Oxford Handbook of Midwifery (135 page)

• In PTV the ventilator rate is controlled by the baby. Every time the baby’s breath exceeds a critical level the machine will deliver a breath. If the infant does not breathe within a predetermined period, the machine will deliver a breath. Every breath initiated by the baby will be ventilator assisted.
  
• SIMV can help to prevent the problems caused by asynchronous breathing. The ventilator breaths can be delivered to coincide with the baby’s breathing. A total number of breaths are decided and any further breaths that the baby takes will be unsupported by the ventilator.
  

Temperature and blood sugar
As well as management of babies’ ventilation needs, management of their temperature and blood sugar levels are fundamental to their survival.

Nutrition

Provision of nutrition can be difficult due to:

Tube and intravenous feeding. Total parenteral nutrition may be required.

Minimal enteral nutrition is small amount of milk given continuously via a nasogastric tube which will help to mature the gut and prepare it for receiving full milk feeds when the baby has matured enough to tolerate feeding.

Once the baby improves, breast or bottle feeding can be introduced. Breastfeeding, or the provision of expressed breast milk, is preferred as it has many benefits for the premature baby, especially for protection against infection and the prevention of NEC. It has also been shown to improve the longer-term development of the brain.
⁴

Physiological jaundice

This occurs because of an immature liver and will probably need treat- ment with phototherapy and or exchange transfusions (b see Neonatal jaundice, p. 604).

CHAPTER 23
Care of the newborn

636

Preventing infection

The baby’s immune system will be immature, resulting in an increased sus- ceptibility to infection.

• Early recognition and treatment with antibiotics is important.
  
• If infection is suspected, carry out a full infection screen and commence the baby on a 10-day course of antibiotics (b see Antibiotic therapies and sensitivities, p. 603).
  
• Scrupulous handwashing and drying by staff and visitors has been proved to be the most effective way of reducing the risk of infection.
  ⁵
  
• All equipment is sterilized and used only for one baby.
  
• Each baby has its own personal equipment for day-to-day care.
  

  Visiting policies
  

• These are in place to protect the baby from too many visitors.
  
• Parents are encouraged to be with the baby at all times.
  
• Other visitors are allowed at the discretion of the parents.
  
• Special arrangements are made for siblings to visit with parental support.
  

  Observations
  

  Make constant observations of:
  

• Colour/activity
  
• Temperature/respirations/blood pressure and oxygen saturation
  
• Incubator and inspired oxygen humidity and temperature
  
• Fluid intake
  
• Ventilator settings and oxygen concentrations.
  

  Record all of these hourly over a 24h period. It is important to keep an
  accurate record of events, as even the slightest change can be very signifi-
  

  cant in detecting the problem as early as possible.
  

  Physiotherapy and suction
  

  While the baby is on ventilation this is carried out by specialist physiother- apists who prescribe a daily treatment for each baby following individual assessment of its requirements.
  

  The physiotherapist will advise the nursing staff and parents about how to correctly position the baby according to his or her gestation and medical needs. This is often referred to as ‘supported positioning’.
  

  The importance of supported positioning
  

• The muscle tone of premature babies is poor and their movement is limited because of underdeveloped muscles.
  
• They tend to lie in a ‘frog-like’ posture with the limbs extended.
  
• Being left to lie for long periods of time without a position change can lead to long-term muscular skeletal and developmental problems.
  
• Several supported positions are used, including prone, supine, and lateral.
  ⁶
  
• The prone position is considered to be the best for preterm babies who are being monitored, as it promotes oxygenation and energy conservation.
  ⁷
  ,
  8
  
• Once the baby is ready to go home, advise the parents to use the supine position as advocated by the DH campaign for the prevention of cot death.
  ⁹
  

  MANAGEMENT OF THE PRETERM BABY
  

  637
  

  Environment
  

  Babies can be affected by constant exposure to:
  

Much research has been done into the possible short- and longer-term effects that these factors have on the baby and how to soften the nursery environment by reducing levels of noise and light, and ways of assessing and reducing the discomfort and distress caused by painful procedures.

The use of therapeutic touch

Premature babies have a poor tolerance to the excessive handling they are often subjected to, but have been shown to have a positive response to parental handling.

