Category: Health care

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Neonatal Resuscitation

Introduction

Is there a thing that is as defenseless and precious as a baby who is newly born? I agree with the fact that thousands of babies in the United States are premature before their small bodies can sustain life.  The normal time needed for a fetus to be fully developed in to a normal baby is usually thirty six to forty weeks. Premature infants therefore, are those born before the thirty sixth week.

Infants born before the twenty sixth gestation week have anatomically underdeveloped lungs and, they cannot physiologically support ventilation. I appreciate that there has been giant leaps forward within the last decades which has enabled us all but the most premature and smallest infants.

Currently, analyzing the Millennium Development Goals on Neonatal resuscitation in the developing world indicates that there is an impressive progress in child health. However, there is barely any notable achievement as far as neonatal health is concerned. Neonatal deaths’ proportion (death within the initial twenty eight days) is anticipated to increase as a result of the reduction in postneonatal deaths burden.  

The World Health Statistics shows that the health-related MDGs indicate that approximately thirty seven percent of the under-five mortality is usually within the neonatal period. Most deaths occur during the first week (early neonatal period). More than one million neonates lose their life within the first twenty four hours as a result of poor quality care, globally and annually.

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Continuum of Care

The key principle in developing strategies aimed at addressing (NHC) Neonatal Health Care revolves within the continuum of care. Throughout the lifecycle, including childhood, childbirth, pregnancy and adolescence, the care need to be offered as a seamless continuum spanning the health center, community and home, globally and locally (Atkins and Murphy, 1994, 50).  Therefore, decreasing child mortality depends entirely on managing neonatal mortality or otherwise, tackling Neonatal Health Care.

Personal Experience

I am a RRT (Registered Respiratory Therapist) and have worked in NICU (Neonatal Intensive Care Unit). Additionally, I have visited many other units as part of the duties as a Respiratory Care nurse. I have experienced the procedures and tests, the angst and waiting as well as the sensitive roller coaster of emotions that both parents and child endure. In case the infant is developed adequately and is strong enough for survival, there is anxiety concerning the quality of life for the child and the family that has to cater for the child’s specific needs.

Is the cost measurable in terms of real dollars and emotionally? Mezirow (1990) argues the mortality and morbidity rates in particularly low birth weight children is remarkably high; it is in fact, so high that the sole ethical choice is to leave them die a painless and natural death. Infants that are born before the twenty fourth gestation week need not be resuscitated for financial, medical and ethical reasons.

Medical ethic principles are justice, beneficence, non-maleficence and respect for autonomy. These principles act as the guideline for health care professionals when dealing with all their patients. There is no exception. Respect for autonomy recognizes “the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act” (Lim et al, 2000, 492).

In the case of neonates, the biological parents have the responsibility of making the child’s health care decisions, as far as ethics in medicine is concerned. The non-maleficence principle implies that healthcare professionals should not create needless injury or harm intentionally to the patient, either with omission or commission acts. All procedures ad tests should have their benefits weighed. Beneficence can be defined as “the duty of health care providers to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient”.

In respect to the justice principle, each patient should be given what is rightfully theirs. Equal persons should be given equal treatment (Speck, 1985, 93).  Moreover, patients need to be treated with honesty and dignity, and together with their families, the healthcare community’s total disclosure is necessary so that they are able to make informed decisions. Even if, a health care professional does not agree with the decision made, it is necessary to treat the patient with dignity; the choice should be respected.

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My Critical Experience

From my many years of practice as a nurse, I choose this critical experience since it was tremendously emotional and had a profound impact on me until today. Douglas was delivered at twenty five weeks of gestation with a weight of five hundred and fifty grams. He was born spontaneously preterm in vertex presentation. His primigravida single mother, Annette, had pre-eclampsia which led to the preterm birth.

Annette was given a dose of steroids thereby delivering Douglas within the next hour. Using antenatal steroids is considered as critical intervention in anticipation of prematurity which improves preterm babies outcome (Teasdale, 2000, 581).

