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Newborn Care: Communication


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Communication

  1. 1. 15 Communication COMMUNICATION WITHObjectives PARENTSWhen you have completed this unit youshould be able to: 15-1 Why is it important that you are able to communicate well with the parents of a• Communicate better with parents. newborn infant?• Encourage and promote parental bonding. Most parents are excited and thrilled to meet their healthy newborn infant. For many• Manage bereaved parents. months they have been imagining what their• Communicate better with colleagues in infant will look like and how the infant will your health-care region. behave. The first few days after delivery are a• Arrange transport of an infant to a very special time for parents, therefore, and hospital or clinic. it is a pleasure for the nurses and doctors to• Assess the perinatal health status in your share this experience with them. region. However, if the infant is not normal and healthy, then the parents are anxious, afraid and confused. They need a lot of help from the nurses and doctors caring for their infant. To give this care to the parents you must be able to communicate well with them. Poor communication makes this unhappy experience all the more difficult and unpleasant. Parents of unplanned (often unwanted) infants also need extra help with bonding.
  2. 2. 264 NEWBORN CARE15-2 What can you do to improve your photograph of the fetus strengthenscommunication skills? bonding. 2. Allow the mother to hold her infant and1. Make time to speak to parents. put the infant to the breast as soon as2. Be honest when you tell parents about possible after birth. The father should also their infant. see and hold the infant. If possible, the3. Listen to what they say and ask. father should be present during the labour4. Use simple language. and delivery.5. Allow parents to ask questions. 3. Let the mother room-in with her infant6. Look at the parents when you speak to and encourage her to demand feed. them. 4. Practising skin-to-skin care (kangaroo7. Address the parents by name. mother care) is a very powerful way of8. Watch, listen and learn when more promoting and strengthening bonding experienced colleagues speak to parents. with both parents.9. Try to understand what the parents are 5. The infant should be given a name soon feeling. after delivery.10. Be kind and helpful. 6. Take a photograph of the infant for the11. Find a place where the parents can speak to parents if the mother and the infant cannot you in private. be together. 7. If the infant is small or ill and has to be cared for in the nursery, the parents mustPARENTAL BONDING be allowed to visit their infant whenever they want. After washing their hands, they can touch their infant. They can also help15-3 What is parental bonding? with simple nursing procedures such asBonding is the special emotional relationship changing nappies and giving nasogastricthat parents develop with their infant. Bonding feeding. Intermittent kangaroo mother carestarts during early pregnancy, especially after (KMC) can be used with small infants inthe mother first feels her fetus move. Bonding an intensive care unit once they are stable.can be compared to ‘falling in love’. Every 8. Parents should be encouraged to bringeffort must be made to ensure that bonding greeting cards and toys for their infant.takes place, especially in teenage mothers Mothers can also bring clothes for theand mothers who do not want the pregnancy. infant. This helps them realise that it isBonding is often poor with preterm infants their infant and that the infant ‘does notwhen the parents are separated from their belong to the hospital’.newborn infant. Anxiety about a sick infant oran infant with a birth defect can also interferewith the normal bonding process. It is very important to promote parental bonding15-4 How can you encourage the bonding 15-5 Should grandparents and siblings beprocess? allowed to visit a newborn infant?1. During pregnancy you should encourage Grandparents should be encouraged to the parents to speak about their unborn visit the newborn infant, especially if the fetus. They should think of possible grandmother is going to help care for the names. Most prospective parents will infant. This is particularly important with imagine what their infant will look like. single mothers. Brothers and sisters should When available, an antenatal ultrasound also be allowed to visit the infant. They can even touch the infant if they first wash their
  3. 3. COMMUNICATION 265hands. However, visiting children must not be 6. Give the parents a momento such as aallowed to become a nuisance in the nursery. name band, piece of hair or a Polaroid photograph.15-6 How can parents be encouraged to 7. Prepare the parents for having to breakbond with an infant who has a birth defect? the news to any other children and other family and friends.1. The sooner the parents are told of the abnormalities the better. If possible, tell the 15-8 Should parents visit and touch a sick parents together. or dying infant?2. Encourage them to handle the infant. Point out the normal as well as the abnormal Yes, parents of a sick infant should be features. encouraged to visit as often as possible. They3. Handle the infant yourself as if you care must be allowed to touch their infant and, if and are not afraid to touch the infant. possible, to help with the nursing care. Many4. If possible, try to be optimistic. Explain the parents want to be present when their infant