatively benign. Amanda didn't appear sick. She had called me because although she had been told this was normal, it just seemed to be persisting. In addition her choice to call me was that I was accessible, whereas the clinic wasn't. Although discussing options for clearing thrush is easy to do over the telephone, a voice inside me said, "go look at the baby".
When I arrived, Amanda had just finished nursing. Rebecca handed her to me. Her mouth was painted purple. I couldn't tell if it was bleeding or not. I trusted Rebecca's history of noticing blood. As I held Amanda I grew very hot and began to sweat under my hairline. I felt like I was holding a heater. I asked Rebecca if she had noticed that Amanda had a temperature. She hadn't. I was feeling nauseated by the heat. Heat and sweat around my hairline often occur when Reiki pours out of my body to an individual who is really in need of healing. I noticed not only was Amanda pulling the Reiki energy as my two hands held her, but she fell asleep. She was breathing heavily. Was this labored breathing? I counted her respiration rate. 60 breaths per minute. I opened up her clothes and looked at her rib cage. She had retractions. Then I began to wonder if Amanda was not sleeping, but had slipped into lethargy? As I held Amanda with both hands firmly encompassing her back, the baby sitter was asking me how I got Amanda to sleep? She explained that for two days, Amanda had been unusually fussy. She reported that she had been unable to console her. She couldn't believe this baby would just go to sleep in my hands so quickly. Sleep is a normal response during a Reiki session. Nevertheless, Amanda was very sick and I had barely started my physical examination of her. I told Rebecca to call her pediatrician because she needed to be seen by a doctor. When I related to the office nurse what was happening, the doctor said to bring Amanda to the hospital. It was close to noon. We called Rebecca's mother to help drive her to the hospital. At this point, I am thinking the worst. There was some feces in the birth water. Was this bacterial contamination from her water birth? Was this DIC?
Rebecca: Before Sandra came over I wasn't thinking that Amanda was very sick. I thought she had thrush and that I hadn't treated it well. Amanda had been to the clinic about 5 days earlier. She didn't seem sick to me at that point. In fact, I later told Sandra I didn't know how she knew Amanda was sick. I wasn't even sure she needed to go to the hospital. But, that night after she was admitted I could tell she was very ill. They initially put her on antibiotics thinking it was a strep infection from her birth even though I was Group B strep negative. During the night, Amanda's condition worsened and they life flighted her to Dallas. I kept telling the nurses that Amanda bled easily. No one seemed to be taking me seriously. I finally had them look at the bandages where they had drawn blood from Amanda. I told them about the two PKU's. She had one at the clinic, and one with Sandra. With both of them, Amanda had prolonged bleeding. I was concerned about it, but when the nurse at the clinic, and Sandra wasn't, I let it go. Finally the second doctor in Dallas who saw Amanda decided to do coagulation studies and give her vitamin K.
Sandra: The next morning I got a call from a doctor in Dallas, and from a local doctor trying to determine if Rebecca was group B strep positive? "No." Did I give a vitamin K injection at birth? "No." Was Gentian violet a treatment of choice for thrush out there in East Texas? "Yes, I think so," I don't know. I didn't tell her to do that, the clinic did. Why aren't they calling the clinic? That's when I was told that Amanda had been transported to Children's. She was on a ventilator. She had had a MRI. There was bleeding into the brain, the lungs and liver. Rebecca was told Amanda could have one of several problems, one of which was vitamin K deficiency. The hospital gave Amanda large doses of vitamin K. The bleeding began to subside. She was on a ventilator her full week in the hospital. Rebecca was told that Amanda might have some developmental delays from her cerebral hemorrhage. It was during that second day, that I remembered the PKU test that I had performed. I had poked Amanda's foot three times, a technique I learned while working in the hospital, and I felt a pulsation as I filled the circles. I thought I was lucky since the circles filled so easily. I also thought it was due to my technique. Wow!! I've finally mastered the art of drawing a PKU!! I had had to place pressure over her foot for a full two minutes and ended up putting a pressure bandage on it. The rest of her physical exam and her umbilical site was normal. Amanda appeared healthy and had no other symptoms of bleeding. Therefore that one episode didn't clue me in to the pathology that was lurking in Amanda's system. When I talked to Rebecca during the hospitalization, and she related the first PKU test to me, I could have kicked myself for being so ignorant. It wasn't just one incident, it was two.
Rebecca: I went through the hospital stay as if in a dream. How could my child be that sick? I blame myself for not researching my choices thoroughly before I made them. I also found out later that my mother had bleeding problems twice in her life. Even though she was present at one of the prenatal history discussions, (I had two, one from each care provider) this information was either never asked or my mother forgot. When this all ended, it was amazing to me that no one considered a vitamin K deficiency sooner. Vitamin K shots are given routinely in the hospital. It seems they are so routine, no one remembers what they are for. I certainly didn't know. After diagnosis I wondered how she had gotten so far along… so sick. I later thought, "doesn't anyone know about vitamin K?!!!!!
Sandra: Here is where I must diverge into the politics of birth and the reluctance of local physicians to believe the research that reveals home birth to be safe when coupled with medical back-up. Rebecca was my fifth home birth client. I had been delivering in the hospital prior to establishing a home birth practice. As I started my home birth practice, and requested prescriptions or collaboration agreements, I was met with an echoing "NO". I was told that any relationship with me would raise liability insurance policies by $40,000 or more a year. That I "would be run out of town with a stick where the sun don't shine". That certain doctors at the local hospital hate midwives. That our goals run in opposition to one another. The physicians in my locality as a whole could not envision a collaborative practice with a CNM. The education and privilege of wearing my degree as a CNM did not matter as long as I was choosing to give women choice and power in the birth place. Even after Amanda's diagnoses, the local physician who witnessed Amanda's ordeal debated with me over the safety of home birth and admonished me to give vitamin K to all of my clients. I replied that I would gladly comply if he would furnish me with a standing order for vitamin K. He refused. He did not want to support a midwife in the "dangerous business of delivering babies at home". Who he truly was not willing to support were the families. However, Rebecca was not bereft of medical resources, she had double the prenatal care, and had established a viable link for Amanda at the local clinic. Amanda had been seen three times at the clinic before her hospitalization. Vitamin K can be administered at any point after birth, she could have received it at her first routine clinic visit when she was two days old. Rebecca had told them her baby had absolutely no medications at birth. She was relying on their judgment to give the appropriate medications since I could not provide them.
My protocol at that time was to have my parents obtain the prescription from their doctor prior to the birth. In Rebecca's situation, she was relying on the clinic in case of hospitalization. The clinic was afraid of liability if they issued her a prescription. I am to be faulted because during the prenatal period when we did discuss the issue of vitamin K, I told her it was rare. 1 in 10,000 infants might be affected. That breast feeding provided plenty of bacteria and was protective since the synthesis of vitamin K by the intestinal tract was how vitamin k is mainly supplied in the human diet. Therefore Rebecca had no incentive to pursue the issue further. This particular incident, was complicated by not only the political agendas of local health care providers but by my own ignorance. Ignorance of the facts, and ignorance of the simplicity with which vitamin K deficiency manifests in the healthy newborn.

