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Caring for the small and sick neonate

Caring for the Small and Sick Neonate

Introduction

This assignment will critically discuss the care given to Emma (Twin 1) who developed Respiratory Distress Syndrome (RDS). She weighed 1200 grams at 31 weeks gestation and fell into the category of very low birth weight but was appropriate for her gestational age. The Pathophysiology of RDS will be critically explored alongside its aetiology and its effects on the neonate with particular reference to hypoxia. The psychological effects on the family will be discussed as well as the ethical issues that were confronted. The role of the midwife will also be discussed particularly her required statutory duties related to the sick neonate being cared for by the miltiprofessional team. Bain (1999) states that the admission of the neonate to the neonatal unit disrupts the normal course of events that surround the birth of a baby. Liaison between the midwife and the multidisciplinary team is vital in involving the parents, as partners in care. Full informed consent has been given by Anna for the use of her records to aid in this care study. As instructed by the United Kingdom Central Council UKCC (1992), all details identifying the individual has been changed in order to maintain anonymity and confidentially.

Respiratory Distress Syndrome (RDS) or Hyaline Membrane Disease (HMD) is responsible for the most number of neonatal deaths, from a single disease, in normal, live born babies. It most commonly affects preterm babies, especially those of less than 34 weeks’ gestation, babies born by caesarean section or after antepartum haemorrhage and babies of diabetic mothers. Gestational age correlates to the incidence of respiratory distress syndrome (RDS), with those of low gestational age being at greatest risk. Approximately 25% of babies at 34 weeks’ gestation are affected, whilst 90% of 26 weeks’ gestation babies require treatment (Halliday et al, 1985). According to Klause and Fanaroff (1993) approximately 10% of all preterm neonates are affected with the greatest incidence occurring in those weighing less than 1500g (3lb.5oz.) It is not fully understood why some neonates at 28 weeks gestation do not develop RDS while some at 38 do develop RDS.

In Emma’s case the cause of RDS was thought to be due to prematurity, suspected from IUGR, poor placental perfusion and an increased risk as she was born by caesarean section. IUGR is often considered to cause a boost to surfactant production because of the endogenous cortisol that is produced by the fetal adrenal gland. Surfactant is produced from 22-24 weeks gestation but does not reach maturity until 34-34 weeks gestation. It begins to be excreted into the lung alveoli at 22 weeks with surges at 33 weeks and again at birth. Surfactant is a phospholipid, which reduces surface tension in the alveoli where air and fluid interface, thereby facilitating lung expansion. It prevents the complete collapse of the alveoli during expiration so that when there is a deficiency of surfactant a greater negative intrathoracic pressure is required to inflate the alveoli with every breath. According to Anderson et al (1994), atelectasis or imperfect expansion of the lungs, with poor gaseous exchange, is the main problem in RDS. Pressures in the alveoli become unequal and some take longer to fill than others. The normal alveoli become overdistended and the smaller ones collapse, reducing functional residual capacity and creating dead space within the lungs (Blackburn & Loper 1992).

The twins were delivered by elective ceararean section at 31+2weeks gestation due to suspected IUGR detected in twin 1 (Emma). The multidisciplinary team was present should resuscitation be needed. Following their delivery tactile stimulation was initiated through quick drying and being kept warm by towels. Facial oxygen was administered but within a minute respirations were established. Emma did not have hypoxia at birth and scored an Apgar of 9 @ 1+ 5 minutes. It is the duty of the midwife that the infant is correctly identified with a name band corresponding to the mother’s hospital number, the name, date and time of birth, twin 1 & 2. These were checked with Anna’s mother who was present at the delivery. Complying with the hospital policy a name band was attached to each of the twins’ ankles and information was given to Anna if any of the name bands were absent. It is a statutory requirement enacted by the UKCC that the midwife keeps detailed records that must be made as contemporaneously as is reasonable. Record keeping is an essential aspect of midwifery practice as stated in rule 42. It is one of the requirements that the midwife records details of the delivery. Every person that is present at the delivery must also be recorded, as this is hospital policy in the event that any litigation would be encountered in the future. It is also the duty of the midwife to notify the Registrar of Births and Deaths within 6 hours of birth UKCC (1998). As both Emma and Kerry was at risk of developing RDS and hypoxia they were closely monitored in the neonatal unit to detect early signs of the condition and were been constantly observed of skilled nurses, midwives and paediatricians working as a team, indeed neonatal intensive care has been described as the most successful of all medical technologies (Neonatal Association Working Party 1994). During the twins admission on to the neonatal unit it was not addressed that they might die however they were considered to be critical and Anna was continuously updated about their condition from the midwife communicating with the multidisciplinary team. While Anna was admitted to the Antenatal ward she was shown around the neonatal unit and introduced to the team that would be caring for the twins. This helped Anna adapt a positive attitude and it was emphasised that her twins were expected to live and that she too had an important role to play in their care. A friendly environment in the neonatal unit reassured Anna and this gave her the opportunity to ask questions. It is important for the multiprofessional to be truthful with Anna; this is also essential in providing holistic midwifery care. Support for parents is essential during the initial phase, as everything is a blur of shock, bewilderment and fear. Parents and family often feel vulnerable and rely on a confident team for reassurance, and as Farrell & Frost (1992) agree a friendly attitude displayed by the multidisciplinary team, enables parents to start working through their stress and grief. Empowering parents, that is redistributing the power of responsibility for the baby between nurses and parents to one which initially becomes more balanced, encourages independence and trust between parents and professionals (Skelton 1994).