implications of the abnormalities and stress dies. If an infant is dying on a ventilator, the what can be done to correct them. Tell the endotracheal tube can be removed and the parents what the management will be. infant given to the mother to hold. Intravenous5. Where applicable, show photographs of a lines can be disconnected and the infant can corrected abnormality, e.g. a repaired cleft be wrapped in a blanket. Kangaroo mother lip and palate. care can be used with terminaly ill infants. Parents must be allowed time with terminally illMANAGING THE FAMILY OF infantsA SICK OR DYING INFANT 15-9 Should the other children in the family15-7 How should bad news be told to be told that the infant has died?parents? Yes, it is very important that the parents tell1. If a fetus or newborn infant has died or is the siblings the truth. They should be given a very sick, it is important that the parents simple explanation and be told that the infant’s be told as soon as possible. Sedation for the death has made the whole family sad. Siblings parents is usually not needed. often feel jealous about the new infant and,2. A member of staff who knows the parents, therefore, feel guilty when the infant dies. or the most experienced member of staff, Children need to be reassured that it is not should give the bad news. Never delegate their fault and that they will not also die. this responsibility to a junior staff member.3. If possible, tell the parents together. Allow them to cry if they so wish. BEREAVEMENT4. Make sure that the parents have some privacy. Even a screen around the bed is helpful. 15-10 What is bereavement?5. Give the parents the best explanation Bereavement (or mourning) is the normal possible for the cause of the death. Use emotional process that a person experiences simple language and always be honest. when a close family member or friend dies. These details may have to be repeated over Bereavement is the same after a miscarriage, a few days. stillbirth or neonatal death as when an older child or adult dies. Bereavement lasts from a
  4. 4. 266 NEWBORN CAREfew weeks in some people to many months in their infant has died and that nothingothers. As death and bereavement are often can be done to bring the infant back.taboo subjects, their correct management is They realise that life must continue andcommonly not discussed or taught. Many that they have responsibilities to otherdoctors and nurses feel distressed, threatened members of the family. With time theyand inadequate when discussing death and, think about the infant less often as othertherefore, avoid the subject. needs and problems of day to day living take up their time.There are 5 major stages in bereavement: Some parents do not pass through all the1. Denial. At first the parents cannot believe above stages of bereavement, while others that their fetus or newborn infant has often move backwards and forwards from died. They often ask if there has not been one stage to another. However, most bereaved a mistake; ‘it cannot be true’. The parents parents gradually progress from denial, may appear shocked and dazed, and do not anger and bargaining, through depression, seem to understand what the doctors and to eventual acceptance. The time it takes nurses tell them. This phase usually lasts a for different people to work through the few hours. bereavement process varies. Often one2. Anger. After the initial denial, parents parent takes longer than the other. Each often express their distress as anger. They person’s personality, outlook on life and may believe that the nurses or doctors religious convictions influence the process of are the cause of their infant dying. One bereavement. Some parents do not complete parent may blame the other parent. They the mourning process but develop a severe, may even blame themselves for something chronic depression and need professional help. that they did or did not do during the pregnancy. Parents often feel very guilty and believe that they are responsible for Bereavement is the normal emotional process the infant’s death. that a person experiences when a close family3. Bargaining. Parents often bargain with member or friend dies themselves, e.g. ‘if the infant is not really dead I promise that I will never …’4. Depression. The following are common 15-11 What are the goals of bereavement features of depression after a stillbirth or counselling? neonatal death: • The parents feel very sad and distressed. Every effort should be made to help the • They cry a lot. parents and family to progress through and • They often feel restless and cannot sleep complete the normal mourning process. at night. With the correct management, parents can • They lose their appetite. experience bereavement without suffering • They have difficulty concentrating at permanent emotional damage. For the work. successful achievement of this goal, however, • Life seems empty and hopeless. the parents must be encouraged to accept that • They keep thinking about the infant all they have had an infant who has died. In the the time. past the opposite was practised by doctors, • They often dream about the infant. nurses, family and friends who tried to • They may even think that they hear prevent bereavement by advising the parents the infant crying, and fear that they are to forget about the painful experience and to going mad. even pretend that it never took place. It was5. Acceptance. After a varying amount of also thought that the suffering would be less time, most parents eventually accept that if the parents did not bond with their infant.
