Neonatal nurses' response to a hypothetical premature birth situation: What if it was my baby?

BACKGROUND:: Evolving technology and scientific advancement have increased the chances of survival of the extremely premature baby; however, such survival can be associated with some severe long-term morbidities. RESEARCH QUESTION:: The research investigates the caregiving and ethical dilemmas faced by neonatal nurses when caring for extremely premature babies (defined as ≤24 weeks' gestation). This article explores the issues arising for neonatal nurses when they considered the philosophical question of 'what if it was me and my baby', or what they believed they would do in the hypothetical situation of going into premature labour and delivering an extremely premature baby. PARTICIPANTS:: Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia. ETHICAL CONSIDERATIONS:: Relevant ethical approvals have been obtained by the researchers. FINDINGS:: A qualitative approach was used to analyse the data. The theme 'imagined futures' was generated which comprised three sub-themes: 'choice is important', 'not subjecting their own baby to treatment' and 'nurses and outcome predictions'. The results offer an important and unique understanding into the perceptions of nursing staff who care for extremely premature babies and their family, see them go home and witness their evolving outcomes. The results show that previous clinical and personal experiences led the nurses in the study to choose to have the belief that if in a similar situation, they would choose not to have their own baby resuscitated and subjected to the very treatment that they provide to other babies. CONCLUSION:: The theme 'imagined futures' offers an overall understanding of how neonatal nurses imagine what the life of the extremely premature baby and his or her family will be like after discharge from neonatal intensive care. The nurses' past experience has led them to believe that they would not want this life for themselves and their baby, if they were to deliver at 24 weeks' gestation or less.

Experience of mothers of premature babies from birth to discharge: notes of field journals. / Vivência de mães de bebês prematuros do nascimento a alta: notas de diários de campo.

OBJECTIVE: To describe the maternal care process mediated by nurses during the period of hospitalisation and discharge of premature babies. METHOD: This is a descriptive, exploratory, and qualitative study, using the methodological framework of convergent care research, with seven mothers of premature babies admitted to a hospital in southern Brazil, from October to December 2011. Data from the mother's daily journals were submitted to content analysis. RESULTS: Analysis resulted in three categories portraying the path and the adaptation process of the mothers to the care of their premature babies, from preparation for discharge to overcoming her fears and insecurities concerning home care. CONCLUSION: It is important for mothers in this initial and critical stage of hospitalisation of preterm infants to receive assistance, especially in terms of receptiveness and ongoing care, as a strategy to promote maternal autonomy and home adaptation.

Investigating Preterm Care at the Facility Level: Stakeholder Qualitative Study in Central and Southern Malawi.

Objectives Malawi is estimated to have one of the highest preterm birth rates in the world. However, care of preterm infants at facility level in Malawi has not been explored. We aimed to explore the views of health stakeholders about the care of preterm infants in health facilities and the existence of any policy protocol documents guiding the delivery of care to these infants. Methods We conducted 16 in-depth interviews with health stakeholders (11 service providers and 5 policy makers) using an interview guide and asked for any existing policy protocol documents guiding care for preterm infants in the health facilities in Malawi. The collected documents were reviewed and all the interviews were digitally recorded, transcribed and translated. All data were analysed using content analysis approach. Results We identified four policy protocol documents and out of these, one had detailed information explaining the care of preterm infants. Policy makers reported that policy protocol documents to guide care for preterm infants were available in the health facilities but majority (63.6 %) of the service providers lacked knowledge about the existence of these documents. Health stakeholders reported several challenges in caring for preterm infants including lack of trained staff in preterm infant care, antibiotics, space, supervision and poor referral system. Conclusions Our study highlights that improving health care service provider knowledge of preterm infant care is an integral part in preterm child birth. Our findings suggests that policy makers and health decision makers should retain those trained in preterm new born care in the health facility's preterm unit.

Incremental Hospital Costs Associated With Comorbidities of Prematurity.