Throughout hospitalisation of the twins and Anna, the midwife provided support by listening and accompanying Anna to the neonatal unit. This ensured that there was continuity of care and carer as stated in the Changing Childbirth (1993). This helped Anna to build up a rapport with the midwife whereby early signs if anxiety can be detected and relieved. This also helped Anna with the transition to parenthood. According to Crnic and Greenberg (1987), social support has been identified as a mediator of anxiety, hostility, depression and adjustment in the normal transition to parenthood, particularly in parents of low birth weight infants.

Emma was nursed in a incubator to avoid hypothermia not only because it leads to an increased consumption of oxygen and use of more energy to produce heat, but also as it may inhibit the production of surfactant. She was partially dressed to conserve heat leaving the chest exposed as it was continuously observed for chest recession. Emma’s temperature on admission to the neonatal unit was 36oC. Ideally her temperature should be maintained between 36.5 - 37oC. Neonatal thermo regulation is a problem as neonates are not able to utilise adults’ methods to maintain heat. They usually have a large surface area 3 times that of the adult from which to lose heat, relative to the small mass to produce heat and the head makes up 25% of this area. The maintenance of Emma’s temperature was achieved by providing an ideal environmental temperature, the thermoneutral environment, which is a very narrow range for a small naked baby (Kelnar et al 1995). An incubator providing an ambient temperature of 36oC and a bonnet to prevent heat loss from her head was sufficient in Emma’s case. Due to the large surface area to weight, fat stores are often quickly depleted including the brown adipose tissue, which is utilised in the neonate for energy. The very low birth weight baby (VLBW, <1500g) is less able to withstand the metabolic consequences of hypothermia so thorough drying soon after birth and skin to skin contact with the mother helps to maintain the thermal neutral environment. Babies with RDS often do not present with respiratory signs at birth but do so gradually over a few hours. This is because the neonate is using the available surfactant made from 24 weeks gestation, but as it starts to run out it is not replaced quickly enough. Shortly after Emma’s birth she developed signs of respiratory distress, which is caused by an increasing hypoxia (oxygen below normal range in the blood and tissues) and hypercapnia, (raised levels of carbon dioxide in the blood and tissues). Emma signs included respirations >60 per minute with increased respiratory effort, intercostal recession and grunting on expiration. Grunting on expiration indicated that she was expiring against a closed glottis, thus maintaining a higher residual lung volume, preventing the alveoli to collapse and in this way the neonate compromises and is able to maintain gaseous exchange in the lungs. In addition there was chest wall recession and Emma was unable to maintain her oxygen saturation. This appeared to be the result of depleted surfactant whereby the alveoli collapse and the lungs lose their compliance. Reduced synthesis of surfactant can also be due to the presence of lung fluid as in a normal vaginal delivery the lung fluid is squeezed out during descent through the birth canal and surfactant is released into the airways. Robertson (1995) agrees that infants that are delivered by caesarean section are at an increased risk of RDS as they are denied the b adrenergic mediated surfactant release and reduction in lung fluid that occurs in the lungs in the proceeding 24-48 hours to delivery. Relief of hypoxia is essential to prevent brain damage. It was evident that her oxygen requirements were increasing, so Intermittent Positive Pressure Ventilation was commenced via a bag and mask by the neonatal nurse. This was continued for 2 minutes. Emma showed signs of improvement by becoming pink and her haemoglobin saturation increased to 92-96%. She was also maintaining a heart rate of 140-160 beats per minute (bpm) showing no signs of bradicardia. Emma continued to be nursed in 39% humidified oxygen thus providing oxygen enriched air whereby she continued to maintain her heamoglobin saturation and respiration rate of 50 – 60 resps. per minute. As with any medication, oxygen needs to be administered carefully and if oxygen levels are not monitored it can be toxic causing retinopathy of prematurity. This is caused when the capillaries of the premature retina die when perfused with blood with high oxygen content, (Robertson 1995).