  5. 5. COMMUNICATION 267The mother, therefore, was not shown her 9. Contact a local person or group that isdead infant, the subject was not discussed or experienced in helping bereaved parents,even mentioned, and the parents were told e.g. a minister of religion or social ‘put the loss behind them’ and to ‘get on 10. Ensure that the paper work (notificationwith their lives’. Every attempt was made to of birth and death certificates) and funeralprotect the parents from sadness and stress. arrangements are completed rapidly andUnfortunately, these well-intentioned actions efficiently.often interfered with the normal bereavement 11. Encourage parents to contact you if theyprocess because the infant’s death was would like to discuss the infant’s deathemotionally denied. or their own feelings after the patient is discharged.Today, parents who have had a stillbirth or 12. Advise them not to plan anotherneonatal death should still be supported with pregnancy for at least 6 months, or untilkindness and understanding but, at the same the mourning process is completed,time, must be helped to accept the reality of so that they can fully recover from thethe dead infant. death. Never suggest that they should have another infant as soon as possible to15-12 What can be done to help parents replace the dead infant.during bereavement? 13. Start a local support group that can discuss1. Tell them that you are sorry that their the management of bereavement and offer infant has died. A hand on the shoulder, a help to bereaved parents. A support group hug or even a handshake makes physical may already be available. contact with the parent and helps to 14. If possible, the parents should be seen indicate to them that you care. If possible, again in 6 weeks time to assess whether the speak to the parents together. mourning process is progressing normally.2. Make yourself available to listen to them, Signs such as persistent insomnia, loss to explain the process of bereavement and of appetite and depression suggest that to be sympathetic. Do not avoid grieving further counselling is needed. This meeting parents. allows parents to ask further questions and3. Remember that people from different the doctor or nurse to provide guidance cultural and religious groups sometimes and the results of any outstanding have different beliefs about death. These investigations. attitudes must always be respected.4. Allow the patient to decide whether she 15-13 What should you not say to bereaved wants a private room or to be with other parents? mothers. If she is still in hospital, try to 1. ‘It does not matter.’ discharge the patient as soon as possible. 2. ‘I understand how you feel’. Unless you5. Allow parents to cry. have had a perinatal death yourself, you6. If necessary, the mother’s breasts can be cannot know what they are feeling. strapped with a crepe bandage to help 3. ‘It is better that the infant died than suppress milk production. survived with brain damage.’ While this7. Sedatives are usually not helpful, but a might be true, the parents are still sad that hypnotic to help parents sleep for the first their infant has died. few nights is sometimes needed. 4. ‘You can always fall pregnant again’. They8. Allow the parents to keep a memento of can never replace the infant that has died. their dead infant, such as a name band, 5. ‘Try to forget about the infant.’ piece of hair or a Polaroid photograph. 6. ‘You are lucky to have other healthy children.’
  6. 6. 268 NEWBORN CARE7. ‘You must pull yourself together and stop take into consideration the best transport crying.’ routes, distances from health facilities and8. ‘You are lucky that your infant died now municipal boundaries. Therefore, all aspects rather than later.’ Parents mourn the death of preventive, promotive and curative care for of an infant even if they did not have the pregnant women and their newborn infants opportunity of getting to know the infant. in a given region should be planned and9. ‘It is your fault that your infant died.’ Even managed by a single authority. All levels of if this might be true, it is very cruel to care in that region should be the responsibility blame the parents. Rather suggest that the of the regional authority which then co- pregnancy might be successful the next ordinates care provided within districts. This time if they take your advice. requires excellent communication between all areas and levels of care.15-14 Should parents see and hold their This contrasts with the pure district modeldead infant? which is very useful in an underdevelopedYes. The parents should be allowed to spend country or in rural areas where only primarysome time with their dead infant, alone if they care is available. Here all health care is planned,wish. It is important that they see and hold the funded and managed within health districts.body. Although distressing to both parents and A combination of district and regional health-staff at the time, most parents are very grateful care models may also be used where healthfor the opportunity to say farewell to their care is controlled within districts but a numberinfant. Even infants with severe birth defects of districts are then grouped and co-ordinatedcan be dressed and shown to parents. Always into a health-care region. This model is usefulstress the normal parts of the body, e.g. hands, when only level 1 and 2 care is available. Whenfeet and genitalia in an anencephalic infant. level 3 care is available, a regional model isThe imagined malformation is often worse essential to co-ordinate health-care activitiesthan the real thing. However, if parents do not between and within districts.want to see and hold their dead infant, theymust never be forced to do so. A