Nursing the Neonate

Maggie Meeks, Maggie Hallsworth, Helen Yeo, Maggie Meeks, Maggie Hallsworth, Helen Yeo

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118697436
• Edition: 2
• Topic: Medizin
• Subtopic: Pedriatische Krankenpflege

Written by a multidisciplinary team of medical and nursing experts, this fully-updated second edition provides evidence-based coverage of all frequently seen neonatal conditions. Divided into chapters based on body-systems, each section includes discussion of relevant embryology, anatomy and physiology.

Designed for real-life practice in the ward, each chapter includes clear guidelines for procedure and discussion of best practice. Case studies are used throughout to aid discussion of specific equipment, conditions, and situations.

An essential resource for neonatal nursing and midwifery students, as well as practicing neonatal nurses, this acclaimed text may also be of use to junior doctors beginning neonatology.

• Evidence-based theory clearly linked to application in the ward with case studies throughout
• Procedure and equipment guidelines included, with specific recommendations for practice
• Accessible format designed for easy reading and reference
• Highly illustrated with relevant diagrams and pictures
  

Chapter 1

THE EVOLUTION OF NEONATAL CARE

David Field and Andy Leslie

Learning outcomes

After reading this chapter the reader will be expected to be able to:

• Summarise the history of the development of neonatal care
• Explain the influences which have lead to the current model of delivery of neonatal care
• Relate the published mortality rates to the analysis of reproductive health services
• Explain the term ‘evidence based practice’
• Summarise the origin of the best evidence that guides current practice
• Explain the term ‘research governance’

The photo in Figure 1.1 shows an intensive care space at a modern well-designed neonatal unit that allows enough space for parental access as well as for the neonatal nurse and clinical team to provide neonatal intensive care comfortably (Christchurch Women’s Hospital, New Zealand).

Introduction: historical accounts of neonatal care

Throughout history there are records of medical interventions focused on babies. In pre-modern societies, as well as in much of the developing world today, pregnancy and childbirth was the main cause of death for women of childbearing age. Infants have always been born preterm and with the other problems commonly seen on neonatal units, but it is only in the last fifty years that there has been sufficient understanding of these problems for significant effective treatments to be developed.

The problem of how to resuscitate infants at birth is a good example of these developments. It has long been recognised that some newly born infants are unresponsive and apparently lifeless. Many interventions for use in this situation were advocated by people with apparently positive experiences of their use. These included such bizarre treatments as applying onion or mustard to the infant’s mouth and nose, blowing smoke into the infant’s rectum and the use of an inhaled brandy mist¹. We now understand that the apparent success of some of these treatments was simply due to the fact that most infants who do not breathe immediately at birth will go on to establish spontaneous respirations without any help at all; in other words, these historical infants were getting better despite what the attendants at the birth did, not because of it. As an understanding of the physiology of the establishment of breathing at birth was gained, so it was possible to develop effective tools and procedures to deal with infants who do not breathe immediately, and for these to be incorporated into protocolised teaching programmes that are now widely disseminated to those engaged in newborn care².

Figure 1.1 This photo shows an intensive care space at a modern well-designed neonatal unit that allows enough space for parental access as well as for the neonatal nurse and clinical team comfortably to provide neonatal intensive care (Christchurch Women’s Hospital, New Zealand).

Similar processes, which could be characterised as a movement away from care that was based on poor understanding of physiology and towards care based on good evidence founded on well-established physiological studies, have occurred in every aspect of the care of sick newborn infants.

Implications for practice

The development of neonatal care can be summarised as occurring because of an improved understanding of the physiology of the newborn with well established physiological studies leading to evidence for the practice of effective care.

The development of modern neonatal care

Neonatology and neonatal nursing as specialty areas of work are relatively new, having largely emerged over the period since 1970. Prior to this period sick newborn infants were mostly cared for by obstetricians and midwives and there was scant specialist provision. Most hospitals did not have a dedicated unit for sick infants.

Technology

Starting slowly, clinical care has advanced ever more rapidly during the modern era. The possibility of using warmth from incubators and additional oxygen to breathe as treatments for premature infants were first explored at the end of the nineteenth century but the term ‘neonatology’ wasn’t invented until 1960 and the first newborn ICU didn’t open until 1965³.