PURPOSE: Preterm birth (PTB), defined as birth at a gestational age (GA) of less than 37 weeks, is associated with increased hospital costs. Lower GA at birth is negatively correlated with the presence of neonatal comorbidities, further increasing costs. This study evaluated incremental costs associated with comorbidities of PTB following spontaneous labor at 24-36 weeks. DESIGN: Birth records from January 2001 to December 2010 at the Medical University of South Carolina were screened to identify infants born at GA 23-37 weeks after uncomplicated singleton pregnancies and surviving to discharge. METHODOLOGY: Comorbidities of interest and incremental costs were analyzed with a partial least squares (PLS) regression model adjusted for comorbidities and GA. Incremental comorbidity-associated costs, as well as total costs, were estimated for infants of GA 24-36 weeks. RESULTS: A total of 4,292 delivery visit records were analyzed. Use of the PLS regression model eliminated issues of multicollinearity and allowed derivation of stable cost estimates. Incremental costs of comorbidities at a mean GA of 34 weeks ranged from $4,529 to $23,121, and exceeded $9,000 in 6 cases. Incremental costs rangedfrom a high of $41,161 for a GA 24-week infant with a comorbidity of retinopathy of prematurity requiring surgery (ROP4) to $3,683 for a GA 36-week infant with a comorbidity of convulsions. Incremental comorbidity costs are additive, so the costs for infants with multiple comorbidities could easily exceed the high of $41,161 seen with ROP4. CONCLUSIONS: The PLS regression model allowed derivation of stable cost estimates from multivariate and highly collinear data and can be used in future cost analyses. Using this data set, predicted costs of all comorbidities, as well as total costs, negatively correlated with GA at birth.

Perceptions and experiences of community members on caring for preterm newborns in rural Mangochi, Malawi: a qualitative study.

BACKGROUND: The number of preterm birth is increasing worldwide, especially in low income countries. Malawi has the highest incidence of preterm birth in the world, currently estimated at 18.1 percent. The aim of this study was to explore the perceived causes of preterm birth, care practices for preterm newborn babies and challenges associated with preterm birth among community members in Mangochi District, southern Malawi. METHODS: We conducted 14 focus group discussions with the following groups of participants: mothers (n = 4), fathers (n = 6) and grandmothers (n = 4) for 110 participants. We conducted 20 IDIs with mothers to preterm newborns (n = 10), TBAs (n = 6) and traditional healers (n = 4). A discussion guide was used to facilitate the focus group and in-depth interview sessions. Data collection took place between October 2012 and January 2013. We used content analysis to analyze data. RESULTS: Participants mentioned a number of perceptions of preterm birth and these included young and old maternal age, heredity, sexual impurity and maternal illness during pregnancy. Provision of warmth was the most commonly reported component of care for preterm newborns. Participants reported several challenges to caring for preterm newborns such as lack of knowledge on how to provide care, poverty, and the high time burden of care leading to neglect of household, farming and business duties. Women had the main responsibility for caring for preterm newborns. CONCLUSION: In this community, the reported poor care practices for preterm newborns were associated with poverty and lack of knowledge of how to properly care for these babies at home. Action is needed to address the current care practices for preterm babies among the community members.

Perinatal genomics: Current research on genetic contributions to preterm birth and placental phenotype.

Significant maternal, fetal, and newborn morbidity and mortality can be attributed to complications of pregnancy. There are direct links between perinatal complications and poor fetal/newborn development and impaired cognitive function, as well as fetal, newborn, and maternal death. Many perinatal complications have pathophysiologic mechanisms with a genetic basis. The objective of this chapter is to focus on perinatal genomics and the occurrence of two specific complications: preterm birth and dysfunctional placental phenotype. This chapter includes discussions of genetic variation, mutation and inheritance, gene expression, and genetic biomarkers in relation to preterm birth, in addition to the impact of maternal tobacco smoke exposure on placental phenotype. The concept of epigenetics is also addressed, specifically the regulation of gene expression in the placenta and fetal origins of adult health and disease. There is great potential for nurse-researchers to make valuable contributions to perinatal genomics investigations, but this requires perseverance, increased genetics-based understanding and skills, as well as multidisciplinary mentorship.