regional model of health care is an effective method of providing perinatal services within Parents should be allowed to see and hold their urban and peri-urban areas dead infant 15-16 How can communication in a health- care region be improved?COMMUNICATING WITH 1. Each clinic must be linked to a referralCOLLEAGUES AT OTHER hospital. This may be either a district or regional hospital. The clinic staff shouldHOSPITALS AND CLINICS contact this hospital for help or advice and patients with problems must be referred to this hospital. The staff at the15-15 How should perinatal services be referral hospital should provide trainingorganised? for the clinic staff and draw up guidelinesHealth care is usually planned on a regional for management and referral. Regularbasis, especially in urban and peri-urban areas meetings of clinic and hospital staff must(towns and their surroundings). The health be arranged. Hospital staff should helpregion is then divided into districts. Each with mortality and referral audits in theregion and district must be well defined and clinic. Management guidelines and referral
  7. 7. COMMUNICATION 269 criteria should be agreed upon by both blood glucose concentration, signs of clinic and hospital staff. respiratory distress, etc. before they contact2. It is important for the nursing, medical the hospital. It is essential that the clinic and administrative staff in the region to staff identify the infant’s problems. appreciate that they are all members of the 5. When speaking to the hospital staff, same health team working to provide the stress the important information and best possible care for mothers and infants. summarise the problem. State clearly Therefore, the responsibility for all mothers where advice is needed. and infants is shared. Ideally, nursing staff 6. Always give your name and rank and ask should be rotated between the hospital who you are speaking to. If necessary, and clinics for training. It is of particular insist that you speak to a senior staff importance that the clinic and its referral member if you are not satisfied with the hospital work together as a unit and not advice you receive. regard themselves as separate services. 7. Good, systematic notes are essential and3. Good notes must always accompany these must be sent with the infant. Good infants who are transferred between notes are one of the most effective methods different parts of a health-care region. of communication. The staff at the clinic and referral hospital must 15-18 How can a referral hospital improve communication with the clinic? always work as a team 1. A telephone line for incoming calls onlyOne of the major reasons why primary health (a ‘hot line’) should be available in thecare fails is because of poor teamwork and nursery so that the clinic staff can contactinadequate communication between hospitals the nursery staff without delay.and clinics. 2. The most senior and experienced nurse or doctor should receive the call. Each day15-17 How should clinic staff communicate and night someone should be allocated towith the referral hospital? answer the clinic calls. 3. Listen carefully, be patient, and try to1. A telephone or 2-way radio is essential so obtain a clear idea of the problem. Try to that the clinic staff and the hospital staff put yourself in the position of the colleague can speak directly to each other. Mobile asking for help. (cells) phones have made an enormous 4. Ask for important information that has not difference in improving communication. It been provided. is so much easier if the clinic staff know the 5. It is better to admit the infant if there is any staff at the hospital. doubt about the infant’s condition.2. Clear guidelines are needed to indicate 6. Arrange the transfer. This is often best which infants should be referred to hospital. done by the referral hospital rather than by If the clinic staff are uncertain whether an the clinic. infant needs referral, they must discuss 7. Suggest any emergency treatment needed the problem with the staff of the referral before or during transfer. hospital. When in doubt, ask. They should 8. Always inform the clinic after the infant not be afraid to seek help when it is needed. has arrived at the hospital. A reply slip can3. The staff at each clinic must know which be used to give the patient’s condition on hospital to contact if they need help. The arrival, the diagnosis made by the hospital hospital’s telephone number must be staff and the infant’s response to treatment. displayed next to the clinic’s telephone. Feedback to the referring clinic or hospital4. The clinic staff must collect all the relevant is essential. It is a good way of learning. information, e.g. birth weight, temperature,
  8. 8. 270 NEWBORN CARE9. When infants have recovered they can be 15-20 What is the aim of caring for the transferred back to the clinic. The clinical infant during transfer? notes and a referral letter must accompany The aim is to keep the infant in the best the infant. The transfer must be arranged possible clinical condition while it is moved with the clinic. from the clinic to the hospital. This is achieved10. All infants transferred from a clinic must by providing the following: be reviewed every month. In this way problems with referrals can be identified 1. A warm environment and corrected. 