Part Three
Vitamin K Deficiency Disease - The Facts.

During Amanda's hospitalization I had purchased my first copy of Maye's Midwifery. I expected it to re-state American nursing texts. It was here that my assumptions regarding breast feeding as protective against vitamin K deficiency were challenged. In fact, I closed the book and decided I did not like what I read. Maye's was stating exactly the opposite of what I believed. Until this time I was sure bottle fed infants were more at risk due to the sterile nature of formula, especially since my parents had a difficult time getting oral vitamin K prescriptions filled by their physicians. They were told that oral vitamin K preparations didn't work. So why would vitamin K fortification in formula work any better? In addition my personal bias that breast feeding offers optimal nutrition for infants and could not possibly be associated as a risk factor for any disease allowed me to continue along the line of thought that there was a natural protection with breast feeding. I believed that vitamin K deficiency was a genetic problem. After all the human body has survived well during birth and breast feeding since humans have walked this Earth. There are plenty of home born babies who have been exclusively breast fed, did not receive vitamin K, and did not have a deficiency. What makes one infant at risk, and another not if isn't genetic? Again, vitamin K administration is a new phenomenon in the relative history of mankind. Researchers are still attempting to decipher if Vitamin K presents a cancer risk, although research has pretty much revealed that vitamin K administration is more than likely benign. (Passmore, et al , 1998. ) As I began to allow myself to search the medical literature, I realized I needed to rethink vitamin K issues and had to realign myself with current literature.
I would like to quote M. Andrew from the February 1997 Perinatology Seminars: "Clinically, the hemostatic system is effective and healthy infants do not suffer from spontaneous hemorrhagic complications." (Andrew. 1997). Vitamin K is essential so that the liver can manufacture prothrombin and factors II, VII, IX, X in the clotting cascade. While the newborn infant has a deficit in these factors as long as his vitamin K stores are low, he also has increased factors V, VIII, and XIII surpassing those of the adult and thus providing the infant with an inborn protective mechanism. However, Andrew also states that infants are more vulnerable than adults to bleeding disorders. Andrew states that the most common causes of bleeding in newborns is vitamin K deficiency, DIC, and liver disease.
It is fact that newborn babies are born without sufficient vitamin K stores. For most babies this noted deficiency is not enough to cause hemorrhagic disorders in the newborn . However the medical literature is replete with research, and various case studies of breast fed infants developing vitamin K deficiency bleeding (VKDB). VKDB can cause serious internal and intracranial bleeding leading to death. In addition, case studies revealed that the infants who died from late onset vitamin K deficiency bleeding had received the initial one milligram dose of vitamin K injection at birth. One injection was not always protective. (Solves, et al. 1997., Rutty, Smith and Malia, 1999., Soylu, et al. 1997.). VKDB can occur within days to up to two months after delivery. Bacterial synthesis of vitamin K appears to be a deficient source for providing satisfactory levels of vitamin K in the newborn infant. Antibiotic administration has been documented to further interfere with vitamin K synthesis in the human intestinal tract. (Huigol, Markus, & Vakil, 1997.) This is significant given the reliance of the medical community on antibiotics. Colostrum and Breast milk contain very low levels of vitamin K, thus placing breast fed infants at higher risk than formula fed infants. (Sweet, 1997., Creasy and Resnik, 1989.) However, dietary sources can prevent vitamin K deficiency disease. One study revealed that Vitamin K plasma levels in the newborn were elevated during maternal supplementation of vitamin K up to 5 milligrams per day during first 12 weeks post delivery. (Greer et al, 1997). While it was generally accepted that IM vitamin K regimens were effective, a single dose of oral vitamin K at birth is not as effective as a single IM dose of vitamin K at preventing the development of late onset VKDB. New protocols are being considered that include three 2 milligram oral doses of micellular vitamin K preparations, at birth, at 8 days and at 30 days. Infants with this particular oral dosing had vitamin K plasma levels comparable to infants receiving an injection of vitamin K with the same sequential pattern. (Greer et al 1997, Schubiger, Gruter, Shearer, 1997.). Large multinational comparisons where failure rates per 100,000 infants revealed that of the various vitamin K protocols, even three routine oral doses of vitamin K were not as effective as intramuscular administration unless the breast fed infant was given an additional daily dose of 25 micrograms of vitamin K. (Cornielsen et al. 1997).