Parent decision making for life support for extremely premature infants: from the prenatal through end-of-life period.

Most deaths of extremely premature infants occur in the perinatal period. Yet, little is known about how parents make life support decisions in such a short period of time. In the paper, how parents make life support decisions for extremely premature infants from the prenatal period through death from the perspectives of parents, nurses, and physicians is described. Five cases, comprised of five mothers, four neonatologists, three nurses, and one neonatal nurse practitioner, are drawn from a larger collective case study. Prenatal, postnatal and end-of-life interviews were conducted, and medical record data were obtained. In an analysis by two research team members, mothers were found to exhibit these characteristics: desire for and actual involvement in life support decisions, weighing pain, suffering and hope in decision making, and wanting everything done for their infants. All mothers received decision making help and support from partners and family, but relationships with providers were also important. Finally, external resources impacted parental decision making in several of the cases. By understanding what factors contribute to parents' decision making, providers may be better equipped to prepare and assist parents when making life support decisions for their extremely premature infants.

Effects of Relaxation-Focused Nursing Care in Women in Preterm Labor.

BACKGROUND: Threatened preterm labor is a common problem that causes women to be hospitalized. During this period, physical problems such as a decrease in muscle functions, edema and pain, and psychological problems such as anxiety and stress may develop. OBJECTIVE: This study aimed to investigate the effect of relaxation-focused nursing care state anxiety, cortisol, contraction severity, nursing care satisfaction, knowledge, and birth weeks on threatened preterm labor. METHOD: This study was a pre-post single-blind randomized controlled trial. The study was conducted with 66 women in the threatened preterm labor process, 33 in the intervention group and 33 in the control group. The intervention group received relaxation-focused nursing care, which comprises a 2-day program in four stages. The data were collected before and after the relaxation-focused nursing care, and after the birth. RESULTS: In the intervention group, state anxiety, cortisol level, and contraction severity were lower than those in the control group (p < .05). The knowledge level about threatened preterm labor, satisfaction from nursing care, and birth weeks were higher in the intervention group (p < .05). CONCLUSION: Relaxation-focused nursing care was found to reduce the state anxiety in women, improve the knowledge level about threatened preterm labor and birth weeks, and decrease the level of cortisol. Therefore, it is recommended to use relaxation-focused nursing care in threatened preterm labor.

Relationships between nurse care-giving behaviours and preterm infant responses during bathing: a preliminary study.

AIMS: The purpose of this study was to explore the relationships between specific nurse care-giving behaviours and preterm infant behavioural responses during bathing and to identify nurse behaviours associated with infant 'stress'. BACKGROUND: Although recent advances in medical technology have improved neonatal intensive care, the high mortality and morbidity rates in preterm infants have not decreased proportionally. As caregivers strive to reduce infant mortality and morbidity, a factor for consideration is which caregiver behaviours are associated with preterm infant well-being. DESIGN: A descriptive correlational design. METHOD: Convenience samples of 24 preterm infants and 12 nurses were recruited. A total of 120 baths were videotaped. Infant and nurse behaviours were measured using the coding schemes developed by the researchers. Pearson coefficient correlation, non-parametric Kruskal-Wallis test, t-test and generalised linear models were methods for data analysis. RESULTS: As nurses provided more support, stress was reduced in the infants, and their self-regulation during the bath was enhanced especially by the use of 'containment' and 'positional support'. Conversely, non-therapeutic caregiver behaviours including 'rapid and rough handling' of the baby, 'chatting with other people' and 'inappropriate handling' increased infant 'stress' during the bath. CONCLUSION: The findings provide new information about the link between care-giving and infant responses and how caregivers can better interact with preterm infants during a very sensitive period of brain development. RELEVANCE TO CLINICAL PRACTICE: How nurses take care of the preterm infants influences their responses to care-giving stimuli. To interact better with the infant during care-giving procedures, nurses need to provide more supportive care-giving behaviours especially 'position support' and 'containment' based on the infant's needs, and avoid care-giving that may be too rough and occur too quickly without attending the baby's stressful signals, positioning the baby in hyperextension posture, or chatting with other people during procedures.