2. An adequate supply of oxygen if needed 3. A source of energyThese principles of good communication apply 4. Careful observationsas well when mothers are transferred from aclinic to hospital. This greatly increases the infant’s chance of survival without damage.TRANSFERRING NEWBORN 15-21 Which infants should be transferredINFANTS from a clinic to a hospital? All infants that need management which cannot be provided at the clinic must be15-19 Why should newborn infants be referred to the nearest hospital with a nursery.transferred? The following infants should be transferred:If pregnant women are correctly categorised 1. Preterm infants, especially infants less thaninto low-risk, medium-risk and high-risk 36 weeks gestation.groups during pregnancy and labour, infants 2. Infants with a birth weight under 2000 g.should be delivered at clinics or hospitals with Most infants between 2000 g and 2500 gthe necessary staff and equipment to care for do not need to be referred to a hospital andthem. However, when maternal categorisation can be sent incorrect, when unexpected problems 3. Infants that will not suck well.present during or after delivery or when a 4. Infants with respiratory distress.mother with a complicated pregnancy or 5. Infants with neonatal asphyxia that requirelabour arrives in advanced labour at a clinic, ventilation during resuscitation.then the infant may need to be transferred to a 6. Any sick infant may need to be transferredhospital with a level 2 or 3 nursery. All women to hospital.should be offered care at the most appropriate 7. Infants with major birth defects, especiallyhealth facility. It is not in the best interests of if urgent surgery is needed.the mother or the service if her clinical need Each region should establish its own clearlyand the level of care are mismatched, e.g. a understood referral criteria so that the staffnormal mother delivering in a level 2 or 3 know which infants need to be transferred.facility or a mother at high risk of problems All facilities in the region must agree withdelivering at a level 1 facility. these referral criteria. For example, if KMCIf possible, it is almost always better for the is used it may be possible to keep some smallinfant to be transferred before delivery than but healthy infants for a few days at the clinicafter birth. The mother is the best incubator before discharge home.during transfer. A list of referral criteria for infants must be It is better to transfer the mother before delivery available at all level 1 facilities than to transfer the infant after birth
  9. 9. COMMUNICATION 27115-22 Why should the infant be temperature should be regularly measured.resuscitated before being transferred? A transport incubator is the best way to keep the body temperature normal. IfIt is very important that sick infants be fully an incubator is not available, kangarooresuscitated before being transferred. The mother care can be used to preventinfant must be warm, well oxygenated and hypothermia. Ambulance or nursinggiven a supply of energy before being moved. staff or the father can give KMC if theTransferring a collapsed infant will often kill mother does not get transferred with herthe infant. The clinic staff and the transfer infant. Hypothermia can also be avoidedpersonnel should together assess the infant in a warm infant by dressing the infantand ensure that the infant is in the best and then wrapping the infant in a silverpossible condition to be moved. swaddler (space blanket) or heavy gauge tin foil. No transferred infant should ever Infants must be in the best possible condition by cold on arrival. before transfer 2. Hypoxia: It is essential that oxygen is available during transfer, but only given if this is needed. All the equipment required15-23 How should the transfer be arranged? for the safe administration of oxygen should be available. Infants who do not need extraIf possible, the hospital that will receive the oxygen must not be given oxygen routinelyinfant should make the transfer arrangements. while being transferred. Some infants withThe hospital staff can then advise on respiratory distress or apnoea may needmanagement during transfer and be ready CPAP or ventilation during transfer. Ato receive the infant in the nursery. The pulse oximeter is very useful to monitorunexpected arrival of an infant at the hospital oxygenation during transfer.must be avoided. The clinical notes and a 3. Hypoglycaemia: Some supply of energyreferral letter must be sent with the infant. must be provided during transfer. EitherA sample of gastric aspirate, collected soon milk feeds or intravenous fluids should beafter delivery for microscopy and the shake given. The blood glucose concentrationtest, is very helpful, especially in preterm should be regularly measured withinfants, infants with respiratory distress and reagent strips.infants with suspected congenital pneumonia.Consent for surgery should also be sent if asurgical problem is diagnosed. The emergency 15-25 Who should transfer a sick infant?management and plan for transfer must be Vehicles to transfer patients must be provideddiscussed between the referring facility and by the local authority in each region. Ideallythe receiving facility before the infant is an ambulance should be used. If possible,moved. Often the problem can be managed at ambulance personnel should be trained tothe clinic following advice from the hospital. care for sick infants during transfer. When this service is not available, the referral hospital should provide nursing or medical staff to care The infant must be discussed with the hospital for the infant while it is being moved from the staff before transfer clinic to the hospital. A transport incubator, oxygen supply and emergency box of essential resuscitation equipment should always be15-24 What are the greatest dangers available at the referral hospital for use induring transfer? transferring newborn infants. Only as a last1. Hypothermia: Infants must be kept warm resort should the clinic provide a vehicle and during transfer and their skin or axillary staff to transfer a sick infant to hospital.
