Nursing: Special Care of the Newborn - Essay Example

Nursing: Special Care of the Newborn Introduction: This is a reflective about the care of Suzy and John’s baby, Dan that I conducted during my clinical placement in the neonatal nursery unit as the midwife in charge for that unit. For reasons of confidentiality and for ethical reasons, the names of these patient and his parents are not real, and throughout this reflective essay, they will be termed in these names. In this essay, I am presenting an account of the care given to the newborn and his family. From the background below, it would be apparent why the care given was special. Background: It was like any other day during my duty as the midwife-in-charge in the Special Care Nursery (SCN) of our hospital. I have one other midwife working with me in the SCN. The workload was not much. It was 11 pm, and there were 8 infants under our care. There was a call from the Delivery Suite about a patient, Suzy who presented to the Labour and Delivery accompanied by her husband John. They wanted SCN midwife to attend the delivery. I enquired about the history. The Delivery Suite personnel told me that Suzy is a primigravida at 33 weeks of gestation. This was an unexpected presentation to the Labor and Delivery for her. There was onset of established labour pain. On examination, it was found that labour has progressed already to the extent that the cervix was fully dilated, and Suzy would birth soon. After talking to John, her husband, Suzy was admitted, and the birthing would occur soon. Since this was a preterm delivery, there is a high chance that the baby would be low birth weight, premature, and would have every chance of many catastrophic events during delivery putting the baby at risk. Therefore, the Delivery Suite wanted SCN presence there for immediate resuscitation of the baby post delivery and assessment and arrangements for admission to the SCN. This was a very rational approach on the part of the Delivery Suite personnel to contact Special Care Nursery on the verge of this preterm delivery. Newborn period encompasses the first four weeks of extrauterine life, but it is an important link in the chain of events of transition of the fetus to adulthood. The morbidity and mortality rates in the newborn infants are high, and most occur during the newborn period. Any neonate born before 37th weeks of pregnancy irrespective of birth weight is termed as preterm. Since the fetus had not had enough time to grow appropriately within the uterus, the birth weight of the baby will be low. Along with that, a preterm baby will be small in size. There would be physical evidence of prematurity in almost all organ systems, but from the activity point of view, general activity of such a newborn would be poor, and activity indicated by reflexes would register a downsize, such that, Moro, sucking, and swallowing would be sluggish (Jain A, Fleming P., 2004). I reviewed the current status of the SCN and went to attend the Delivery Unit to attend Suzy’s delivery, mainly in order to help resuscitate the baby. Preparing appropriately for the delivery and immediate care of the preterm is essential when the time permits, since an appropriate and methodical care has impacts on the eventual outcome of the newborn. These babies are vulnerable due to several reasons, and it calls for skills and equipment for care and possible resuscitation. The family and the parents need support at this time since they have several concerns that must be addressed (Resuscitation Council (UK), 2002). The premature baby has several handicaps. The nervous system is immature, and all reflexes are impaired due to that. Many functions, particularly the feeding becomes problematic. The most important system that needs a much focused care and monitoring is the respiratory system. The respirations in these babies tend to be irregular in depth and rate with periods of apnea lasting for a few seconds. The cough reflex is poor, and this leads to decrease clearance and increased stagnancy of secretions leading to increased chances of infection. Poor development of lungs, deficiency of surfactants, poor blood supply to lungs, shunting of most of the blood through ductus arteriosus, weak respiratory muscles, all combined together may lead to areas of atelactasis. These, if not taken care of or supported adequately would lead to more secondary atelactasis and the resulted respiratory distress syndrome. The GI system is immature, including limited capacity of the stomach. Liver cannot function to its fullest extent. The resulting problems are regurgitation, hyperbilirubinaemia, hypoglycaemia, and poor detoxification of drugs. Apart from these, there may be problems with temperature regulation, problems with renal function, instability of the circulatory system, metabolic disturbances, intolerance to drugs, liability to nutritional deficiency, and increased susceptibility to infections (MacDonald H, 2002). This event of preterm delivery and cell to attend the occasion raised alarms in me, since there was hardly any time to make a programme and plan the care of the newborn. Ideally, in an event of anticipated preterm delivery, it is prudent and necessary to discuss intrapartum and postnatal care with the parents. With this less time due to the fact that delivery was impending, I decided to have a quick discussion with John and Suzy, where I collected relevant historical details, so I can have a fair idea about what is going to happen to the baby. This was designed to anticipate problems and to prepare for the arrival of this obviously preterm baby. The