Innovation and new treatments have followed rapidly since this period. Some, with minor modifications, remain in use to this day. For example, the first observation that light has an effect on bilirubin levels was made in 1956 by Sister Ward, a nurse on the premature baby unit at Rochford General Hospital in Essex and remains the mainstay of treatment^4,5. Other treatments have been adopted enthusiastically and subsequently substantially modified, most notably the use of inhaled oxygen for premature infants with respiratory distress. Early work showed that additional oxygen improved the respiratory status of infants with premature lung disease, but it needed the first ever randomised controlled trial in newborns to show that too much oxygen often led to severe visual impairment by the development of retinopathy of prematurity (ROP)⁶. Oxygen saturation monitoring for newborns was first described in 1987, and now is ubiquitous in neonatal units. It is of note, however, that the ‘right’ level of blood oxygen saturation for premature newborn infants has yet to be reliably established, and research continues (http://www.npeu.ox.ac.uk/boost).

Nursing

The establishment of neonatal nursing as a speciality occurred in the UK in the 1970s. The need for skilled nurses to staff newly-established neonatal units led to training courses being designed (English National Board Course 405 in Special & Intensive Care of the Newborn, and others). The nurse staffing units at this time started to come together regionally and nationally to discuss common concerns, and this led in 1977 to the formation of the Neonatal Nurses Association, and later of the Scottish Neonatal Nurses Group. While the educational framework for neonatal nursing has changed as higher education has developed, courses in universities which educate nurses in neonatal care remain a cornerstone of care provision. A number of specialist roles for nurses developed subsequently, in areas such as family support and transport.

Advanced neonatal nurse practitioners (ANNPs) have been trained in the UK since 1992⁷, following earlier development of the role in the USA. ANNP training builds on the role of the neonatal nurse to produce a professional able to integrate both nursing and medical aspects of care. Differing approaches have been developed, both to the education programmes and to the subsequent deployment of ANNPs in practice. ANNPs have been evaluated in structured research projects and found to offer equivalent or better care when compared to existing caregivers in doing acute transport, resuscitation at birth and routine neonatal checks^8–10. While their ability to provide cohesive and comprehensive care has been a strength, their identity as neither wholly medical nor nursing has hindered group development and recognition.

For nursing careers, the latest development has been the emergence of Neonatal Nurse Consultants. Envisaged as a new group giving nursing increased influence, and with diverse areas of responsibility, from transport to low dependency care, they are a group whose ability to influence quality of care is under some scrutiny and where further evaluation is needed.

Organisation

As clinical care has evolved, so has the organisation of the services in which clinical care is provided. In the UK, important steps in the establishment of neonatal care are marked by Government reports. In 1971 the Sheldon Report recommended that neonatal care be provided in some form wherever infants were being born¹¹. It also recognised that not every unit would be able to provide every treatment, and so a distinction was drawn between intensive and special care units and the report recommended that expert transport facilities would be needed to move sick infants to the place best able to care for them. Subsequently, a variety of influences have helped shape the service in the UK and elsewhere. Initially, it was the enthusiasm of a small number of individuals that led to the formation of a handful of units specialising in the care of sick newborn infants. However pressure from the professions and the public encouraged successive governments in the UK to develop a service with nationwide coverage^12–17. The rate of evolution varied around the country but, particularly during the 1980s, there was a steady move towards a three-tier service based on the health regions (populations of 2 to 4 million) that existed at the time. The intention was that each of these geographical areas would be served by three types of neonatal unit:

Level 1

• Hospitals which delivered infants expected to be well; resuscitation could be provided if necessary but no ongoing care. Infants requiring such support were transferred.

Level 2

• Hospitals with higher delivery rates capable of providing resuscitation and limited ongoing care. Infants with more complex problems were transferred.

Level 3

• Regional centres, based largely in teaching hospitals, capable of providing a full range of neonatal services.

The rationale for this approach was:

• Reasonable geographical coverage was ensured
• High throughput for the level 3 units enabled clinical skills to be maintained
• High levels of bed occupancy (in level 3 units) permitted efficient use of expensive resources

The regional centres also had additional responsibilities, including specialist training for nurses and doctors and the provision of a transport service for sick babies born elsewhere. Although this structure, which had been adopted by a number of other high-cost, low-volume specialties, appeared a sensible approach for the delivery of neonatal intensive care it was never fully established across the UK at that time. Concerns that a centralised system of care was not appropriate centred on the following:

• Infants in outlying units were disadvantaged in terms of access and availability
• Shortage of cots, leading to very long distance transfers
• Deskilling in local units
• Disruption to family life foll...