  10. 10. 272 NEWBORN CAREIn contrast, well infants being transferred 15-28 What is the low birth weight rate?from a hospital back to a clinic can usually be The low birth weight rate is the number ofsafely transported in a car or van. KMC is very infants weighing less than 2500 g at birth peruseful to keep these infants warm. 1000 deliveries. It is usually expressed as a percentage. In a developed country the low15-26 Should the mother also be birth weight rate is usually less than 10% whiletransferred to hospital? in a developing country the low birth weightYes, whenever possible, the mother should rate is usually much more than 10%. In Southbe transferred to hospital with her infant. Do Africa the low birth weight rate is about 15%.not separate the mother and her infant if at This is similar to many developing countries.all possible. In South Africa the low birth weight rate is about 15 per centASSESSING THEPERINATAL HEALTH-CARE 15-29 What is the stillbirth rate?STATUS IN YOUR REGION The stillbirth rate is the number of stillborn infants per 1000 total deliveries (i.e. liveborn15-27 How can the perinatal health-care and stillborn). The international definition ofstatus be assessed? stillbirth, used for collecting information on perinatal mortality, is an infant that is bornA very important method of measuring the dead and weighs 500 g or more (i.e. aboutperinatal health-care status within a health 22 weeks gestation or more). In a developedregion, and comparing the status between country the stillbirth rate is about 5 per regions, is to determine the low birth In a developing country, however, the stillbirthweight rate, stillbirth rate, early neonatal rate is usually more than 20 per 1000. In Southmortality (death) rate and calculate the Africa the stillbirth rate is about 24/1000,perinatal mortality rate of each region. This typical of a developing country.information is very useful if you want toimprove the standard of perinatal care in your NOTE The legal definition of stillbirth in Southregion. Africa is an infant born dead after ‘6 months of intra-uterine life’ (i.e. 26 weeks since conception orThe results of pregnancy outcome are usually 28 weeks since the start of the last period). Whengiven for a district, health region, province the gestational age is not known, 1000 g is oftenor whole country. The results for developing used as the cut off. Only legally defined stillborncountries are similar to most developing infants require a stillbirth certificate and must be buried or cremated. However, for the collectioncommunities within developed countries. of information on perinatal mortality, the inter-Perinatal information (data) is usually divided national definition of stillbirth (500 g) is used.into 500 g categories. 15-30 What is the early neonatal mortality rate? The low birth weight, stillbirth and early neonatal mortality rates help to assess the An early neonatal death occurs if a liveborn perinatal health-care status of a region infant dies during the first 7 days after delivery. Therefore, the early neonatal mortality rate is the number of infants that die in the first week of life per 1000 liveborn deliveries. A liveborn infant is defined as an infant that
  11. 11. COMMUNICATION 273shows any sign of life at birth (i.e. breathes or 15-32 What is the value of knowing thesemoves). However, liveborn infants below 500 g rates?at birth are sometimes regarded as abortions, It is very important to know the low birthespecially if they die soon after birth. The early weight, stillbirth, early neonatal and perinatalneonatal mortality rate in a developed country mortality rates in your region as these ratesis usually about 5 per 1000. In a developing reflect the living conditions, standard ofcountry the early neonatal mortality rate is health, and quality of perinatal health-careusually more than 10 per 1000. In South Africa services in that region. It is far more importantthe early neonatal mortality rate is about to know the mortality rate for the whole12/1000 (half the stillbirth rate). region than simply the rates for one clinic orIn a developing country the stillbirth rate is hospital in the region.about double the early neonatal mortality rate. An increased low birth weight rate and highIn contrast, the stillbirth and early neonatal stillbirth rate suggests a low standard of livingmortality rates are about the same in most with many socio-economic problems such asdeveloped countries. undernutrition, poor maternal education, hard physical activity, poor housing and low income Most developing countries have a high stillbirth in the community. A high early neonatal and early neonatal mortality rate mortality rate, especially if the rate of low birth weight infants is not high, usually indicates NOTE The neonatal mortality rate is the number poor perinatal health services. Therefore, both a of infants that die in the first 4 weeks (28 days) poor standard of living and poor health services of life per 1000 liveborn deliveries. The neonatal will increase the perinatal mortality rate. mortality rate is divided into early and late neonatal mortality rates. Most neonatal deaths occur during the first week of life. The late An increased low birth rate usually reflects poor neonatal death rate is the number of infants that socio-economic conditions while a high early die between 8 and 28 days after delivery per 1000 neonatal mortality rate usually indicates poor liveborn deliveries. perinatal health services15-31 What is the perinatal mortality rate? The low birth weight rate of 15% and stillbirthThe perinatal mortality rate is the number of rate of 24/1000 in South Africa suggests a lowstillbirths plus the number of early neonatal standard of living while the early neonataldeaths per 1000 total deliveries (i.e. both death rate of 12/1000 suggests that thestillborn and liveborn). The perinatal mortality standard of perinatal care can be improved.rate is about the same as the stillbirth rate NOTE Worldwide four million infants younger thanplus the early neonatal mortality rate. Most one month die each year. One million die on daydeveloped countries have a perinatal mortality one while a further one million die between daysrate of about 10/1000 while most developing 2 and 7. Of these neonatal deaths 99% are incountries have a perinatal mortality rate developing countries. 