Oxford Handbook of Midwifery (137 page)

• Pneumothorax
  
• Effusions
  
• Pulmonary oedema
  
• Abnormal cardiac silhouette
  
• Congenital diaphragmatic hernia
  
• Bell-shaped chest as seen in neuromuscular disorders
  
• A ‘ground glass’ appearance seen with idiopathic RDS, congenital pneumonia, or aspiration.
  

determined by the underlying diagnosis.
^1,2

Causes

These include:

• Surfactant deficiency seen in premature babies with RDS (b see p. 634)
  

• Pneumomediastinum
  
• Pulmonary interstitial emphysema
  
• Pleural effusions
  

• Asphyxia
  
• Hypothermia
  
• Rhesus disease
  
• Left-sided heart failure
  

• Retained or slow absorption of fetal lung fluid at birth
  

• Pneumonia
  
• Septicaemia
  
• Meningitis
  

• MAS
  
• Milk
  
• Blood
  

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  • Pulmonary hypoplasia: Potter’s syndrome (renal agenesis and diminished amniotic fluid (oligohydramnios) leads to a lack of lung fluid which prevents the development of the lungs)
    
  • Surgical conditions:
    
    • Choanal atresia
      
    • Pierre Robin syndrome
      
    • Diaphragmatic hernia
      
    • Lobar emphysema
      
    • Oesophageal atresia with tracheo-oesophageal fistula
      
  • Following birth asphyxia
    
  • Persistent fetal circulation (persistent pulmonary hypertension of the newborn (PPHN))
    
  • Congenital heart abnormalities leading to heart failure:
    
    • Hypoplastic left heart syndrome
      
    • Obstructed total anomalous pulmonary venous drainage
      
    • Severe coarctation of the aorta
      
  • Congenital lung malformation: cystic adenomatoid formation
    
  • Congenital malformations:
    
    • Pulmonary lymphangiectasia
      
    • Pulmonary hypoplasia
      
    • Congenital nasolacrimal duct obstruction (congenital dacryocystocele)
      
  • Congenital surfactant protein B deficiency
    
  • Cold stress
    
  • Hypoglycaemia
    
  • Anaemia
    

    •
    Polycythemia
    

  • Cerebral damage
    
  • Neuromuscular disorders:
    
    • Spinal muscular atrophy type1
      
    • Myotonic dystrophy
      
  • Inherited metabolic disease (b see Metabolic disorders and the neonatal blood spot test, p. 614)
    
  • Maternal drugs (e.g. opiates)
    
  • Chronic causes of respiratory distress:
    
    • Bronchopulmonary dysplasia
      
    • Wilson–Mikity syndrome
      
    • Chronic pulmonary insufficiency of prematurity.
      ¹
      ,
      2
      

      Management
      

      The aims of management are to identify the underlying cause and to provide supportive care with appropriate interventions. The care needed is similar regardless of the aetiology.
      ^1,2
      

  • Correct acid–base balance.
    
  • Alleviate hypoxaemia and respiratory failure.
    
  • Warm cold babies (b see Neonatal temperature control, p. 588).
    
  • Correct hypoglycaemia.
    
  • Give supplemental oxygen if needed.
    
  • Intubate and give surfactant to premature babies with RDS (b see Respiratory distress syndrome in the newborn, p. 640).
    

    RESPIRATORY PROBLEMS IN THE NEWBORN
    

    647
    

• IV infusion of 10% glucose for the first 24h during initial stabilization and assessment of the condition.
  
• IV infusion of total parenteral nutrition may be used from 48h if the baby is very unstable or if there is an underlying abnormality which requires surgery.
  
• If the condition stabilizes and the condition does not require surgery then early enteral nutrition via a naso-gastric tube is recommended preferably with expressed breast milk especially if the baby is premature.
  

• Temperature
  
• Blood pressure
  
• Heart and breathing rates
  
• Blood gases:
  
  • Umbilical or radial arterial samples
    
  • Pulse oximetry
    
  • Transcutaneous
    p
    O
    ₂
    and
    p
    CO
    ₂
    
• Oxygen needs
  
• Ventilation requirements
  

• Fluid intake and output.
  

• Thermal stability
  
• Warmth and humidity
  
• Administration of oxygen
  
• Observation
  
• Isolation
  
• Protection from excessive handling.
  ¹
  ,
  2
  

  The parents will need to be given support and an explanation of the condition and treatment required. They will also need to be with or near to their baby during transfer and admission to the neonatal or surgical unit (b see Management of the preterm baby, p. 634).
  

  1. Mupanemunda RH, Watkinson M (2000).
     Key Topics in Neonatology
     , 2nd edn. Oxford: Bios Scientific, pp. 275–7.
     
  2. Levene MI, Tudehope DI, Thearle MJ (2000).
     Essentials of Neonatal Medicine
     , 3rd edn, London: Blackwell, pp. 93–115.
     

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     Neonatal abstinence syndrome
     

     • Neonatal abstinence syndrome results from prenatal exposure to opioids, such as the morphine derivative, heroin.
       