Symptoms of vitamin K deficiency include: Breast feeding, melena (Melena is black tarry stools that may be difficult to differentiate from meconium, but can be tested by placing the stool in water to see if the water turns pink. Meconium will not cause the water to turn pink.), cephalohematoma, vomiting of blood, prolonged jaundice, failure to thrive and warning bleeds such as bleeding from the umbilical site, nasal and oral bleeding, and prolonged bleeding at puncture sites.
Diagnoses of vitamin K deficiency is made by drawing a Prothrombin time (PT), fibrinogen, and platelet count. A prolonged PT together with normal fibrinogen and platelet levels is indicative of vitamin K deficiency. Laboratory values of plasma or urinary vitamin K levels can be drawn in addition to PT and fibrinogen studies. Administration of 1.0 mg of vitamin K should produce a correction of the prolonged PT, and bleeding. Vitamin K is rapidly absorbed and begins to work within 30 minutes of administration. Vitamin K can be given at any time after birth, especially if prolonged or abnormal bleeding is noted in the newborn. In addition, the newborn may appear quite healthy for several days or weeks, and the only sign will be what the practitioner may consider as prolonged or inconsequential bleeding around the umbilical stump. Note: Newborns do not bleed easily!!!
When discussing vitamin K issues with your clients your teaching tools need to be clear. Your clients need to understand why it is suggested their baby receive vitamin K, and they must understand that one injection is not necessarily adequate to prevent a later onset of this disorder in exclusively breast fed infants. Your clients must be told signs and symptoms of VKDB that they might notice during the course of normal care taking. VKDB can be fatal, or produce developmental and cognitive delays in the infant. It's rarity may not allow the practitioner ample experience to recognize it. In addition, a good teaching tool would include potential concerns for infants receiving vitamin K injections. Davis's Drug Guide for Nurses states the general side effects of phytonadione ( vitamin K1) one milligram include jaundice, hemolytic anemia, flushing, rash, urticaria, or a mild local reaction at the injection site. In addition any foreign entity given by injection can cause an anaphylactic reaction. While this is extremely rare, if that were to happen in the home, that would be a devastating event. One half to one milligram of vitamin K1 is the standard intramuscular dosage for a newborn, whereas 2 mg is the standard oral dosage. Phytonadione is not absorbed from the gastro-intestinal tract unless there are some bile salts present.
In addition to a clear, informative written teaching tool, I suggest having your parents sign that they desire vitamin K, or that they decline vitamin K irregardless of how the medication is provided (by you or by the parent). Prior to Amanda's birth, if the parents did not provide me with the medication then I felt it was safe to assume they chose not to give it. However, if a parent is not truly informed, or their practitioner refuses on the grounds that they are "aiding and abetting home birth", then that may place the midwife in legal limbo for not providing a standard routine medication, not to mention the heart ache of having a baby die or become developmentally disabled over a disease that can be prevented nutritionally.
I am not a licensed lawyer but what I am about to assert appears clear. Should a baby suffer the consequences of a medical practitioners neglect, whether due to ignorance or a personal bias regarding the safety of home delivery, given the laws of the land, where only medical doctors may prescribe medications, then the jury is left with one fact; a medical doctor was the only person licensed to prescribe medications for your client. If he or she refused to honor your clients rights as parents, and did not provide a standard medical treatment when so requested, then if you have educated your client, and done your best to present the facts, then it ultimately falls on the shoulders of the physician. In addition, if your state does not provide a legal clause for you to furnish newborn medications, (Texas does provide that for documented midwives), and you do so without a physicians order, you are breaking the law. It is called "practicing medicine without a license".
I propose that a registry of babies not given vitamin K prophylaxsis be started through Mana. With a registry, midwives can document statistics of health and well being. Babies who have not received vitamin K prophylaxis are now a rarity. Home born babies are the control population if we are to get to the truth regarding cancer epidemiology and vitamin K administration.

