Oxford Handbook of Midwifery (101 page)

Babies with congenital abnormalities who are not seriously ill, for example, babies with Down’s syndrome who are otherwise well, stay with their mothers on the maternity ward or in the transitional care unit (b see Guidelines for admission to transitional care, p. 452).

1. Yeo H (ed.) (2000).
   Nursing the Neonate
   , 2nd edn. Oxford: Churchill Livingstone, pp. 1–16.
   
2. World Health Organization (1992).
   International Statistical Classification of Diseases and Related Health Problems
   , 10th revision. Geneva: WHO.
   
3. Roberton NRC (1993). Should we look after babies less than 800 grams?
   Archives of Diseases of Childhood
   68, 326–9.
   
4. Rennie JM, Roberton NRC (eds) (1999).
   Textbook of Neonatology
   , 3rd edn. London: Churchill Livingstone, pp. 389–99.
   

   

   CHAPTER 19
   Emergencies
   

   452‌‌
   

   Guidelines for admission to transitional care
   

   A transitional care ward is an environment where infants requiring specific nursing and medical management can be cared for without being sepa- rated from their mothers. The typical length of stay varies between 2 and 3 days and 3 weeks.
   

   Transitional care is instrumental in the development of attachment between the mother and infant, as it allows 24h parenting. Moderately compromised babies (see below) gain weight more quickly and are discharged earlier with less chance of readmission than if they were cared for in a standard neonatal unit.
   

   In a busy obstetric unit, over a 6-month period approximately 150 babies weighing >1.5kg will be admitted to the neonatal unit, for an average of
   

   1. special care days each. It is likely that most of these infants could be cared for on a transitional care ward, reserving neonatal care facilities for sicker infants.
      

   Admission criteria
   

   • Gestational age 34 weeks to term
     
   • Birth weight >1.5kg
     
   • Babies requiring nasogastric tube feeding
     
   • Babies requiring calculated feeding regimens
     
   • Persistently hypoglycaemic babies
     
   • Hypothermic babies
     
   • Dehydrated babies
     
   • Babies requiring increased observation, e.g. traumatic delivery
     
   • Babies with congenital abnormalities.
     

     It may be possible to extend the admission criteria, if the ward is well established and adequately staffed, to include:
     

   • Infants of unstable diabetic mothers
     
   • Difficult to manage babies with neonatal abstinence syndrome (b see Neonatal abstinence syndrome, p. 648).
     
   • Babies requiring palliative care.
     

     Not for admission
     

   • Sick babies requiring the care of a neonatal unit, e.g.:
     
     • Any baby requiring extensive resuscitation and/or ventilatory support
       
     • Any baby requiring oxygen therapy.
       
   • Babies who can be cared for on a normal postnatal ward, e.g.:
     
     • Babies who only require IV cannulation and antibiotics
       
     • Babies who are slow to feed with no excessive clinical symptoms of hypoglycaemia/dehydration
       
     • Multiple births babies who are clinically well.
       
   • Sick babies for foster care or adoption, are treated in a neonatal unit whether or not they meet admission criteria for a transitional
     

     care ward.
     

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     CHAPTER 19
     Emergencies
     

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     Neonatal resuscitation
     

     Stimuli resulting in the initiation of respiration
     

   • At birth, gas exchange changes from placental to alveolar.
     
   • As the fetus is propelled down the birth canal, a negative intrathoracic pressure is exerted, so that on delivery air is sucked into the lungs.
     
   • Clamping and cutting the cord.
     
   • Physical stimuli: tactile, cold, and gravity.
     ¹
     

     Changes from fetal to normal circulation
     

   • The first breath increases
     p
     aO
     ₂
     and closes the ductus arteriosus between the aorta and pulmonary artery, allowing more blood to flow to the lungs.
     
   • There is a decrease in the pulmonary vascular resistance and an increase in blood flow from the lungs.
     
   • The increased left atrial pressure and decreased right atrial pressure closes the foramen ovale.
     ¹
     

     Prevent hypothermia
     

   • The intrauterine environment is 1.5°C higher than maternal temperature.
     
   • The temperature of a newborn is approximately 37.8°C. The core temperature of a wet, asphyxiated infant will decrease by 5°C in as many minutes.
     
   • Surfactant production is decreased if body temperature goes <35°C.
     
   • The baby will increase oxygen intake by breathing rapidly, using up glycogen stores to produce body heat, leading to hypoglycaemia.
     ¹
     

     Preparation for delivery
     

     Ensure that:
     

   • Personnel capable of initiating resuscitation are always available
     
   • A person capable of complete resuscitation is in attendance for all high- risk deliveries
     
   • Resuscitaire and overhead heater, with dry and warmed towels are prepared
     
   • Oxygen with a Neopuff
     ^®
     ventilation system is available. This system allows for the setting of an inspiration pressure which will not cause damage to the lungs. It also allows for the setting of a positive end expiratory pressure to help prevent the collapse of the alveoli at expiration thus allowing for more efficient oxygenation
     
   • Suction and suction tubes (varying sizes) are available
     
   • Laryngoscopes, endotracheal tubes, and connections are at hand
     
   • Medications are readily available.
     ²
     

     Initial assessment at birth
     

   • Start the clock.
     
   • Dry and warm the baby.
     
   • Assess:
     
     • Colour
       
     • Breathing
       

NEONATAL RESUSCITATION

455

• Heart rate by listening with a stethoscope or palpate the base of the cord
  
• Tone
  
• Response to stimuli.
  

These observations form the basis of assessment and reassessment throughout the resuscitation.

Provided the airway is clear, most babies who are apnoeic at birth will resuscitate themselves.
²

ABC of resuscitation

• Hold the head in a neutral position.
  
• Do not flex or overextend the neck.
  
• Apply gentle suction to the mouth and nose, but this is not always needed. Avoid deep pharyngeal suction as the vagal stimulation can cause bradycardia.
  
• Jaw thrust will be needed if the baby is very floppy, with one or two fingers under each side of the angle of the jaw, push forwards and outwards.
  ²
  These manoeuvres may be all that is required to initiate breathing.
  

• Administer 5 inflation breaths.
  
• Inflation pressure 30cmH
  ₂
  O for 2–3s.
  
• This will sufficiently aerate the lungs.
  
• As the first few inflations will be replacing lung fluid with air, chest movement will not be detected until the fourth or fifth inflation.
  

• Start chest compressions for 30s.
  
• After 30s, check the heart rate. If there is still no response despite adequate inflations and chest compressions, emergency drugs may be needed.
  ²
  

  Chest compression
  

  There are two methods:
  

The main principles for both are the same, using the lower third of the sternum one finger’s breadth below the nipple line: