Sunday, September 22, 2019

Respiratory Distress in Newborn Essay Example for Free

Respiratory Distress in Newborn Essay Respiratory problem are often the case in newborns. It accounts for nearly half of neonatal deaths. Research by Kumar Bhat (1996, p. 93) states that Respiratory Depression (RD) is a common neonatal problem that generally occurs in preterm infants due to surfactant deficiency which relates to antenatal history of immature lung development and term infants of diabetic mothers. To describe some of the common diagnosis associated with RD are: Transient Tachypnea of the newborn (TTNB) was found to be common in both term and preterm babies. Hyaline membrane disease (HMD) was common among pre terms, and meconium aspiration syndrome (MAS) among term and post-term babies. Fatality for RD was found to be 19%, being highest for HMD (57. 1%), followed by MAS (21. 8%) and infection (15. 6%). Therefore, it is crucial to recognise the signs of RD and ensure prompt treatment is rendered to minimize mortality and mobility in newborns at the delivery wards. Accurate physical assessment is done on the newborn on the first and fifth minute at birth to determine if the newborn is getting enough oxygen. By administering APGAR scoring based on each of the components that are assessed in the APGAR scoring are : Cardiovascular (heart rate, color of the skin), fetal respiratory (quality of breathing and neuromuscular function (tone and reflexes based on fetal tone and response to external stimuli). According to Apgar cited in Letko(1996, p. 299) the leading concerns was the ability to rapidly identify newborns requiring resuscitative measures in improving the prognosis. It is done to prevent respiratory depressed newborns from being incorrectly assessed, while minimizing delivery of oxygen and other unnecessary treatment to healthy newborns. Giacoia stated in Letko (1996, p. 300) indicates that a low APGAR score implies an abnormal condition in the newborn, but it does not suggest a specific etiology. Hypotonia in newborn with neuromuscular disorder, for example, may be mistakenly diagnosed to be the cause of birth asphyxia when the newborn is unable to establish or maintain breathing. Maternal sedation and analgesia likewise may decrease tone and responsiveness, resulting in lower score. Managanaro (1994, p. 99) added that infants with 1-min APGAR score was influenced by the mode of delivery and by gestational age rather than asphyxia. Instead, 5-min APGAR score had a high correlation with metabolic acidemia. Infants with low APGAR scores, presented with metabolic acidemia and arterial desaturation have the highest occurance of neonatal intensive care unit . admission and poor neonatal outcome. Therefore, study suggests that the 5-min APGAR score is necessary for immediate assessment and care of the neonate. Scoring APGAR is subjective in terms of interpretation and may lead to biasness. Therefore to correct this deficit, midwives are scoring APGAR at 1 and 5 minute intervals as recommended by Apgar supported in Letko( 1996, p. 00). Letko (1996, p. 302) furthermore, points out by determining oxygenation status by observing cyanosis is an inaccurate method. The manipulating factor consists of the examiner’s skill, adequate lighting, newborn’s skin condition, peripheral perfusion, and hemoglobin level. Physiological changes in the newborn such as functional closure of ductus arteriosus, ductus venosus, and foramen ovale may cause the newborn looking cyanosed. Midwives’ ability to differentiate central and peripheral cyanosis is critical for initiating treatment. Letko (1996, p. 02) explains when present throughout the body, including the mucous membranes and tongue, this condition is termed central cyanosis. When limited to the extremities, it is termed peripheral cyanosis or acrocyanosis. In comparison, central cyanosis refers to central cyanosis is more detrimental as it can result in range of disorder in areas such as cardiac, metabolic and neurological disorders. Newborns may require supplemental oxygen therapy to correct cyanosis. To decrease the subjectivity of the color changes, new technologies, such as pulse oximetry, can be employed with APGAR scoring. Research conducted by House. et. al (1987, p. 96) with regards to the examination of oxygen saturation of neonates in delivery room via the use of pulse oximetry is applicable in my current setting. It states that oxygen saturation did not differ significantly whether by vaginally or by ceaserean section or the presence of any or type of anaesthesia administered. They then concluded that pulse oxygen saturation values are highly accurate and useful in objective judging the adequacy of resuscitative efforts and identifying arterial desaturation during early neonatal period. Alternative methods of assessing oxygenation in neonates, consists of evaluation of cord gas status. Blood gas values are significant for determining oxygenation levels in ill newborns. There are challenges faced in aspects such as blood sampling posed by fast changing bodily processes, difficult assess to arterial sites coupled with small blood volumes and mixed venous samples. Clinicians must consider the importance of associating cord gas results with history taking (maternal history), physical assessments findings and laboratory indices in order to have a comprehensive picture and formulate therapeutic decisions. Brouillette and Waxman (1997, p. 215) suggests when obtaining cord gas samples, arterial blood gas measurements were preferred and taken as the gold standard compared to capillary measurements. Arguments cited in Huch, Huch and Rooth (1994, p. 168. ) against capillary blood sampling include: The skills of the operator, the presenting part of the fetus and membranes must be ruptured. However, it is argued that the merits of sampling capillary blood via fetal scalp sampling for analysis of blood gases are that it is technically easier due to easy access to sites and less likely to result in serious complications than arterial puncture. Therefore, it is a clinically useful method only if the blood gas samples obtained are a sufficiently accurate for arterial measurements. Adapted from Brouillette and Waxman (1997 p. 219), pH values more than 7. 