relevant histories that I took were Suzy’s medical and obstetric history that was provided by both Suzy and John and the delivery team. Her first day of last menstrual period was recorded to estimate her period of gestation. The status of the pregnancy in terms of whether this was a singleton or twin. I corroborated this with the ultrasonography done at 16 weeks of gestation. I also recorded whether there was any suspected congenital anomaly. I assessed the uterine size to have a rough estimate of the fetal growth, and the fetal heart sound was recorded to assess the fetus’ wellbeing. Suzy was laboring, and I inquired about the course of the labour. I took a history of any other interventions that might have been done in terms of tocolytic drugs, steroids, antibiotics, opiates, or anesthetics agents (British Paediatric Association, 1993). These were necessary to prevent difficulties in initiation of respiration at birth and to help anticipate other problems that might threaten survival of the newborn. These answers to these questions would help me to recognize the high risk situation. For the baby, there is always a necessity for physiological adjustment on the part of the new born while transitioning from intrauterine to extrauterine life, and many a things may go wrong in this phase, and anticipatory preventive management should be undertaken. Broadly, however, the level of resuscitation that may be necessary is related inversely to the gestation of the preterm infant. The standard approach taken for the term infants is successfully applicable to resuscitate preterm infants greater than 32 completed weeks of gestation. Since Suzy has 33 completed weeks, most of the babies born at the stage would need only drying and stimulation. Infants of gestational age of less than 32 weeks who has a birth weight of less than 1500 g would require more active support, and those that are less than 28 weeks would need more aggressive intervention, such as, endotracheal intubation and ventilation. This would need the presence of an experienced neonatologist. I noted that there were no pediatrician in the Delivery Room, and ideally this kind of immediate after birth care would need the presence of two members of the staff who are experienced in early care of the preterm infants, and I was only alone present there due to shortage of staff (British Paediatric Association, 1993). Obviously, this would be a high-risk baby, naturally all care must have been taken to avoid drugs such as pethidine, scopolamine, and barbiturates in the mother, and I observed that an epidural anaesthesia was induced in Suzy. Before entering into the Delivery Unit, I made it a point to talk to John to brief him about the condition of Suzy, and I explained the risks of preterm delivery for the baby along with the expected course and the risks. I assured him that we would do our best to resuscitate the baby. It would also be important to take strict aseptic precautions while handling Suzy and her child during these interventions since preterm babies are more prone to contract infections that may lead to life-threatening sepsis (Joint Working Party of Royal College of Paediatrics and Child Health and Royal College of Obstetricians and Gynaecologists, 1997). While preparing for the birth and admission of Suzy’s baby to the SCN, I reminded myself about the risks involved in these newborn babies. These are more likely to develop anoxia during or soon after delivery. Birth asphyxia constitutes a major neonatal problem leading to high mortality and morbidity of not attended to. Setting aside the disastrous consequences of hypoxaemic ischaemic pathologies especially in the brain, it is to be highlighted that birth asphyxia is preventable through appropriate neonatal resuscitation. I have been trained in neonatal resuscitation, and from that training, it was mandatory that I prepare myself for any eventuality right from the zero hour, from the time of the birth in the labour room to save the life of the baby and prevent anoxia during the baby’s stay in the SCN. Consequently, it was important for me to identify this as a high-risk delivery and anticipate that this newborn may need resuscitation after birth. From my previous experiences, I have seen that in such cases problem may happen when least expected. Preparedness to handle any emergency, hence, was of utmost importance. As the baby is deprived of oxygen, initially there would be rapid breathing, then breathing would stop, and the heart rate would start falling. At this stage of primary apnoea, administration of oxygen and tactile stimulation helps in revival. If the asphyxia continues, the respiration becomes deeper and gasping. The heart rate would drop further, and blood pressure decreases. In this stage, much dependence is not placed upon tactile stimulation, and positive pressure ventilation can only revive the newborn. Early resuscitation is the cornerstone of management in this stage of secondary apnoea, since that only can establish spontaneous breathing, and in that sense, every case of apnoea in a newborn is to be treated as a case of secondary apnoea. Very weak respiratory effort due to any reason fails to clear fluid from the lungs of the newborn, and the lungs would normally fill themselves with air as the fluid is removed. This is possible only with bag and mask breathing at two to three times the pressure of a normal breath. At the outset when the baby is born, the pulmonary blood flow increases by opening up of pulmonary arterioles and closure of the ductus arteriosus. Only this would ensure proper oxygenation provided the breathing