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CAUSE
Infants are born prematurely for many reasons.
Prenatal risk factors leading to premature birth
are many and are listed under the following
categories:
Predisposing maternal factors: socioeconomic status, nutritional state, age, and
drug use, stress, and so forth
Pre-existing medical conditions: diabetes,
hypertension, thyroid disorders, anemia,
cardiac compromise, systemic lupus
erythematosis, and so forth
Obstetric issues: habitual aborter, blood
group sensitization, history of stillborn,
Cooper University Hospital, Nursing Administration #213, One Cooper Plaza, Camden, NJ 08103, USA
E-mail address: charsha-dianne@cooperhealth.edu
Crit Care Nurs Clin N Am 21 (2009) 5765
doi:10.1016/j.ccell.2008.09.003
0899-5885/08/$ see front matter 2009 Elsevier Inc. All rights reserved.
ccnursing.theclinics.com
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Fetus is premature and lungs are immature
(amniotic fluid analyses: lecithin/sphingomyelin ratio, phosphatidyl glycerol, and
optical density 650)3
Maternal status is healthy
If premature birth is unavoidable or anticipated before 34 weeks gestation, maternal steroids should
be considered to optimize fetal lung maturity. The
following indications may necessitate an extremely premature delivery:
Acute fetal distress
Chorioamnionitis
Severe pre-eclampsia or eclampsia
Severe fetal growth restriction
Maternal physiologic instability4
Depending on the institutions maternal or neonatal capability, the mother or neonate may need to
be transported to a higher level of care.
Periventricular Leukomalacia
Periventricular leukomalacia (PVL) is hypoxicischemic necrosis of the periventricular white
matter. It can occur with or without IVH. The incidence of PVL increases with decreasing gestational age. Asphyxia or a decrease in cerebral
blood flow are the primary causes of PVL and
these events can occur around the time of birth.
Because PVL results in a loss of brain tissue, it is
usually diagnosed by a neural ultrasound or MRI
performed at least 30 days following a birth. PVL
seen on neural ultrasound at 1 week of life usually
indicates an old event in utero. PVL can result in
cerebral palsy.
COMPLICATIONS OF PREMATURITY
Retinopathy of Prematurity
The complications of prematurity are many, especially with decreasing gestational age. The following disorders are of significant importance to the
overall outcome of the smallest infants.
Intraventricular Hemorrhage
Intraventricular hemorrhage (IVH) is an intracranial
hemorrhage that occurs in the highly vascular periventricular germinal matrix area and can extend
into the ventricular system and out into the parenchyma. The incidence of IVH has fallen to below
20% but 90% of the bleeds occur during the first
3 days of life and ELBW infants are at greatest
risk.5 Other risk factors for IVH include asphyxia,
resuscitation, ventilation, pneumothorax, rapid
administration of hypertonic drugs, or sudden
change in blood pressure. The Papile IVH classification system is shown in Box 1.
Signs and symptoms of IVH include apnea, bradycardia, anemia, acidosis, seizures, bulging fontanel, shock, change in level of consciousness,
or they can be completely asymptomatic.
Box 1
Papile intraventricular hemorrhage classification
system
Grade 1: Germinal matrix hemorrhage
Grade 2: IVH without ventricular dilatation
Grade 3: IVH with ventricular dilatation
Grade 4: Germinal matrix or IVH hemorrhage
with parenchymal involvement6
Box 2
International classification of retinopathy
of prematurity
Stage 1: Thin demarcation line between the
vascularized region of the retina and
the avascular zone
Stage 2: The demarcation line develops into
a ridge protruding into the vitreous
Stage 3: Extraretinal fibrovascular proliferation
occurs on the ridge
Stage 4: Neovascularization extends into the vitreous, causing traction on the retina, resulting in subtotal retinal detachment
Stage 5: Total retinal detachment
Hearing Deficit
Hearing deficit may be caused by medical administration of ototoxic drugs required during the neonatal course (ie, furosemide, aminoglycosides) or
by a central neurologic deficit like an IVH or PVL.