40% of the 10 million underof more than 30/1000. South Africa has a 5 deaths annually are neonatal deaths. Thereforeperinatal mortality rate of about 36/1000. it is essential to lower the neonatal death rate if the under 5 death rate is to be reduced.Note that the early neonatal mortality rate isexpressed per 1000 livebirths while the low 15-33 What are the main neonatal causesbirth weight rate, stillbirth rate and perinatal of early neonatal death?mortality rates are expressed per 1000 totalbirths (i.e. livebirths plus stillbirths). In a developing country, the main causes of early neonatal death are:
  12. 12. 274 NEWBORN CARE1. Preterm delivery 15-35 What is a perinatal mortality2. Intrapartum hypoxia meeting?3. Infection This is a regular meeting of staff to discussThese deaths are usually the result of all stillbirths and early neonatal deaths atpregnancy and labour complications such that clinic or hospital. Perinatal mortalityas intra-uterine growth restriction, maternal meetings are usually held weekly or monthly.hypertension, placental abruption and syphilis. The aim of a perinatal mortality meetingThe causes of stillbith are very similar. Many of is to identify causes of death and avoidablethese causes can be prevented or be identified (modifiable) factors. Ways of preventing theseand correctly managed with good perinatal problems in future must be discussed. Carecare. It is essential that you determine the must be taken to review the management ofcommon causes of perinatal death in your perinatal deaths so that lessens can be learnedarea. The preventable causes of perinatal death rather than to use the meeting to blamecan then be addressed. individuals for poor care. The disciplining of staff should be done privately and never at a15-34 What are avoidable factors? perinatal mortality meeting.An avoidable factor is something which could Some causative factors are avoidablehave caused the perinatal death and yet was (e.g. hypothermia) while others are notpotentially avoidable. If that event or condition avoidable (e.g. abruptio placentae). Avoidablewas not present, the death may not have factors should be looked for whenever thereoccurred. Avoidable factors include missed is a stillbirth or neonatal death. Only byopportunities and substandard care. identifying avoidable factors can plans be made to improve perinatal care.Avoidable factors include no antenatal care,no fetal monitoring in labour and inadequateresuscitation after birth. Not screening the The perinatal care can only be improved if themother for syphilis and not giving vitamin causes of poor care are identifiedK to the newborn infants are missedopportunities while substandard care is poorcare before, during or after delivery which mayhave resulted in the perinatal death. CASE STUDY 1Avoidable factors may be associated with An infant of 1500 g has mild neonatal asphyxiathe mother (e.g. did not report poor fetal after a vaginal delivery. After resuscitationmovements), the service (e.g. not enough well the infant is taken to the nursery and nottrained staff) or the health-care workers (e.g. shown to the mother. Only the mother, whodid not follow standard protocols). is unmarried, is later allowed into the nurseryIt is important to identify the avoidable factors but she is not allowed to touch her infant.before planning ways to improve maternal and The rest of the family can only view the infantnewborn care. through the nursery windows. As the infant will need to spend a few weeks in an incubator, the mother is discharged home on the second Avoidable factors, missed opportinities and day after delivery. She is told to bind her substandard care must be looked for in each breasts to suppress her milk. perinatal death
  13. 13. COMMUNICATION 2751. What should have been done to improve breastfeeding. Suppressing her milk willbonding in the delivery room? prevent her breastfeeding.The mother should have been shown herinfant before it was moved to the nursery. 6. What may be the result of this badEven if the infant is too small or too sick to be bonding experience?held and put to the breast, the parents should The mother, father and their families may notbriefly see their infant. bond as well with this infant as they would have if the hospital policies had been different. The2. What do you think about the visiting unmarried mother may abandon the infant.policy in the nursery?The father of the infant and the grandparentsshould also be allowed to visit the infant in the CASE STUDY 2nursery. This is particularly important if themother is unmarried, as she needs her parents’ An infant with severe intrapartum hypoxiasupport. The grandparents must also bond dies when attempts at resuscitation fail. Thewith the infant as they often have to care for body is immediately wrapped up and notthe infant when the mother returns to work. shown to the parents. Only hours later is the mother told that her infant has died. The3. Why should the mother be allowed to father is very angry when she tells him thetouch the infant? news as he feels that the nursing staff are to blame for the infant’s death. No arrangementsThis is a very important part of bonding. are made for the burial.If a mother washes her hands first, there isvery little risk of spreading infection to her 1. Is it better for the mother if she does notinfant. She can also help with simple nursing see her dead infant?tasks such as changing the nappy and givingnasogastric feeds. No. Most parents want to see their infant. The parents should have been allowed to spend4. How could kangaroo mother care have some time with the dead infant before it washelped? taken away.The mother should have been encouraged to 2. When should the parents have been toldgive KMC as soon as the infant was stable. of the infant’s death?Probably within the first few hours with thisinfant. KMC in the labour ward may have As soon as possible. If the father was at thebeen possible. delivery, both parents could have been told together when it was realised that the infant5. Do you think that it was a good idea to was dying.discharge the mother and to suppress her `lactation? 