Women receiving 17-alpha-hydroxyprogesterone caproate hospitalized for preterm labor at less than 34 weeks benefit from daily perinatal nursing surveillance.

OBJECTIVE: The objective of the study was to compare pregnancy outcomes of women receiving 17-alpha-hydroxyprogesterone caproate (17P) prophylaxis for the prevention of recurrent spontaneous preterm delivery (SPTD) hospitalized for preterm labor (PTL) less than 34 weeks' gestation prescribed daily vs weekly perinatal nursing surveillance. STUDY DESIGN: Singleton gestations with prior SPTD enrolled for outpatient 17P administration at less than 27 weeks' gestation were eligible. Women hospitalized for PTL at less than 34 weeks (n = 379) were identified. Women receiving daily perinatal nursing surveillance (dPNS) (n = 99) following PTL were matched by Medicaid status and gestational age at onset of PTL to women receiving weekly surveillance (n = 280), yielding 83 matched pairs. RESULTS: Among patients receiving 17P who were hospitalized for PTL, the addition of dPNS following hospitalization resulted in lower rates of SPTD less than 32 weeks (odds ratio [OR], 0.29, 95% confidence interval [CI], 0.21-0.38) and less than 35 weeks (OR, 0.25, 95% CI, 0.17-0.33), whereas the rates of SPTD less than 37 weeks were similar. CONCLUSION: Women receiving prophylactic 17P hospitalized for PTL before 34 weeks benefit from the addition of daily perinatal nursing surveillance.

Extremely premature birth, informed written consent, and the Greek ideal of sophrosyne.

Most extremely premature infants die in the intensive care unit or suffer significant neurologic impairment. Many therapies result in unhealthy consequences, and the emotional and financial turmoil for families warrant reappraisal of our motives. Shared decision-making and informed consent in preference-sensitive conditions imply the family: (a) understands the medical problem, (b) grasps the risks and benefits of each therapy, (c) has the opportunity to ask questions and reflect upon options, (d) knows their values and preferences are understood, and (e) accepts or declines therapies without judgment or penalty. Mandatory resuscitation of premature infants or inflexible palliative comfort care policies are inconsistent with the principles of informed consent and shared decision-making. Physicians should emulate the Greek ideal of sophrosyne-virtue inherent to balance, reasoned limits, freedom but restraint, and humility. Informed choice is fundamental to liberty; evidence-based periviability guidelines and decision aids bolstered by structured informed consent ensure process integrity.

Implications of Preterm Birth for Maternal Mental Health and Infant Development.

Preterm birth remains a major contributor to infant mortality and morbidity including neurodevelopmental delay and childhood disability. Mothers experiencing a preterm birth are at risk for maternal mental health issues, inclusive of depression and posttraumatic stress disorder (PTSD), which may affect mother-infant attachment and infant development. Depression and PTSD, frequently comorbid, following preterm birth and relationships between these symptoms, maternal-infant attachment, and infant development are reviewed. Assessments and interventions potentially capable of benefitting mother and infant are noted. The need for healthcare professionals to intervene prenatally and at postpartum is significant as maternal distress remains one of the most consistent factors related to infant development. Although depression has received much attention in the literature as a risk factor for preterm birth, impaired attachment, and delayed infant development, some of the consequences of PTSD have only recently gained research attention. A few studies support the role of PTSD in impaired maternal-infant attachment; yet, it is unclear whether preterm infants of mothers experiencing symptoms of PTSD following birth are at a higher risk for motor development problems. Because early mother-infant interactions are influenced by prematurity as well as maternal mental health, consideration for home interventions that stimulate infant development and encourage mother-infant relationships concurrently are important. Directed interventions may be beneficial for infant development and aid in strengthening the mother-infant relationship, potentially reducing depression and PTSD symptoms in the mother.

High-Resolution Metabolomics: Review of the Field and Implications for Nursing Science and the Study of Preterm Birth.