Therefore, all infants being discharged from the
newborn intensive care unit (NICU) should have
a baseline hearing screen assessment. Early detection of hearing loss enables intervention, which
may enhance the infants ability to meet language
developmental milestones.
Bronchopulmonary Dysplasia
Bronchopulmonary dysplasia (BPD) is the neonatal form of chronic lung disease and usually results
from an extended period of ventilation or prolonged oxygen requirement. BPD is defined by
an oxygen need that persists beyond 36 weeks
postconceptual age. Infants born prematurely
have immature lungs. Maternal steroid administration helps enhance lung maturity and surfactant
production. The incidence of BPD increases with
decreasing gestational age. The major contributing factors leading to BPD are oxygen exposure,
mechanical ventilation, and inflammation, which
usually start in the first few days of life. BPD is
best prevented by preventing premature birth or
treating respiratory distress syndrome with surfactant as indicated. It is a priority to administer only
the ventilatory assistance required to support adequate oxygenation and ventilation. Care of the infant who has BPD is supportive.
Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) results from an
injured immature gastrointestinal system so it is
predominately a disorder of premature infants.
Asphyxia, inadequate perfusion, and enteral feedings are commonly identified in the history of
neonates who have NEC. Like all the other complications of prematurity, the incidence of NEC
increases with decreasing gestational age. NEC
is also staged like many of the neonatal complications. See Box 3.
Diagnosis is usually made by identifying pneumatosis, intrahepatic portal venous gas, or free
air by radiograph. Treatment of NEC usually includes supportive management: nothing by mouth
Box 3
Stages of necrotizing enterocolitis
Stage 1: Suspected NEC (feeding intolerance,
guaiac-positive stools)
Stage 2a: Ileus, dilated loops, some pneumatosis intestinalis on radiograph (H1 gas
in bowel lining outlines the bowel on
radiograph)
Stage 2b: Extensive pneumatosis intestinalis,
intrahepatic portal venous gas
Stage 3a: Prominent ascites, paucity of bowel
gas
Stage 3b: Absent bowel gas, evidence of intraperitoneal free air9
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statistics such as IVH, PVL, surgical NEC, and surgical ROP.
It is always preferable to deliver the ELBW infant
in a tertiary care center where perinatal and neonatal services are readily available.10 An ELBW infant
requiring transport in the first few days of life is at
increased risk for complications.11
PREPARATION
If time permits, the parents or family should be told
what to expect in the infants first few hours after
birth. When viability is in question, the decision
points or questions that they might be asked
soon after delivery should be explained. If the birth
precedes parent preparation (timing, illness, and
so forth), decisions can always be made at a later
point when the infant is in the NICU.
The importance of preparing the delivery room
and the neonatal team for the birth of an ELBW infant cannot be overemphasized. Having an ELBW
delivery room protocol can help facilitate preparation efforts. It is important for every person in the
delivery room to have an identified role during
the resuscitation (airway/direction, vital signs/
chest compressions, respiratory and monitoring
equipment, and medication/documentation). Having too many care providers in the delivery room
can cause crowding and potential confusion.
The delivery room should be prewarmed when
possible, along with the stabilization area if separate, to 25 to 28 C or 77 to 82.4 F.12 Rooms
used to deliver/stabilize ELBW infants should be
free from drafts around the neonatal bed area.
Air deflectors can be helpful when drafts are
noted. A neonatal delivery warmer and NICU admission bed should always be warm for the next
delivery/admission,13 with warmed blankets readily available. Beds are on the market that can serve
as warmers/incubators and transport vehicles.