At birth, Douglas’ condition was critical and therefore, the need for resuscitation. As mentioned earlier, surfactant treatment is administered to preterm infants having respiratory distress since they lack a protein referred to as surfactant which prevents the lung’s small air sacs from collapsing. Douglas was therefore given surfactant treatment together with a breathing mechanical ventilator aid so that his lungs could remain expanded.

The boy’s condition improved, and he was successfully transferred to CPAP (Continuous Positive Airway Pressure).  This was aimed at delivering pressurized air to his lings via small tubes in the nose to help in breathing. Douglas developed bleeding in the brain (intracranial bleed) of grade III on the second day. Intracranial bleed is prevalent during the first 3 days of life and an ultrasound examination diagnoses it. Mild intracranial bleeds resolve themselves and no of few lasting problems (Miles, 1989, 71).

More severe bleeds cause the brain ventricles to expand rapidly, causing brain pressure which brings about permanent brain damage. The results are neuro developmental delay or cerebral palsy. Douglas also had PDA (Patent Ductus Arteriosus), a common heart problem in premature babies. This however did not need treatment as it was small.

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Irrespective of the boy’s critical condition during the first week in life, there was an improvement in his general condition. Naso-gastric tube feeds started being used, and intravenous fluids stopped (Shields-Poe and Pinelli, 1997, 32).  While still an inpatient at the hospital, Annette visited Douglas for 2 days during which she was updated of his critical condition. Annette did not bond with her son comfortably, although the nurses encouraged her to.

She gave excuses so that she could not express milk and therefore Douglas was fed with donor breast milk. On the 3rd day, she was discharged, and she visited only once every week. However, she called nurses most of the times to enquire about his progress. Annette’s behavior was brought to the attention of a social worker, and it was reviewed. When I was delegated to look after Douglas, I met the mother once during which I spoke with her and encouraged her to hold and touch the baby which she did.

On the 22nd day after birth, the CPAP was working for Douglas; he could tolerate the feeds and was adding weight. For the six days I took care of him, his general condition was satisfactory. Annette called at nights to check on Douglas’ condition. I informed her he was stable with a 30 grams weight gain. She was enthralled and promised to come the following day.

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On my seventh night duty, on the twenty eight days after birth, I was surprised to meet Douglas re-intubated and on Nitric oxide high frequency mode ventilator. Douglas has developed PPHN (Persistent Pulmonary Hypertension), stopped breathing and was cyanotic. According to Wood (2009), preterm PPHN is linked to high risk adverse neurodevelopmental and health outcomes. To date, it is among the most complicated conditions experienced in NICU.

His critical condition made him be supported using various intravenous infusions, among them morphine to manage pain. Annette had visited at day time and cuddled her baby. She also has a social talk with the in-charge nurse and she was to come during the evening and stay overnight with her son. Unfortunately, Douglas succumbed to cyanotic attack after she left. She was updated of this on her way back to the hospital. On arrival, Annette and the friend she had come with were confused to see the extreme technical situation surrounding the boy.

I offered a drink and a chair to Annette. The serving consultant counseled her and recommended the life support to be withdrawn since Douglas IVH was at grade IV. Annette was unable to decide on the care withdrawal. She begged to leave and come back with her mother the following morning to discuss the situation further and come up with a decision. She immediately left.

At NICU, 4 nurses are delegated with the responsibility of receiving admissions from the theatre and labor ward and taking care of sick babies. We were 3 three nurses that night as a result of staff shortage. An emergency came from the clinical nurse manager from the labor room. One of the nurses rushed to the labor room and brought back twenty eight weeks preterm Mark who was intubated. He required medications and infusions and since his condition was grave, attention was focused to him.

After Mark settled, I was beside Douglas when I realized that his heart rate had gone down to 120 per minute from the usual 160 per minute. The consultant agreed with me that nothing more could be done. The morphine infusion had to be increased to manage pain (Reid, 1993, 307). I called Annette as they were driving home with the friend to inform her of the development. She confirmed that she would come back the following with her mother as earlier agreed.