Most complex health conditions do not have a single etiology but rather develop from exposure to multiple risk factors that interact to influence individual susceptibility. In this review, we discuss the emerging field of metabolomics as a means by which metabolic pathways underlying a disease etiology can be exposed and specific metabolites can be identified and linked, ultimately providing biomarkers for early detection of disease onset and new strategies for intervention. We present the theoretical foundation of metabolomics research, the current methods employed in its conduct, and the overlap of metabolomics research with other "omic" approaches. As an exemplar, we discuss the potential of metabolomics research in the context of deciphering the complex interactions of the maternal-fetal exposures that underlie the risk of preterm birth, a condition that accounts for substantial portions of infant morbidity and mortality and whose etiology and pathophysiology remain incompletely defined. We conclude by providing strategies for including metabolomics research in future nursing studies for the advancement of nursing science.

Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: an 18-year single-center experience.

OBJECTIVE: Review all live births 22 0/7 through 26 6/7 weeks gestation born 1996 through 2013 at our institution to describe the decision process and immediate outcomes of palliative comfort care (PCC) versus neonatal intensive care (NICU) and whether any significant family complaints or quality assurance concerns arose. STUDY DESIGN: Retrospective chart review, physician and ethicist interview process and database review focused upon our established periviability counseling guidelines that are directive of PCC at 22 weeks gestation and NICU at 26 weeks but supportive of informed family choice of either option at 23, 24 and 25 weeks. RESULT: At 22 weeks--all 54 infants had PCC; at 23 weeks--29/78 (37%) chose NICU care, 6/29 (21%) infants survived; at 24 weeks--79/108 (73%) chose NICU care, 47/79 (59%) survived; at 25 weeks--147/153 (96%) chose NICU care, 115/147 (78%) survived; and at 26 weeks--all infants had NICU care, 176/203 (87%) survived. Over 18 years and 606 births, we identified only three significant concerns from families and/or physicians that required formal review. CONCLUSION: Most pregnant women and families choose NICU care for their extremely premature infant, but if given the option via shared decision making, a significant proportion will choose PCC at gestational ages that some NICUs mandate resuscitation. We support a reasoned dialogue and bioethical framework that recognizes human values to be irreducibly diverse, sometimes conflicting, and ultimately incommensurable--value pluralism. Respectful shared decision making requires thoughtful and compassionate flexibility, nuanced and individualized suggestions for PCC or NICU and the reduction of hierarchical directives from physicians to families. We continue to advocate and rely upon informed family preference between 23 and 25 weeks gestation in our updated 2015 periviability guidelines.

Reflexiones sobre el cuidado canguro y bebés prematuros / Reflections on kangaroo care and preterm babies

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Evidence-based practice to improve outcomes for late preterm infants.

Infants born between 34 weeks 0 days to 36 weeks 6 days gestation have been identified as late preterm infants (LPIs) and account for 70% of preterm births and 9% of all births. The rise in elective deliveries in the past decade is believed to have contributed to the number of late preterm births. An interprofessional team including labor and delivery, neonatal intensive care, and postpartum care providers collaborated to address this issue at an urban academic medical center.

A descriptive correlational study of bacterial vaginosis in pregnancy and its association with preterm birth: implications for advanced practice nurses.

PURPOSE: To expand on prior (often contradictory) research implicating maternal infection as a cause of preterm birth, specifically exploring whether bacterial vaginosis (BV) in pregnancy caused preterm birth in a sample of 103 women in a rural Mississippi obstetric-gynecologic clinic. DATA SOURCES: This descriptive correlational study explored the relationship between BV and preterm birth, using retrospective chart data from a purposive sample of 103 women (for a power level of 95%) from one rural obstetric-gynecologic clinic. CONCLUSIONS: Contrary to the majority of published research, this study did not find a positive correlation between BV and preterm birth. This unexpected result raises questions, particularly given that the preponderance (86%) of women who tested positive for BV during their pregnancy were African American, a population in which both BV and preterm birth are more prevalent. IMPLICATIONS FOR PRACTICE: Whether to screen for BV in pregnancy is a clinically important question not only in terms of the health of mother and child but also in terms of responsible use of resources. Clear findings supporting beneficial health results for screening would dictate screening regardless of the cost. But research continues to lack consensus on the efficacy of BV screening during pregnancy in preventing adverse pregnancy outcomes. In this study, as in some of the literature, the risk of preterm birth did not correlate positively with BV during pregnancy. In the absence of that correlation, cost gains importance. Nurse practitioners (NPs) must use resources wisely, including time, laboratory tests, and medications. Although some specialists recommend screening or treating all pregnant patients for BV, the current practice of not screening or treating all pregnant patients seems warranted until definitive findings establish a conclusive correlation between BV and preterm birth.