Emma’s condition remained stable and enteral feeding was implemented. Breast milk is the milk of choice for any baby in the neonatal unit and a continuos feed of 0.5 mls per hour was commenced via a nasogastric tube. This helps to stimulate the gut hormones and encourage maturity thus preventing gut stasis and necrotising enterocolitis, Morgan (1992). Anna was happy to express her milk although she hadn’t intended to breastfeed. Breast milk can significantly reduce the risk of infection in the very low birth weight and reduces the incidence of necrotising enterocolitis, Lucas et al (1994), possibly because of the immunoglobulins (IgA) in the breast milk. Contrary to Anna not wanting to breast-feed she was happy to express milk. This was obtained by informed consent as the benefits of breast milk were explained to Anna. Prior to the twins delivery by caesarean section Anna had expressed 10 mls of breast milk which was in the neonatal unit. This had positive effects for Anna and boosted her self esteem as she felt she was contributing to their nutrition and that they were getting the immunity that they needed. It is the role of the midwife in the postnatal period to ensure that Anna makes a good recovery both physically and emotionally. Good communication skills are vital and the recognition of sign of distress should be resolved. Both Emma and Kerry were discharged home at one month old to the care of the Health visitor and the Family Care Sister.

Conclusion

This assignment has critically discussed the care of Emma (Twin 1) who suffered the effects of been a very low birth weight baby and developing Respiratory Distress Syndrome. The pathophysiology of RDS has been analysed and the care evaluated. The statutory duties of the midwife in the delivery room and then caring for the postnatal woman and her family whilst visiting on the neonatal unit have been discussed. The ethical dilemmas of information giving and truth telling have been briefly included. Finally, the role of the midwife who professional applies the medical model. Finally, it has argued that the midwife is an important member of the multiprofessional team, who despite role constraints, is able to successfully integrate the holistic midwifery model into the medical model in order to enhance the care of postnatal women and their babies.

References

Arias F. 1993 Practical Guide to High Risk Pregnancy and Delivery. Mosby Year book, Chicago.

Anderson KN, Anderson LE, Glanze WD (eds) Mosby’s Medical, Nursing and Allied Health Dictionary, 4Th. Edn. Mosby, St. Louis.

Bain J (1999) Recognizing the Ill Baby. In: Myles textbook for midwives. Bennett R, Brown L (editors) 13Th. Edition. Chpt. 38, pp 749-763. London. Churchill Livingstone.

Blackburn ST, Loper DL. 1992 Maternal, Fetal and neonatal physiology, A clinical perspective. WB Saunders, Philadelphia.

Crnic K, & Greenberg M. 1987. Maternal stress, social support and coping: Influences on the early mother-infant relationship. In research on support for parents and infants in the postnatal period, Boukydis CFZ, ed. Norwood, New Jersey: Ablex, 25-40

Enkin. M, Keirse. M, Renfrew. M, & Nelson. J (1995) A guide to effective care in pregnancy and childbirth, Oxford University Press, Oxford.

Farrell MF, Frost C, (1992) The most important needs of parents of critically ill cjhildren. Intensive and Critical Care Nursing, 8, 130-139

Halliday, H.L., McClure, G. & Reid, M (1985) Handbook of Neonatal Intensive Care, 3rd. edn. London: Bailliere Tindall

Klause MH, Fanaroff AA. (1993) Care of the High Risk Neonate, 4Th. Edition. WB Saunders, Philadelphia

Kelnar CJH, Harvey D, Simpson C. 1995 The sick newborn baby. Bailliere Tindall, London

Lucas A, Morlet R, Cole TJ. (1994) A randomised multicentre study of human milk versus formula and later development in preterm infants. Archives of Disease in Childhood, Fetal and Neonatal Edition, 70 (2), 141-146

Maresh M. Neales K (1995) High Dependency Care of the Obstetric Patient. In: High Risk Pregnancy. Management options. Chpt 73 pp 12227 (5Th. Edition) James D, Steer P, Weiner C, Gonik B, (editors) London. Saunders Co.

Morgan JB. (1992) Nutrition in the very low birth weight infant. Care of the critically ill, 8 (3), 122-124

Skelton R (1994) Nursing and empowerment: concepts and strategies. Journal of Advanced Nursing. 19, 415-423.

Ten Centre Study Group (1987) Ten centre trial of artificial surfactant (artificial lung expanding compound) in very premature babies. Br. Med. J. 294: 991-996

Bibliography

Bonnar. (1995) Recent advances in Obstetrics and Gynaecology. No. 13. Churchill Livingstone. London

Campbell and Lees. (2000) Obstetrics by ten teachers. 17Th. Edition. Arnold. London.

Clement. (1998) Psychological Perspectives on Pregnancy and Childbirth. Churchill Livingstone

Enkin, Keirse, Neilson, Crowther, Duley, Hodnett AND Hofmeyr. (2000). A guide to effective care in pregnancy and childbirth. 3rd. EditionOxford University Press.

Fraser (2000) Professional Studies for Midwifery Practice. Churchill Livingstone.

James, Johnson and McEwan. (2000) An obstetrics and Gynaecology Vade-Mecum. Arnold. London.

Naidoo and Wills (2000) Health Promotion: Foundations for practice. 2nd. Edition Bailliere Tindall. London.

Sweet (1997) Mayers Midwifery: A textbook for midwives. 12Th. Edition. Balliere Tindall. London.

Stables (1999) Physiology in Childbearing: with anatomy and related bioscience. Bailliere Tindall. London



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