Crawford, Doreen

Teesdale, D

De Montfort University Open Research Archive

The changing face of neonatal careBy D Crawford and DT Teasdale The art and science of neonatal nursing is relatively new. Until recently neonatal care tended to fall between two specialties, that of midwifery practice and children’s nursing. This identity confusion can sometimes be reflected in the funding, management and location of today’s neonatal nurseries. Sometimes these are located in the directorates of obstetric and women’s services, sometimes in child health. This article reviews the origins of ‘neonatology’ as a specialty and makes links with today.Documented evidence regarding the care of the newborn in the past is sparse. Research resulted in small traces of information being culled from sources detailing the history of medicine, the history of hospitals and the history of midwifery. It is probably true to say that the history of neonatal units is about a century old and they only became the dynamic, technologically advanced, specialty that we know today about 50 years ago.That is not to say that no special attention or care was given to the newborn before this. The ancient Greeks had a custom, whereby the father would inspect the child during the first ten days following birth. If he found that there was any sign of physical abnormality, or that the infant was weak, or was female, he could instruct that the infant be exposed to die. Hippocrates was supposed to have regarded the life expectancy of a child born at eight months as "brief or null”. Some Spartans plunged their newborn infants into icy water to test for physical fitness and ability to live (Bowra 1965). Today, the father’s role is more positively focused since they have become valued members of the care team and their opinions respected and valued along with those of the mother. Neonatal assessment is as important now as it was then but with parents’ advocacy and attention to medical legal requirements, any non-resuscitative steps are made in full consultation with the team. The first recognised textbook for midwives was written at the beginning of the second century, by a doctor called Soranus. The level of literacy was not high but the start of a trend is clear – medical men writing for midwives, who were mainly women. Little progress seemed to be made in the care of the infant during the Dark Ages and the early Medieval period. However, where there is political and economic instability the first casualties will be the weakest and the most vulnerable from either ends of the age spectrum. During these periods, care of the sick newborn seemed to consist of early baptism, which midwives were encouraged to do. Today there is a wealth of published material informing our care, with much written by nurses and midwives for nurses and midwives. Political influence and economies in care are as important now as they were then and there is a resurgence in the interest of spiritual care as part of a holistic perspective to meet care needs. In Reformation England, the care of the sick was the domain of religious and charitable organisations. Little formal care seemed to be given and, in many institutions, the pregnant and the young were specifically excluded. After the dissolution of the monasteries, care of the sick was given by a variety of humanitarian or charitable groups. The "Royal" hospitals were formed in London, on old monastic sites, at about this time. From the chaos came the new order and Parish relief, but how much of this was available to the pregnant and the sick newborn was very variable. The NHS has inherited many old and unsuitable buildings which do not lend themselves to modern neonatal care. Charity finance is as important now as it was then for the “extras” in care and increasingly creative means are being found to fund hospitals and sometimes very necessary neonatal unit rebuilds. As midwifery developed there was a rise in medical antagonism. Both struggled for recognition as emerging professions. King James I was petitioned and counter-petitioned on behalf of physicians and midwives. A pre-term baby would have been cared for as any other – immediately parted from their mother and chilled by being washed, then wrapped in swaddling clothes to ensure the development of straight limbs. Infant mortality was horrifically high. This was expected and tolerated by society and the loss of infants affected rich and poor alike. Actual figures for these times are difficult to collate and those available depend on examination of old Parish records. The legal obligation to record an infant fatality did not arise till 1929. These days there is more mutual respect between the professions and with interdisciplinary education, this has the potential to create closer working collaboration to benefit the neonate. Nowadays recording birth and death statistics are a statutory and mandatory part of the care process, being seen as part of a useful measurement in justifying care provision; however, information remains poor in the public domain surrounding neonatal care outcomes in local areas. While many neonatal units collect additional statistics to inform/justify local provision and funding, results are often hidden within trust reports or viewed only at local perinatal meetings. The lack of transparency is compounded by a lack of standardisation across the country in dataset collection – despite the efforts of the BAPM. This causes concern for professionals and policy makers, who are endeavouring to deliver cost-effective best practice. Currently representatives from the RCN PNIC Forum are part of the RCPCH project team involved in identifying a standardised dataset which could allow comparison in performance against the best evidence available including resuscitation practices.For the newborn in distress, by 1700, infant resuscitation was performed and in some cases consisted of mouth-to-mouth resuscitation, plunging the infant into a warm bath and by rubbing the baby with spirits. Europe, by the late 1700s, was slightly more progressive than the UK, particularly in France and Germany. However, those who survived the initial traumas were delivered during a time of great industrial growth. The general public had increased disposable income and leisure time. Since tiny infants required funding for care they became fairground attractions. Care was centralised not in ‘scientific parks’ but in ‘Expositions’ (illustrations still viewable on the internet