Bibliography
Andrew, M., (1997). The relevance of developmental hemostatsis to hemorrhagic disorders of newborns. Seminars In Perinatology. 21:1 pp.70-85.

Booth, S., & Suttie, J., (1998). Dietary intake and adequacy of vitamin K. Journal of Nutrition. 128:5. p.p. 785-788.

Cornelissen, M., Von Kries, R., Loughnan, P., & Schubiger, G., (1997). Prevention of vitamin K deficiency bleeding: efficacy of different multiple oral dose schedules of vitamin K. European Journal of Pediatrics. 156:2 p.p. 126-130.

Creasy, R., & Resnik, R., (1989). Maternal-Fetal Medicine: Principals & Practice. Saunders: Philadelphia.

Deglin, J., & Vallerand, A., (1999). Davis's Drug Guide for Nurses. 6th Ed. FA Davis :Philadelphia.

Golding,J., Emmett, P., & Rogers, I. (1997). Does breast feeding have any impact on non-infectuous, non- allergic disorders? Early Human Development. Supplement s131-42.

Greer, F., Marshall, S., foley,A., & Suttie, J. (1997). Improving vitamin K status of breast feeding infants with maternal vitamin K supplenets. Pediatrics. 99:1 pp. 88-92.

Greer, F., Marshall, S., Severson,R., Smith,D., Shearer, M., Pace, D., & joubert, P. (1998). A new mixed micellular preparation for oral vitamin K prophylaxis: randomised controlled comparison with an imtramuscular formulation in breast fed infants. Archives of the Disabled Child. 79:4 pp. 300-305.

Huilgol, V., Markus,S., &Vakil, N. (1997). Antibiotic induced iatrogenic hemobilia. American Journal of Gastroenterology. 92:4. Pp.706-707.

Passmore, S., Draper,G., Brownbill,P., & Krill, M. (1998). Ecological studies of the relation between hospital policies on neonatal vitamin K administration and subsequent occurrence of childhood cancer. British Medical Journal. 316:7126 pp.184-189.
Passmore, S., Draper,G., Brownbill,P., & Krill, M. (1998). Case control studies of relation between childhood cancer & neonatal vitamin K administration. British Medical Journal. 316:7126 pp.178-184.

Rutty, G., Smith,C., & malia,R., (1999). Late form hemorrhagic disease of the newborn; a fatal case report with illustration of investigations that may assist in avoiding the mistaken diagnosis of child abuse. American Journal of Forensic Medical Pathology. 20:1 pp. 48-51.

Solves,P., Altes,A., ginovart.G., Demestre, J., & fontcuberta, J. (1997). Late hemorrhagic disease of the newborn as a cause of intracerebral bleeding. Annals of hematology. 75:1-2 pp. 65-66.

Soylu, H., Aslan,Y., Sari, A., & Erduran, E. (1997). Intracerebral hemorrhagic: a rare late manifestationof vitamin K deficiency in a breast fed infant. A case report. Turkish Journal of Pediatrics. 39:2 pp. 265-269.

Sweet, B., Ed. (1997). Maye's Midwifery: A Textbook for Midwives. Balliere Tindall: Philadelphia.

Zipursky, A. (1999). Prevention of vitamin K deficiency in newborns. British Journal of of Haematology. 104:3 pp. 430-437.

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