rate is fine. When the newborn is asphyxiated, there would be hypoxaemia and acidosis. At this stage to counter these, 100% oxygen and intravenous sodium bicarbonate is mandatory (Gee H, Dunn P., 2000). In the delivery room, I started checking and preparing the resuscitation kit. I checked the oxygen supply and suction points and their electrical connections. I checked the neonatal resuscitation trolley and all its connections. Apart from these, I made handy a clock with a second hand; dry, warmed towels and heat source (Lyon AJ, Stenson B., 2004); light source; wide bore suction device; face masks in variety of sizes; inflatable bags with blow-off valve; oxygen source with pressure limiting device; laryngoscope with neonatal blades; neonatal endotracheal tubes of sizes 2.5, 3.0, and 3.5; needles and syringes; and umbilical catheters. Similar arrangements were made in the SCN where additionally my colleague was instructed to check and arrange all these materials and set up. Apart from these, a suction bulb like DeLee mucus trap, several suction catheters, feeding tube, and syringes were arranged. In case the intubation was not necessary, inflatable bags were checked to be ready with cushioned face masks, and airway tubes were made handy (Royal College of Paediatrics and Child Health, 2000). The mother’s medication history and social history in terms of drugs or alcohol and duration that she was on antenatal care were very important in predicting the outcomes from the perspective of the newborn. I checked for those data in the records while examining the progress of the labour as recorded in the chart. Supply of medications on the resuscitation tray was checked, and similar resuscitative medications were arranged in the SCN. These were epinephrine hydrochloride, naloxone hydrochloride, sodium bicarbonate, dextrose 10%, sterile water for injection, normal saline, and volume expanders such as Ringer’s Lactate, Normal Saline, or albumin. I instructed a prewarming of the delivery room to an ambient temperature of 25 degrees, and an overhead radiant warmer was kept ready (Johansson S, Montgomery SM, Ekbom A, et al., 2004). Part B: Suzy progressed rapidly to full dilatation, and the baby was delivered uneventfully. As the head was being delivered, I requested the delivery room staff to check whether the mouth was full of meconium. Before even assessing the baby, the baby was placed supine on his left side with the neck in the neonatal position on the resuscitation tray. Gentle suction was done for 3 to 5 seconds while the baby’s heart was monitored. During this initial stabilization, I started the assessment. The baby was received in a dry towel and was gently dabbed to remove excess vernix and amniotic fluid. This also would serve to provide gentle tactile stimulation expected to help initiating breathing. I instructed to switch on the radiant warmer (Sinclair JC., 2002). A small hand towel was folded and placed under the shoulder blades of the baby to gently extend the neck. With a second bulb suction device, the mouth was aspirated first, then the nose. The reason for this is suction of the nose would initiate breathing, and that would cause aspiration of secretions in the oropharynx down into the lungs, further worsening the situation. Mouth was examined, there was no evidence of thick meconium in the oropharynx. I gently rubbed the baby’s lower back and flicked the sole to provide tactile stimulation for initiating breathing. In this way 20 s of time passed, but breathing did not start. I monitored the heart rate of the baby, but still the heart rate was below 100 and colour was not pink. An assessment of Apgar scores gave a result of 6 at 1 minute of birth, and I decided that further action was necessary. The self-inflatable bag was attached to the oxygen source, and an appropriate-sized padded mask was placed on the newborn’s face. The baby was ventilated three times and observed for rise of the chest with each compression of the bag. As with all acute airway resuscitation, my aim was to ensure airway patency and to support the breathing and circulation. The chest was rising but not to the extent that I expected, and this was most probably due to the fact that I could not apply the mask appropriately with a perfect fit around the face. I reapplied the face mask taking care to plug the air leak, repositioned the baby’s head, aspirated the secretions, and slightly boosted the ventilation pressure with the bag. The chest was seen to rise up with each squeezing pressure on the bag, the baby was ventilated for 15 to 30 seconds with 100% oxygen (Royal College of Paediatrics and Child Health, 2002). Failure to establish regular breathing in the first minute after birth indicates assisted ventilation in order to inflate the premature, poorly complaint lungs to recruit alveoli for gas exchange. As described earlier, about 5 initial inflation breaths of 2 to 3-second duration followed by ventilation at a rate of 40 breaths per min using pressure of 20 to 25 cm of water could ultimately establish spontaneous breathing after about 4 minutes. As with all acute resuscitations, the aims were to ensure airway patency and support the breathing and circulation. The colour, respiratory effort, tone, and heart rate were assessed, and the Apgar scores improved at 5 minutes to 8. Heart rate per minute was calculated precisely since this was the next best indicator for adequate resuscitation. However, the baby was not yet stabilized, and after a brief show to the parents, the newborn was quickly transferred to the SCN, and the baby was admitted to the nursery