today) where newborns were exhibited in glass cases against the outer walls of the room with visitors paying to view. But such open access, rising infection rates and variable levels of nursing care led to increased levels of mortality. During this period much was learnt about the key elements of survival - warmth, hygiene and feeding. Many believe that Pierre Budin wrote the first ‘evidence-based’ neonatal textbook, however much of its content is likely to be contributions of observations made over the previous 50 years by his seniors. The infants benefited, however – they were removed from public access, being cared for segregated from the rest of the world, a feature still common today. Although few pioneers had seen the need for institutions devoted to caring for sick children, ‘baby’ units were first created inside maternity hospitals – with nurses receiving additional training in the care of the sick baby.The Hopital des Enfants Malades in Paris is reported to be the world's first children's hospital. More followed, although not all included care for neonates. Developments in Britain, along these lines, met opposition from some unexpected quarters. Florence Nightingale stated that if children needed to be admitted to hospital, she would rather see them nursed among women. So at the first British children’s hospital, Great Ormond Street, for many years paediatricians trained and cared for infants from two years old and upward, with neonates remaining under the care of the obstetricians and midwives. Until fairly recently some units in Scotland remained the domain of the midwife, however the workforce has become increasingly diverse reflecting the pattern throughout the UK (Scottish Neonatal Nurses Group (SNNG) 2004). However, some neonatal units remain closely attached to maternity hospitals, while others are located in children’s areas. In both the relationship between infant and parent is recognised as crucial and had Florence Nightingale been alive today she would no doubt have agreed with the concept of family-centred care.The impetus to care for newborn infants came from concern over a declining birth rate and the impact that this would have on the ability to fight a war. The strategy to reduce neonatal mortality was spurred on by patriotic, rather than humanitarian, interests. Great advances were made. Incubators were developed and teams of specially trained nurses cared for weakling children. These measures were quite effective in reducing mortality but babies who weighed less than 1 kg were considered pre-viable. The success rate quoted is rather biased in favour of the new mode of management, as only the strongest infants survived the rigors of the first few hours or days before being transferred from the place of birth to the incubator baby station (Silverman 1979). There remains concern over the population, but the focus has shifted to control and stabilise it, rather than use its masses in armed conflict. Technology has not provided all the answers as some has associated morbidity. Infants under 1000 g are still a challenge, but the ongoing centralisation of care is muted to improve outcomes. This movement of NICU cots into tertiary centres has only been possible by the use of experienced personal within neonatal transport teams which have increased the likelihood of survival in transit. As previously described, these extremely low birthweight  babies often had a particularly high, if inappropriate, public profile which aimed as much to generate funding as to illustrate the advancing technology of the time (Silverman 1979). Nothing much changes and the public are still fascinated by small and light infants, with interest often fuelled by good news stories within the popular media. However, such enthusiasm has been injected with realism of late with the insight into morbidity and mortality being more accurately depicted by serious investigative documentaries reflecting the dilemmas that parent and professionals face. Nowadays interest in neonatal care spans a wide variety of organisations, Royal colleges, associations and support groups, but much of the original enthusiasm was harnessed in 1888 by the American Paediatric Society. Even at that time this was not without its critics who considered that care for the small, premature or compromised at birth was the result of misguided philanthropy - expensive and short-sighted; a similar critique can be heard today.The rate of progress was considerable by 1946; the first exchange transfusion had been given. By the middle of the 1950s, phototherapy had been developed and by the 1960s neonatal intensive care was here to stay, although provision was patchy driven by local paediatric interest rather than any government plan. As advances were made in obstetrics with the introduction of fetal medicine departments, similar strides were being made in the understanding of infant physiology and biochemistry so mechanical ventilation became possible. Initially this was a resuscitative measure but when refined was used to support infants and by the 1980s became commonplace in our nurseries. Success in ventilation and resuscitation gave force to the impetus to change the legal age of viability. Where once we considered ourselves fortunate to wean a 28-week gestation infant off a ventilator, now some units are managing 24-week infants on minimal ventilation with comparatively early extubations. Thus, many of today’s infants have fewer days supported by ventilation as the associated morbidity has become appreciated. Refinements to CPAP have made considerable differences to the way that neonatal nurses work. Phototherapy is still widely used but fortunately exchange transfusions are seen less frequently. There is still much progress to be made and today’s neonatal nurse faces considerable challenges from a number of fronts but can look forward to the future with excitement and confidence.ReferencesBowra CM (1965) Classical Greece. Time-Life Books, Amsterdam.Scottish Neonatal Nurses Group (2004) Evaluation of the Scottish Neonatal workforce. Silverman W (1990) Neonatal Paediatrics at the Century Mark. Paediatric Research 27(6). 1990. Silverman W (1979) Incubator Baby Side Shows Paediatrics 64, 2.Towler J, Bramall J (1986) Midwives in History and Society Croom Helm Ltd., London.

The Changing Face of Neonatal Care

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The Changing Face of Neonatal Care

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