I touched Douglas’s hand soothingly and wished Annette was there to console and hold him. Suddenly, the nurse attending to Mark called out for drugs as Mark had developed cardiac arrest. We worked to resuscitate Mark but I could see that Douglas was also going in to an arrest since there was continuous drop in the heart rate. Mark was the priority at the moment but I wished I could go over to Douglas and console him.

His monitor stopped indicating vital signs. Mark died shortly after Douglas. We did all we could have done to save the two lives but as with hundreds of other babies, we were unsuccessful.  The social worker had to follow Annette to provide further care.

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The Care of Premature Newborns

“Good ethics begin with compelling facts” is a guiding principle when dealing with ethical care for premature newborns. So as to make a profound decision, the first thing is the qualified obstetrician to assess and gather all the necessary information utilizing all the available resources. Consequently, the parents need to be informed in a way that they can understand (respect for autonomy).

“It should be emphasized that there is some uncertainty with any predictive process, because every infant is unique. The prognosis for the fetus may change after birth, when a more accurate assessment of the gestational age and actual condition can be made” (Daly et al, 2004, 2).After the fetal weight and gestational age are determined; the parents should be presented with the facts and counseled on the child’s possible outcomes.

It is imperative that the health care team and physician address the process of decision making as a team, together with the parents. Moreover, the parent’s belief system and desires as well as the child’s needs should be kept at the forefront. The Journal Pediatrics have categorized the treatment decisions and summarized them on prognosis basis as:

1.         In case there is a high likelihood of early death and survival would encompass high risk of morbidity that is unacceptably severe: intensive care not indicated.

2.         In case there is a likelihood of survival and the risk of inadmissibly severe morbidity is small: indicate intensive care.

3.         In cases that fall within the mentioned categories and there is uncertain prognosis and likely extraordinarily poor, and survival encompasses diminished child’s quality of life, parental desires determine the approach for treatment. (Carkhuff, 1996, 211).

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During the last few decades, there has been an improvement in the prognosis for tremendously premature infants. However, many of the exceptionally small and extremely premature infants die or possess a morbidity rate that is unacceptably high. In this population, the medical complications are usually profound and complicated. Some complications result from the birth event and others are congenital defects. Majority of the morbidities are linked to immature lung development.

Fetuses produce surfactant, an essential proper lung function protein, at the age of thirty two weeks. Surfactant deficiency is treated by medical science by refining and producing porcine and bovine surfactant. However, this is usually not as effective compared to native surfactant.  There is the instantaneous complication of reduced delivery of oxygen to the brain, organs and blood. Besides this, the long term complication is anoxia, brain injury as a result of inadequate oxygen supply to the brain. High morbidity rates attract the greatest categories of complications.

Majority of the morbidities bring about profound and severe disabilities, and cause early demise (Murphy et al, 2003, 227). The mortality rate of neonates in this group is relatively high, and the severe to moderate morbidity rate is more than fifty percent. It is worth noting that the statistics for very small and very premature neonates indicate a one hundred percent mortality rate. These children possess physical limitations and abnormalities that they have to bear with for their entire lives and which their families need to provide care. The outstanding care is extremely expensive and emotionally exhausting.

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Reflect on the cost of offering care to late preterm vs a term infant. Late preterm have far much less complications as well as complicated medical needs as opposed to Extremely Low Birth Weight (ELBW) neonates, and yet the cost of caring for them during their 1st year of life is astoundingly vast. The cost for taking care of a premature infant who is late term is three times more the cost for term infants.

Extremely Low Birth Weight neonates’ cost is six times a term infant’s cost, if the infant survives. At a national level, the cost for ELBW’s care is staggering. United States spends 5.8 billion dollars annually (Raeside, 2000, 98).  This represents forty seven percent of all infant hospitalization costs and twenty seven of all pediatric stays. 65, 600 dollars is the average cost, where the least viable consume most of the resources.