Each center needs to evaluate its selection of
bed devices to determine which equipment choice
will optimize thermal support for the ELBW infant
in its institutions setting. It is optimal to have
a bed scale on the stabilization warmer to avoid
additional cold stress. A chemical mattress can
be used to aid in maintaining the infants temperature but must be activated just before the birth.14 If
using a chemical mattress, one should check the
manufacturers recommendations about placing
a light sheet over the mattress before use and its
maximum duration of thermal support. Some mattresses become cool past their useful life and can
actually remove heat from the infant. A warmed,
U-shaped towel roll can be placed on a warmed
blanket over the chemical mattress to aid extremity flexion and thermal support. If a transporter is
RESUSCITATION
On delivery of the ELBW infant, the physician
should clamp and cut the cord while the other physician or first assistant blots the infants skin of
amniotic fluid and places him/her feet first into
a sterile plastic bag up to his/her neck. This bag
helps reduce convective and evaporative heat
loss during the transfer to the warmer and during
the resuscitation, because vigorous drying of the
infant to prevent hypothermia is not possible with
the ELBW infants fragile skin.15 It is optimal for
the individual receiving the infant from the delivery
table to have a preheated sterile towel in hand to
receive the infant. The bed scale can be zeroed
before placing the infant down on the bed so that
a quick weight can be obtained at the time the
infant is placed on the mattress, which will avoid
further movement, handling, and potential cold
stress. At this point, a loose-fitting hat, which can
be the traditional term delivery room cap, should
be placed on the head to avoid further heat loss.
An alternative hat used to secure a CPAP apparatus or to keep a bilirubin mask in place can also be
chosen.
Whenever possible, the infants head should be
maintained in a midline and slightly elevated position. The elevated position can be maintained by
tipping up the foot of the bed and placing the
infants head at the foot for easy airway access
for the resuscitation team. Midline head position
can be maintained in a supine, right-, or left-sided
position, depending on the alignment of the body.
Research has shown that cerebral blood flow is altered when the newborn head is not kept midline
and elevated.16 This position is usually maintained
during the most at-risk period for IVH (before
96 hours of age).17
Oxygen can be started around 30% to 40%
fraction of inspired oxygen (FIO2) and titrated to
acquire a centrally pink color or until the pulse
oximeter indicates an 85% to 95% saturation.18
Ventilation and oxygenation can be supported
with CPAP or mechanical ventilation, as required.
It is always preferable to offer only the level of
STABILIZATION
Once admitted to the NICU, the ELBW infant should
be assigned to an experienced nurse and respiratory therapist who are familiar with the stabilization
and needs of this fragile population. The infant can
be supported with his/her head on a flat gel pillow to
dissipate pressure across the scalp surface and
support the relatively large head. These pillows
also help minimize head molding and facilitate
a more rounded head shape.21 Because the infant
has a large occiput, a small roll placed under his/
her shoulders can help maintain his/her airway in
an optimal sniffing position. U-shaped boundaries
should be maintained around the infant to maintain
his/her extremities in a flexed position, with knees
and hands supported toward midline.
It is to be hoped that the supportive thermal
measures taken in the delivery room have maintained the infants temperature above 36 C22
when the infant is admitted to the NICU and removed from the plastic bag covering his/her trunk
and extremities. Tracking the NICU admission
temperatures of the ELBW infant, striving to keep
the temperature between 36 C and 37 C, is an excellent performance improvement project for the
neonatal tertiary care setting. The warmer/incubator temperature probe should be placed on the infants abdomen, away from the umbilicus and any
bony prominence, with a hydrogel-backed reflective shield to protect the skin from epidermal stripping.23 Pectin or hydrocolloid barriers, such as
extrathin duoderm, can be used on either side of
the probe as a supportive base to secure the reflective shield on extremely premature thin skin.24
A heating mattress can be used to maintain or enhance thermal support when a warmer or incubator is inadequate to meet the needs of a specific
infant. Shields or saran can be used to minimize
evaporative or convective thermal losses.25 It is
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punctures or peripheral intravenous lines when
possible. Skin punctures increase the risk for infection28 and add stress for the infant.
Blood pressure is a vital sign that should be
monitored closely in the ELBW infant. These
infants do not have the ability to differentiate cerebral perfusion from systemic perfusion.17 Therefore, if systemic pressure is inadequate, then
cerebral perfusion should be in question. The
best continuous method for evaluating the ELBW
infants blood pressure is by way of a functioning
arterial line. The mean blood pressure should be
at least the infants gestational age in weeks.29
Hypotension is common in the ELBW infant and
is most commonly due to adrenocortical insufficiency, poor vascular tone, and immature catecholamine response, rather than hypovolemia.30
Therefore, dopamine and physiologic doses of hydrocortisone are commonly used to treat ELBW
hypotension.31 It is also important to ensure and
maintain an adequate hematocrit of 40% to
50%.32 Perfusion is also essential to evaluate
when determining if a blood pressure is adequate.