     • Specific receptors in the CNS are associated with neurotransmitters called endorphins and encephalins, which are sometimes referred to as endogenous opioids, as they are produced naturally in the brain and activate analgesia. Long-term exposure to opioid drugs results in adaptation of these receptors, leading to tolerance.
       
     • Physical dependence occurs as the CNS adapts and larger amounts of the drug are required to achieve the same physiological effects.
       
     • Following birth, the baby is no longer exposed to maternal levels of the drug and therefore shows acute withdrawal. Physical symptoms are experienced, as the naturally occurring opioids have been suppressed.
       ¹
       
     • The onset, duration, and severity of symptoms vary according to type of drug, length of the mother’s dependency, timing and amount of the mother’s last dose before birth, clearance of the drug by the baby and his gestational age.
       ¹
       
     • The symptoms are less severe if the mother has been on a methadone substitution programme during the pregnancy.
       ¹
       

       Common symptoms
       

       Typically the symptoms involve the CNS and the respiratory, gastrointes- tinal, and vasomotor systems:
       

     • Hyperactivity and hyper-irritability
       
     • High-pitched cry
       
     • Increased muscle tone
       

       •
       Exaggerated reflexes
       

     • Tremors
       
     • Hiccups and yawning
       
     • Disorganized vigorous sucking, hyperphagia (wanting to feed very frequently)
       
     • Vomiting/posseting
       
     • Diarrhoea
       
     • Drooling
       
     • Excess secretions and stuffy nose
       
     • Flushing of the skin and sweating.
       ¹
       

       Principles of care
       

     • Withdrawal symptoms may appear between 24h and 3 weeks after the birth.
       
     • A social model of care following birth, where mothers and babies can be cared for together on the postnatal wards, even if babies require medical support for neonatal abstinence syndrome, has been advocated. By following this model:
       
       • Mothers are encouraged to develop appropriate parenting skills
         
       • They receive support from midwives
         
       • They are not separated from their babies.
         
     • 2 Breastfeeding is not contraindicated as it aids the withdrawal process.
       

  NEONATAL ABSTINENCE SYNDROME
  

  649
  

• Cuddle the baby
  
• Keep the baby wrapped up
  
• Avoid overstimulation
  
• Keep the baby in a quiet environment.
  

• Use score charts to monitor symptoms and their control. Some units have adapted or designed their own.
  

Further reading

Winklbaur AB, Jaqsch R, Peternell A,
et al
. (2007). Management of neonatal abstinence syndrome

in neonates born to opioid maintained women.
Drug and Alcohol Dependence
87
, 131–8.

1
Women and Children’s Health Service (2004).
Neonatal Abstinence Syndrome
. Available at: M

http://wchs.health.wa.gov.au (accessed 20.1.2011).

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Safeguarding children

Definitions

• A number of terms are commonly used, i.e. child abuse (now outdated), child protection, safeguarding children, and children in need. ‘Safeguarding children’ is now the term used to cover all aspects.
  
• Legislation and guidance referred to here is that currently operating in the UK.
  
• The Children Act (2004) is an amendment of the Children Act (1989), largely as a result of the Victoria Climbié inquiry, to give boundaries and help for local authorities to better regulate official intervention
  

  in the interests of children. The Act also made changes to the laws pertaining to children, notably on adoption agencies, foster homes, baby sitting services, and the handling of child related crimes and crimes against children.
  

• A child is defined as a person <18 years (Children Act 1989). However, it is important to remember that a married woman >16 but <18 is not regarded as a child.
  
• In current British law an individual has no legal entity until the moment of birth, i.e. the fetus has no legal rights. This is not the case in all parts of the world.
  

  Safeguarding children is a complex topic and general principles are given here for guidance.
  

• 2The guiding principle in any consideration of the child’s needs is that their welfare and interests are paramount. In other words, the current and future quality and safety of the child’s physical, emotional,
  

  psychological, and cultural upbringing must be central to any decisions
  

  that may be made in this respect by a court.
  

• 2 As a midwife, you must ensure personal familiarity with your national legislation and resulting local policies, procedures and guidance in the child protection process, and update your understanding regularly.
  
• In the UK, each NHS trust has a specialist named nurse and midwife, who can be consulted and must be involved in all stages of child protection procedures, for specialist support, guidance, and leadership. A named midwife, usually the head of midwifery, is the named Midwife for Safeguarding Children within the local maternity service, and
  

  must also be consulted and involved at all stages of the procedure in individual cases. Any midwife dealing with an established safeguarding children situation or who has concerns about any child’s safety must make that concern known to these people in the first instance.
  

• A key, valuable role in safeguarding children situations is that of the supervisor of midwives and the local supervising authority midwifery officer, in supporting the midwife and facilitating a system of tracing mothers of ‘at risk’ newborn babies.
  
• The Local Safeguarding Children Board (LSCB) has overall responsibility for managing the interagency functioning, developing policies and procedures at senior management level, identifying training needs, and conducting reviews of difficult cases or where a child dies as a result of abuse or neglect in their area. The LSCB maintains the local child protection register.
  

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651

The key features of the Children Act