The figures refer to the initial hospital stay costs. This is the first care as far as caring for children with profound or severe disabilities are concerned. Is this burden fair to the society? These are some of the prevailing questions in the light of the discussion on medicine socialization and healthcare coverage. What is the belief of the society on the value of life? Can a baby’s existence be replaced with the dollar value?

Considering that resources are infinite, should they be used on the few neonates and leave the majority to share the smaller percentage? (Schmieding, 1999, 636). What if it is my child is among those that require disproportionate resources and care to survive? What if my child is among those being given a normal care level since there are few providers as majority of the providers are focused on ELBW who need the highest care level? The answer to these questions will vary depending on the role of a person; a parent, health care consumer or a provider.

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Figure 1: Grave Neonatal Morbidities in < 750 g Birth Weight Infants in the National Institute of Child Health and Human Development Neonatal Centers, 1995-1996

This data is for infants who are alive at twenty days (Cotton, 2001, 515).

Conclusion

Preterm neonates require extensive care to ensure their survival. Major challenges that make this goal ineffective include inadequate nurses and medication. More than often, care has to shift to neonates who require immediate attention. It is sue to these reasons that neonate mortality is still high although there has been an improvement in child care as per the MDGs. It takes a lot of courage to work as a nurse and especially when emphatic with the mother to the neonate infant.

Bibliography

Atkins, S. and Murphy, K. (1994) “Reflective Practice.” Journal of Nursing Standard, Vol. 8, iss. 39, 49-56.

Carkhuff, M. H. (1996) “Reflective learning: work groups as learning groups.” Journal of Continuing Education in Nursing, Vol. 27, iss. 5, 209–214.

Cotton, A. H. (2001) “Private thoughts in public spheres: issues in reflection and reflective practices in nursing.” Journal of Advanced Nursing, Vol. 364, iss. 4, 512-519.

Daly, J. Chang, E. and Jackson, D. (2004) “Quality of work life in nursing: Some issues and challenges.” Journal of the Royal College of Nursing, Vol. 13, iss. 4, 2.

Lim, J. J., Childs. J. and Gonsalves, K. (2000) “Critical incident stress management.” The Journal of American association of occupational health nursing, Vol. 48, iss. 10, 487–497.

Mezirow, J. (1990) Fostering critical reflection in adulthood: a guide to transformative and emancipatory learning. Jossey-Bass.

Miles, M. S. (1989) “Parents of chronically ill premature infants: sources of stress.”Journal of Critical Care Nursing Quarterly, Vol. 12, iss. 3, 69-74.

Murphy, F. C., Smith, I. N. and Lawrence, A. D. (2003) “Functional neuroanatomy of emotions: A meta-analysis.” The journal of Cognitive, Affective, & Behavioral Neuroscience, Vol. 3, iss.  3, 207-233.

Raeside, L (2000) “Caring for dying babies: perceptions of neonatal nurses.” Journal of Neonatal Nursing,Vol. 6, iss. 93-99.

Reid, B. (1993) “But we’re doing it already”, Exploring a response to the concept of reflective practice in order to improve its facilitation.” Journal of Nurse Education Today, Vol. 13, iss. 4, 305-309.

Schmieding, N. J. (1999) “Reflective inquiry framework for nurse administrators.” Journal of Advanced Nursing, Vol. 30, iss. 3, 631–639.

Shields-Poe, D. and Pinelli, J. (1997) “Variables associated with parental stress in neonatal intensive care units.”Journal of Neonatal Network, Vol. 16, iss. 1, 29-37.

Speck, P. (1985) “Counselling on death and dying.”British Journal of Guidance and Counselling, Vol. 13, iss. 1, 89-97.

Teasdale, K. (2000) “Practical approaches to clinical supervision.”The journal of Professional Nurse,Vol. 15, iss. 9, 579–582.

Wood, J. T. (2009) Interpersonal Communication: Everyday Encounters. Cengage learning.

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