The distal extremity pulses should be palpable and
the extremities should have capillary refill less than
2 seconds and should be warm to the touch. Urine
output should be at least 0.5 mL/kg/hour on the
first day of life and rise to 1 to 2 mL/kg/hour,33
with a stable bicarbonate level between 19 and
22 mm Hg and an adequate blood pH of 7.25 to
7.35.18 When tissues are perfused inadequately,
the cells will transition to anaerobic metabolism
and produce lactic acid, which will drop the bodys
pH and bicarbonate levels.
The goal of fluid management in the first few days
of life should be to replace losses (through skin,
urine output, respiration, and so forth). ELBW infants at 23 to 25 weeks gestation have 10 times
higher transepidermal water loss (TEWL) than
term infants.34 Several techniques can be used to
minimize TEWL in the ELBW infant. Placing the infant after delivery in an occlusive polyethylene
bag up to his/her shoulders until admission into
the NICU is a first step.34 Providing a 70% to 90%
relative humidity level is an additional technique
that can minimize fluid loss by up to one half in
the ELBW population.35 A preservative-free, water-miscible, petrolatum-based emollient can also
be used to keep the skin moist and free from drying,
fissures, or flaking. Care should be taken when using these products regularly and frequently during
the first couple of weeks of life because an association with coagulase-negative Staphylococcus
epidermidis infection has been reported.36
Phototherapy is almost always required during
the first days of the ELBW infants life. The skin
is extremely fragile and bruises during the birth
CASE PRESENTATION
AE is a 38year-old, gravida 5, para 0 woman at
23 weeks gestation who has a history of spontaneous habitual abortions. She presented to a community emergency department with vomiting and
diarrhea while on vacation. She was diagnosed
with preterm labor, assessed as 3 cm dilated,
given steroids, a tocolytic, fluids, and antibiotics,
and emergently transported to the regional perinatal center.
On arrival at the perinatal center, she was found
to be febrile, with a white blood cell count of 22,
and was 6 cm dilated, and labor was progressing
rapidly. Because chorioamnionitis was highly suspected, another antibiotic was administered and
the team prepared for an ELBW birth. She was
seen by a perinatologist and a neonatologist who
all agreed to try to resuscitate and stabilize the neonate per the parents request. This couple had
wanted a baby for years and was well educated
about the potential complications of delivering
their daughter at 23 weeks gestation.
Baby Girl E was spontaneously vaginally delivered 7 hours after AEs initial presentation at the
referring hospital. She was born vigorous, with
a weak cry, weighing 525 g. CPAP was applied
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a prior neural insult in utero, most likely from
a thrombus. After consultation with the family
and their chaplain, the parents decided to withdraw support and provide comfort care to their
gravely ill daughter. While the parents were at
her bedside, they spoke fondly of the brief time
they had shared with her and the wonderful memories they had. Mom held her daughter as this tiny
infant died peacefully surrounded by her family.
SUMMARY
Caring for the ELBW infant in the first days of life is
complex and challenging, yet rewarding. We never
know what memories or time will be held as most
precious by the family. It is the experienced health
care provider who will be best prepared to meet
the needs of these fragile infants and their concerned/frightened parents. Understanding how to
minimize stress and support body functions will
enable us to better care for these infants in the first
few days of life. We should strive to partner with
parents, using respectful communication and encouraging decision making, even in the resuscitative and stabilization phases of care, particularly
when an infant may not survive. Nursing plays an
essential role in providing this minute-to-minute
support. It is not always what we do, but how we
do it, that may matter most.
ACKNOWLEDGMENT
Special thanks to Gretchen Lawhon, RN, PhD,
NIDCAP Master Trainer, Director, Mid-Atlantic
NIDCAP Center, for her thoughtful review and suggestions to enhance this article.
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