for stabilization (Royal College of Paediatrics and Child Health, 2002). On a scale of priority, the first thing was to maintain temperature and airway suction, patency of the airway followed by oxygenation, establishment of effective ventilation, chest compression to maintain haemodynamic status, and then drugs if necessary. Commonly 100% oxygen is used, and we used bag mask ventilation to induce positive pressure ventilation. Usually for infants greater than 32 weeks of gestation, who shows a delayed response with face mask ventilation, may need an endotracheal intubation in the following care. This baby did not need chest compression since the heart rate improved to 80 beats per minute after ventilation. No drugs were necessary. After the baby was admitted to the nursery, the baby was noted to have grunting respiration, nasal flaring, and chest recession. While maintaining the existing management, I requested a neonatologist visit for opinions regarding management assuming that the baby is going to deteriorate. For this purpose maternal-fetal medicine experts, obstetrician, neonatal nurse practitioner, and nurses from labour and delivery unit would be involved in the care apart from the neonatologist. In my opinion, a clear communication and effective collaboration between these team members are the key components that need to be achieved for a successful outcome in this baby. It was expected that the ventilation would go beyond to the next phase, so an orogastric tube was inserted to relieve abdominal distention. Since positive pressure ventilation just helped momentarily, it is highly possible that the baby would need eventually more aggressive intervention such as haemodynamic support, oxygen supply, endotracheal intubation, protection against infections (Kenyon S, Taylor D, Tarnow­Mordi W., 2001), positive pressure ventilation, and drugs (Royal College of Paediatrics and Child Health, 2002). It was obvious that Dan’s prematurity and acute status were going to play havoc on both Suzy and John’s mind. The birth of premature infant is a matter of stress to the mother and father both. The very distance created by the baby being treated in an acute condition away from the mother produces insecurity in the parents and may be the cause of emotional instability in them. I being in charge of caring the baby when his condition is unstable and vulnerable, both, I had a responsibility to provide a sensitive, nurturing, and stimulating environment to the parents. In my opinion (Halpern, L. F., Brand, K. L., & Malone, A. F., 2001), keeping Suzy and John abreast about their child’s actual condition explaining the reasons about why a certain procedure is done on Dan, what were its benefits, what are the overall risks that Dun is exposed to in the nursery, and what was the expected future course were important, and I made it a point to meet them at least thrice to inform them about Dun’s condition. This was perceived to be an alternative to bonding between Dun and Suzy and John in the absence of the usual well-timed interactions and the usual behavioural, emotional, and social responses that would have been otherwise present in the case of a normal delivery. The birth of a premature infant and his hospitalization in any form disrupts the expected interactive development of bonding, and the main reasons are situational and environmental circumstances associated with this kind of high-risk birth and its management and attendant deterioration of the quality of parent, specially mother-infant interaction. While the baby was in the focus, during the care the parents were not ignored. The baby in the SCN will continue to receive monitoring, airway and haemodynamic surveillance, oxygen therapy, temperature control, positive pressure ventilations, and medical therapy as advised by the neonatologist (Horbar JD, Badger GJ, Carpenter JH, et al., 2002). Part C: The baby was placed on 30% head box oxygen to maintain his oxygen saturations within the acceptable range. For the risk of aspirations due to underdeveloped oesophageal reflexes, he was put nil orally and the orogastric tube was retained. He had an intravenous cannula inserted and commenced on 10% dextrose at 80 mL/kg/day to take care of the calorie and fluid balance. While observation continued, overnight, Dan had increasing tachypnoea indicating increasing oxygen requirements, and by morning, he was requiring 60% of oxygen to maintain oxygen saturations. I placed a call to the medical officer as contemplated earlier, since I thought Dan will be needing more intensive management of his condition that is getting progressively critical. While waiting for the medical officer to arrive, he had an apnoeic spell. The medical officer examined him and advised transfer and management in the Neonatal Intensive Care Unit (NICU). Suzy was called to the postnatal ward to be informed about Dan’s present status and future course, and John was also called at home to keep him informed about the changed condition and plan. While reflecting on the condition of Dan and thinking about the reasons about why he was having these apnoeic spells and progressively increased requirement of oxygen despite support, there were several possibilities. These might be as simple as obstructive sleep apnoea, congenital pneumonia, aspiration, transient tachypnoea of the newborn, diaphragmatic hernia, congenital lobar emphysema, and as complex and article as respiratory distress syndrome. This condition was more likely given the scenario of prematurity where apart from other factors discussed above, there is a high probability that Dan was having