High environmental temperature and preterm birth: a review of the evidence.

OBJECTIVE: to examine the evidence in relation to preterm birth and high environmental temperature. BACKGROUND: this review was conducted against a background of global warming and an escalation in the frequency and severity of hot weather together with a rising preterm birth rate. METHODS: electronic health databases such as: SCOPUS, MEDLINE, CINAHL, EMBASE and Maternity and Infant Care were searched for research articles, that examined preterm birth and high environmental temperature. Further searches were based on the reference lists of located articles. Keywords included a search term for preterm birth (preterm birth, preterm, premature, <37 weeks, gestation) and a search term for hot weather (heatwaves, heat-waves, global warming, climate change, extreme heat, hot weather, high temperature, ambient temperature). A total of 159 papers were retrieved in this way. Of these publications, eight met inclusion criteria. DATA EXTRACTION: data were extracted and organised under the following headings: study design; dataset and sample; gestational age and effect of environmental heat on preterm birth. Critical Appraisal Skills Programme (CASP) guidelines were used to appraise study quality. FINDINGS: in this review, the weight of evidence supported an association between high environmental temperature and preterm birth. However, the degree of association varied considerably, and it is not clear what factors influence this relationship. Differing definitions of preterm birth may also add to lack of clarity. KEY CONCLUSIONS: preterm birth is an increasingly common and debilitating condition that affects a substantial portion of infants. Rates appear to be linked to high environmental temperature, and more especially heat stress, which may be experienced during extreme heat or following a sudden rise in temperature. When this happens, the body may be unable to adapt quickly to the change. As global warming continues, the incidence of high environmental temperature and dramatic temperature changes are also increasing. This situation makes it important that research effort is directed to understanding the degree of association and the mechanism by which high temperature and temperature increases impact on preterm birth. Research is also warranted into the development of more effective cooling practices to ameliorate the effects of heat stress. In the meantime, it is important that pregnant women are advised to take special precautions to avoid heat stress and to keep cool when there are sudden increases in temperature.

European Respiratory Society guideline on long term management of children with bronchopulmonary dysplasia

This document provides recommendations for monitoring and treatment of children in whom bronchopulmonary dysplasia (BPD) has been established and were discharged from the hospital, or who were older than 36 weeks of postmenstrual age. The guideline was based on pre-defined Population, Intervention, Comparison and Outcomes (PICO) questions relevant for clinical care, a systematic review of the literature, and assessment of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. After considering the balance of desirable (benefits) and undesirable (burden, adverse effects) consequences of the intervention, the certainty of the evidence, and values, the Task Force made conditional recommendations for monitoring and treatment of BPD based on very low to low quality of evidence. We suggest monitoring with lung imaging using ionising radiation in a subgroup only, for example severe BPD or recurrent hospitalisations, and monitoring with lung function in all children. We suggest to give individual advice to parents regarding day care attendance. With regards to treatment, we suggest to use bronchodilators in a subgroup only, for example asthma-like symptoms, or reversibility in lung function, no treatment with inhaled or systemic corticosteroids, natural weaning of diuretics by the relative decrease in dose with increasing weight gain if diuretics are started in the neonatal period, and to treat with supplemental oxygen with a saturation target range of 90­95%. A multidisciplinary approach for children with established severe BPD after the neonatal period into adulthood is preferable. These recommendations should be considered until new and urgently needed evidence becomes available.