2 are considered reassuring and below 7. 2 suggest immediate neonatal attention is necessary. To ensure accurate results in cord gas samples, the following aspects should be carried out in clinical practice. These include applying good sterile techniques to the site of arterial assess and prevent hemodilution. Also when interpreting results, the midwife must consider different diagnosis that will affect acid- base balance in newborns. Eg. Pulmonary hypertension. Scopes and Ahmad (1966, p. 25) suggests that by monitoring rectal temperature can be used as an indicator to oxygen requirements. Inadequate oxygenation will lead to decrease in deep body temperature. Correcting hypoxia by increasing oxygen consumption will increase deep body temperature. In practice, it is important to maintain the temperature of the labor room to be constant 21-25 degrees and baby’s body and head should be dried immediately after birth to minimize heat loss by evaporation since newborns have poor ability to retain eat (due to their increase skin surface area) which resulted in hypoxia. Aspiration of meconium distinctively occurs after an event of fetal hypoxic stress which leads to intestinal peristalsis, meconium contamination of the amniotic fluid, and gasping respirations that could draw the harmful meconium-stained liqour deep into the fetal lung. All of these would result in white patches observed in chest X-ray. Reflecting on the current practice, after delivery of the fetal head suction is administered to the oropharynx and nasopharynx to remove meconium in the oral and nasal cavities. Initial treatment following delivery, endotracheal suctioning is carried out to remove any remaining meconium-stained amniotic fluid. Improvement in nursing care as cited in Shorten (1989, p. 167) can be made to minimize negative effects throughout the suctioning procedure includes: length of time away from the oxygen source, both the duration and magnitude of applied suction, the ratio of diameters of suction catheter to endotracheal tube, depth of catheter insertion and the amount the infant is handled throughout the procedure. Strategies to improve methods of maintaining airway and minimise negative effects during suctioning include: preoxygenation with hyperventilation or continuous insufflation of oxygen, limiting the depth of catheter insertion to just beyond the distal end of the endotracheal tube, use of sedation and minimise infant handling. Placing basic resuscitation skills and equipment in the hands of midwives would significantly reduce early newborn deaths . A complete neonatal assessment, midwives should include a detailed history (maternal history). Assessment of family history reveals the presence of inheritable congenital defects on the onset and duration of respiratory symptoms, providing clues for early detection and treatment. Such as TTNB begins early and improves with time. Conversely, sepsis and pneumonia may have no early signs but may develop hours to days later. A proper evaluation is crucial as it allows anticipation of any disease that may cause impairment in oxygenation of neonates. Antepartum infection status is important, with regards to assessment on the duration of rupture, color of amniotic fluid . If Group B streptococcous colonisation is present after rupture of membranes, antibiotics can be administered as prophylaxis Additional skills that a midwife should include to effectively assess oxygenation are: applying skills of cardiac auscultation, it detects murmurs indicative of congenital heart anomalies and allows for early intervention to resolve respiratory depression before it worsens. Adding on to assessment using lung auscultation skills may show asymmetrical chest movement in pneumothorax or crackles in pneumonia, or it can be completely clear in transient tachypnea or persistent pulmonary hypertension of the newborn. General assessment of physical examination, midwives are prudent to look for apnea, tachypnea, grunting, stridor, retraction, nasal flaring and using hands to feel for equal lung expansion to identify signs of RD in neonates. Regular monitoring of vital signs such as maternal temperature, maternal tachycardia, and fetal heart status are essential to identify and arrest meconium aspiration and chorioamnionitis Training programmes are developed to reinforce skills which includes; evidence-based action plans with pictorial algorithm through problem-based scenarios in curriculum to facilitate better understanding and learning. Additional courses can also be conducted to correct any knowledge deficits such as: refresher courses, regular neonatal ‘mock’ scenarios to keep midwives updated of current procedures and aid revision of neonatal resuscitation protocols. To ensure prompt action, better communication pathways can be put in place to reinforce the urgency of NICU staff on the need to attend a delivery by the midwives. Which includes: where, when, urgency, indication and gestational age. (â€Å"Neonatal Resuscitation Reviewing the Past to Improve the Future†, 2001). Hermansen and Lorah (2007, p. 990) suggests treatment for neonatal respiratory distress can be both generalized and disease-specific. As Carr (2011) highlighted that midwives should be updated of current neonatal resuscitation protocols. Simple skills like tactile stimulation could save the majority of babies that require help to breathe at the time of birth. Neonates who require oxygen can be enhanced with supplemental oxygen, nasal cannula, or mechanical ventilation in severe cases. Endogenous surfactant administration may be necessary. Antibiotics are administered if bacterial infection is suspected. In conclusion, midwives are in unique position to render lifesaving care to newborns. They can do so by incorporating their skills in doing general assessment first hand to spot RD. Then, applying proper treatment to correct poor oxygenation levels so that to increase the survival of the newborn. Midwives constantly seek to increase their knowledge to improve their skills by demonstrating evidence- based practice in their daily care.

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