surfactant dysfunction, hypoxaemia, and may be superimposed infection aggravating his condition. His chest x-ray and blood gas analysis was suggesting so, and therefore, he would need a transfer to the NICU. From my experience, I can recollect that low birth weight babies who require extended mechanical ventilator support often present with episodes of hypoxaemia. These are usually detected by monitoring of arterial oxygen saturation by pulse oximetry and should be ideally assisted with transient increase in the fraction of inspired oxygen. It has been suggested by the guidelines that some categories of newborn babies would not recover or stabilize with care in the special care nursery. In case of Dan, although his period of gestation was 33 weeks and the birth weight was just more than 1.5 kg, he had apnoea at birth followed by apnoeic episodes in the SCN despite monitoring and management of hypoxaemia (Symington, A., & Pinelli, J., 2000). This itself constitutes an indication for transfer to the NICU, especially when his oxygen requirement was gradually increasing and he was not stabilized despite management in the SCN. The reason I am saying that Dan’s diagnosis perhaps is respiratory distress syndrome is consistent with the clinical picture of Dan. Chest x-ray and blood gas measurement is the mainstay of diagnosis, but this is prevalent in the premature, underweight babies due to immaturity and deficiency of pulmonary surfactant system. Absence of surfactant leads to collapse of the alveoli which even though perfused do not allow any exchange of gases leading to hypoxaemia. Hypoxaemia, in turn causes severe pulmonary vasoconstriction shunting the blood from right to left. Effective therapy would break this cycle of otherwise continued hypoxia, and subsequent metabolic and respiratory acidosis are prone to occur. To manage such a situation in Dan, it is appropriate to transfer him to the NICU where repeated clinical and biochemical assessments can be done along with technical help from different monitoring systems. The basic management would constitute providing a warm environment, supplying fluids and calories, and providing adequate oxygenation. The RDS scoring system may be used to decide the mode of oxygen therapy which may be CPAP or mechanical ventilation depending on the severity. The goal of the therapy would be to keep the spontaneously breathing baby in an oxygen hood and providing warm humidified oxygen to maintain arterial oxygen concentration to maintain PaO2 level between 50-80 mmHg. As discussed earlier, Suzy and John need to be supported by utmost care. All information was shared with them, and their choice about aggressive intervention must be incorporated in the management plan. They were also assured that any decision to withhold or start resuscitation would be revised depending on clinical circumstances and their informed options. If feasibly Suzy and John were allowed to spend time with the baby. Privacy and sensitive supports were allowed. It was made explicit to them that management decisions about Dan would be at his best interests conforming to the state of the art facilities and all possible outcomes were shared with them depending on the data from the prevalent literature. When Dan is being transferred to the NICU, it was important that all records accompany him. Transit oxygen supply apparatus were to be checked and fixed up, and all other cares such as skin, eye, stomach cares, were executed appropriately under a sterile environment (Talmi, A., & Harmon, R. J., 2003). While reflecting on this, I found that in most cases I could observe standards of care as a neonatal midwife, except during the immediate resuscitation postdelivery, there was an episode of air leak through the mask. I collaborated well with all the other disciplines, and hopefully, Dan will be back to normal with support in the NICU. Reference List British Paediatric Association, (1993). Neonatal Resuscitation. London, United Kingdom: The British Paediatric Association. Joint Working Party of Royal College of Paediatrics and Child Health and Royal College of Obstetricians and Gynaecologists, (1997). Resuscitation of babies at birth. London: BMJ Publishing Group. 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Broad­spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. Lancet;357:979­88. Lyon AJ, Stenson B., (2004). Cold comfort for babies. Arch Dis Child Fetal Neonatal Ed.;89:F93–F94 MacDonald H, (2002). American Academy of Pediatrics, Committee on Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics;110:1024–1027. Resuscitation Council (UK) (2002). Resuscitation at birth: newborn life support provider course manual. London: Resuscitation Council (UK). Royal College of Paediatrics and Child Health, (2000). Resuscitation of Babies at Birth. London, United Kingdom: Royal College of Paediatrics and Child Health. Royal College of Paediatrics and Child Health, (2002). Guidelines for Good Practice. Management of Neonatal Respiratory Distress Syndrome. London, United Kingdom: Royal College of Paediatrics and Child Health. Sinclair JC., (2002). Servo-control for maintaining abdominal skin temperature at 36°C in low birth weight infants. Cochrane Database Syst Rev. 2002;(1): CD001074. Symington, A., & Pinelli, J. (2000). Developmental care for promoting development and preventing morbidity in preterm infants. Cochrane Database of Systematic Reviews (Online: Update Software), 4, CD001814. Talmi, A., & Harmon, R. J. (2003). Relationships between preterm infants and their parents: Disruption and development. Zero to Three, 24(2), 13–20. Read More