Baby massage techniques have been modified for use for premature ill babies. These have become an important way of helping the parents to become involved with their baby by providing a positive loving touch.
¹⁰

Parental needs

The application of family-centred care for parents with a baby in the NICU or SCBU presents a challenge for the nursing and medical staff. These parents:

way, in an alien environment which is also influenced by input from a

variety of nursing and medical personnel

1. World Health Organization (1992).
   International Statistical Classification of Diseases and Related Health Problems
   , 10th revision. Geneva: WHO.
   
2. Roberton NRC (1993). Should we look after babies less than 800 grams?
   Archives of Diseases of Childhood
   68,
   326–9.
   
3. Cameron J (2001). Management of respiratory disorders. In: Boxwell G (ed.)
   Neonatal Intensive Care Nursing
   , 2nd edn. London: Routledge, pp 101–3.
   

   CHAPTER 23
   Care of the newborn
   

   638
   

4. Wheeler J, Chapman C (2000). Feeding outcomes and influences within the neonatal unit.
   

   International Journal of Nursing Practice
   6
   (4), 196–206.
   

5. Yeo H (ed.) (2000).
   Nursing the Neonate
   , 2nd edn. Oxford: Blackwell.
   
6. Downs J (1991). The effect of intervention on development of hip posture in very preterm babies.
   Archives of Diseases of Childhood
   66
   , 797–801.
   
7. Heimler R. Langlois J, Hodel DJ, Nelin LD, Sasidharan P (1992). Effects on the breathing pattern of preterm infants.
   Archives of Diseases of Childhood
   67
   , 312–14.
   
8. Turrill S (1992). Supported positioning in intensive care.
   Pediatric Nursing
   4
   (4), 24–7.
   
9. Department of Health (1991).
   Sleeping Position and the Incidence of Cot Death
   . London: HMSO.
   
10. Appleton S (1997). ‘Handle with care’: An investigation of handling received by preterm infants in intensive care.
    Journal of Neonatal Nursing
    3
    (3), 23–7.
    

This page intentionally left blank

CHAPTER 23
Care of the newborn

640‌‌

Respiratory distress syndrome in the newborn

• RDS is one of the main causes of morbidity and mortality in preterm infants.
  
• The lungs of babies born at 28 weeks or less will be immature, having few alveoli and reduced surfactant production.
  ¹
  

  Surfactant
  

• A substance produced in the type 2 alveolar cells in the lungs.
  
• It is composed of 95% lipid and 5% protein. The lipid adsorbs rapidly to the air–water interface and is responsible for the majority of the surface-active properties of pulmonary surfactant.
  
• Surfactant coats the entire surface of the lung.
  
• It equalizes the surface tension.
  
• It prevents collapse of the alveoli when breathing out.
  
• It stabilizes the size of the alveoli.
  
• It is produced in the fetal lungs from 20 weeks’ gestation.
  
• It is present in small amounts from 24 weeks’ gestation.
  
• It increases steadily up to 34 weeks, when there is a surge in production to prepare for birth.
  

  RDS occurs because of a deficiency of surfactant, which in turn causes atelectasis, and high pressures are needed to reinflate the lungs.
  

  In preterm babies the diaphragm and intercostal muscles are still developing, so that the baby’s efforts to breathe will often be inadequate and the baby will soon become tired, needing mechanical support to help
  

  with breathing.
  ¹
  

  The lack of surfactant leads to:
  

• Alveolar collapse on expiration.
  
• The alveolar walls are thickened due to them not being fully expanded on inspiration, which leads to a decreased amount of oxygen diffusing into the blood, which further leads to hypoxia.
  

  2 The associated hypoxia can cause:
  

• Right-to-left shunting through the foramen ovale.
  
• Left-to-right shunting through the ductus arteriosus.
  
• Failure to make the transition from intrauterine to extrauterine life.
  
• Pulmonary ischaemia.
  
• Further damage to the developing lungs.
  ¹
  

  The onset of RDS
  

  Usually within 4h of birth as the baby becomes increasingly tired.
  

  The signs of RDS
  

• Grunting on expiration caused by the baby trying to force air past a partially closed glottis. This effort can keep air in the alveoli at the end of each breath and prevent atelectasis.
  
• Increased rate of breathing.
  
• Intercostal, sternal and subclavicular recession; where the soft tissues around the clavicles, ribs and sternum are sucked in on inspiration (chin tug).
  

RESPIRATORY DISTRESS SYNDROME IN THE NEWBORN

641