3. Why was the father angry with the nursing staff?The mother should be kept in hospital withher infant for as long as possible. Mothers Anger is a common reaction to news ofand infants should not be separated. In many an infant’s death and is part of the normalhospitals, mothers stay until their infant is mourning process. Staff must realise that thedischarged. She should have been encouraged anger is usually not directed personally at express her breast milk for nasogastricfeeds until the infant was old enough to start
  14. 14. 276 NEWBORN CARE4. Should the hospital staff help with the CASE STUDY 4funeral arrangements?Yes. They should issue a notification of death It is decided to determine the perinatal carecertificate as quickly as possible and advise the status of a region. Therefore, all the birthfamily about arranging the burial. weights of all infants, together with the number of livebirths and perinatal deaths in the hospitals, clinics and home deliveriesCASE STUDY 3 in that region are recorded for a year. Only infants with a birth weight of 500 g or moreA 1700 g infant is born at a peripheral clinic. are included in the survey. Of the 2000 births,The clinic staff call for an ambulance to take 50 were stillborn and 1950 were born alive.the infant to the nearest hospital. The hospital There were 25 infants born alive who died inis not contacted. The infant, who appears the first week of life. One hundred and twentywell, is wrapped in a blanket and not given infants weighed less than 2500 g at birth.a feed. The mother is kept at the clinic. Thenote to the hospital reads ‘Please take over the 1. Why were infants between 500 g andmanagement of this small infant’. 1000 g not also excluded? Because many of these infants are salvageable.1. How should the transfer of this infant Therefore, all infants with a birth weight ofhave been arranged? 500 g or more must be included in a perinatalThe clinic staff should have contacted the survey.referral hospital and discussed the problemwith them. The hospital staff should 2. What was the stillbirth rate for thishave advised the clinic staff as to further region?management. Only then should the infant have There were 50 stillbirths and 2000 total births.been transferred. With advice, the problem can Therefore, the stillbirth rate was 50/2000 ×often be managed at the clinic and the infant 1000 = 25 per 1000.need not be transferred to hospital. 3. Is this stillbirth rate typical of a2. What was wrong with the management developed or developing country?of the infant at the clinic? A developing country, which usually has aThe infant should have been fed before stillbirth rate above 20/1000. In contrast, areferral. A transport incubator, KMC or silver developed country usually has a stillbirth rateswaddler should have been used to prevent of about 5/1000. Therefore the stillbirth rate ofhypothermia on the way to hospital. 25/1000 suggests a developing country.3. Why was the referral note inadequate? 4. What was the early neonatal mortalityThe referral letter should give all the necessary rate?details of the pregnancy, the delivery and the Of the 1950 infants who were born alive, 25infant’s clinical condition. died during the first week of life. Therefore, the early neonatal mortality rate was 25/1950 ×4. Should the mother have also been sent 1000 = 12.8 per hospital?Yes. If at all possible, the mother and infantshould be kept together. She could have givenher infant KMC on the way to hospital.
  15. 15. COMMUNICATION 2775. What is the expected early neonatal 8. Is the low birth weight rate typical of amortality rate for a developing country? developing country?Above 10/1000. Therefore, the rate of No. Most developing countries have a12.8/1000 is what you would expect in a low birth weight rate of more than 10%developing country. Note that the stillbirth rate (100/1000).of 25/1000 is about twice the early neonatalmortality rate of 12.8/1000. This is again what 9. How do you interpret the finding of ayou would expect in a developing country. high perinatal mortality rate with a low birth weight rate of only 6%?6. What was the perinatal mortality rate for It suggests that the living conditions of thethis region? mothers in the study region are satisfactoryThere were 50 stillbirths and 25 early neonatal but the perinatal services are poor. Everydeaths with 2000 total deliveries. Therefore, effort must be made, therefore, to improvethe perinatal mortality rate was 50 + 25/2000 these services. Finding the common causes× 1000 = 37.5 per 1000. Note that the perinatal of perinatal death and the avoidable factorsmortality rate is similar but not exactly the would be very useful in planned ways ofsame as the stillbirth rate plus the early improving care.neonatal death rate.7. What is the low birth weight rate for thisregion?Of the 2000 infants born during the year, 120weighed less than 2500 g at delivery. Therefore,the low birth weight rate was 120/2000 × 100= 6%.