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Most parents are excited and thrilled to meet their healthy newborn infant. For many months they have been imagining what their infant will look like and how the infant will behave. The first few days after delivery are a very special time for parents, therefore, and it is a pleasure for the nurses and doctors to share this experience with them.
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.
Bonding is the special emotional relationship that parents develop with their infant. Bonding starts during early pregnancy, especially after the mother first feels her fetus move. Bonding can be compared to ‘falling in love’. Every effort must be made to ensure that bonding takes place, especially in teenage mothers and mothers who do not want the pregnancy. Bonding is often poor with preterm infants when the parents are separated from their newborn infant. Anxiety about a sick infant or an infant with a congenital disorder can also interfere with the normal bonding process.
It is very important to promote parental bonding.
Grandparents should be encouraged to visit the newborn infant, especially if the grandmother is going to help care for the infant. This is particularly important with single mothers. Brothers and sisters should also be allowed to visit the infant. They can even touch the infant if they first wash their hands. However, visiting children must not be allowed to become a nuisance in the nursery.
Yes, parents of a sick infant should be encouraged to visit as often as possible. They must be allowed to touch their infant and, if possible, to help with the nursing care. Many parents want to be present when their infant dies. If an infant is dying on a ventilator, the endotracheal tube can be removed and the infant given to the mother to hold. Intravenous lines can be disconnected and the infant can be wrapped in a blanket. Kangaroo mother care can be used with terminally ill infants.
Parents must be allowed time with terminally ill infants.
Yes, it is very important that the parents tell the siblings the truth. They should be given a simple explanation and be told that the infant’s death has made the whole family sad. Siblings often feel jealous about the new infant and, therefore, feel guilty when the infant dies. Children need to be reassured that it is not their fault and that they will not also die.
Bereavement (or mourning) is the normal emotional process that a person experiences when a close family member or friend dies. Bereavement is the same after a miscarriage, stillbirth or neonatal death as when an older child or adult dies. Bereavement lasts from a few weeks in some people to many months in others. As death and bereavement are often taboo subjects, their correct management is commonly not discussed or taught. Many doctors and nurses feel distressed, threatened and inadequate when discussing death and, therefore, avoid the subject.
There are 5 major stages in bereavement:
Some parents do not pass through all the above stages of bereavement, while others often move backwards and forwards from one stage to another. However, most bereaved parents gradually progress from denial, anger and bargaining, through depression, to eventual acceptance. The time it takes for different people to work through the bereavement process varies. Often one parent takes longer than the other. Each person’s personality, outlook on life and religious convictions influence the process of bereavement. Some parents do not complete the mourning process but develop a severe, chronic depression and need professional help.
Bereavement is the normal emotional process that a person experiences when a close family member or friend dies.
Every effort should be made to help the parents and family to progress through and complete the normal mourning process. With the correct management, parents can experience bereavement without suffering permanent emotional damage. For the successful achievement of this goal, however, the parents must be encouraged to accept that they have had an infant who has died. In the past the opposite was practised by doctors, nurses, family and friends who tried to prevent bereavement by advising the parents to forget about the painful experience and to even pretend that it never took place. It was also thought that the suffering would be less if the parents did not bond with their infant. The mother, therefore, was not shown her dead infant, the subject was not discussed or even mentioned, and the parents were told to ‘put the loss behind them’ and to ‘get on with their lives’. Every attempt was made to protect the parents from sadness and stress. Unfortunately, these well-intentioned actions often interfered with the normal bereavement process because the infant’s death was emotionally denied.
Today, parents who have had a stillbirth or neonatal death should still be supported with kindness and understanding but, at the same time, must be helped to accept the reality of the dead infant.
Yes. The parents should be allowed to spend some time with their dead infant, alone if they wish. It is important that they see and hold the body. Although distressing to both parents and staff at the time, most parents are very grateful for the opportunity to say farewell to their infant. Even infants with severe congenital disorders can be dressed and shown to parents. Always stress the normal parts of the body, e.g. hands, feet and genitalia in an anencephalic infant. The imagined malformation is often worse than the real thing. However, if parents do not want to see and hold their dead infant, they must never be forced to do so.
Parents should be allowed to see and hold their dead infant.
Health care is usually planned on a regional basis, especially in urban and peri-urban areas (towns and their surroundings). The health region is then divided into districts. Each region and district must be well defined and take into consideration the best transport routes, distances from health facilities and municipal boundaries. Therefore, all aspects of preventive, promotive and curative care for pregnant women and their newborn infants in a given region should be planned and managed by a single authority. All levels of care in that region should be the responsibility of the regional authority which then co-ordinates care provided within districts. This requires excellent communication between all areas and levels of care.
This contrasts with the pure district model which is very useful in an underdeveloped country or in rural areas where only primary care is available. Here all health care is planned, funded and managed within health districts rather than regions. A combination of district and regional health-care models may also be used where health care is controlled within districts but a number of districts are then grouped and co-ordinated into a health-care region as is done in South Africa. A district model model is useful when only level 1 and 2 care is available. When level 3 care is available, a regional model with districts is essential to co-ordinate health-care activities between and within districts.
A regional model of health care with districts is an effective method of providing perinatal services within urban and peri-urban areas.
The staff at the clinic and referral hospital must always work as a team.
One of the major reasons why primary health care fails is because of poor teamwork and inadequate communication between hospitals and clinics.
These principles of good communication apply as well when mothers are transferred from a clinic to hospital.
If pregnant women are correctly categorised into low-risk, medium-risk and high-risk groups during pregnancy and labour, infants should be delivered at clinics or hospitals with the necessary staff and equipment to care for them. However, when maternal categorisation is incorrect, when unexpected problems present during or after delivery or when a mother with a complicated pregnancy or labour arrives in advanced labour at a clinic, then the infant may need to be transferred to a hospital with a level 2 or 3 nursery. All women should be offered care at the most appropriate health facility. It is not in the best interests of the mother or the service if her clinical need and the level of care are mismatched, e.g. a normal mother delivering in a level 2 or 3 facility or a mother at high risk of problems delivering at a level 1 facility.
If possible, it is almost always better for the infant to be transferred before delivery than after birth. The mother is the best incubator during transfer.
It is better to transfer the mother before delivery than to transfer the infant after birth.
The aim is to keep the infant in the best possible clinical condition while it is moved from the clinic to the hospital. This is achieved by providing the following:
This greatly increases the infant’s chance of survival without damage.
All infants that need management which cannot be provided at the clinic must be referred to the nearest hospital with a nursery. The following infants should be transferred:
Each region should establish its own clearly understood referral criteria so that the staff know which infants need to be transferred. All facilities in the region must agree with these referral criteria. For example, if KMC is used it may be possible to keep some small but healthy infants for a few days at the clinic before discharge home.
A list of referral criteria for infants must be available at all level 1 facilities.
It is very important that sick infants be fully resuscitated before being transferred. The infant must be warm, well oxygenated and given a supply of energy before being moved. Transferring a collapsed infant will often kill the infant. The clinic staff and the transfer personnel should together assess the infant and ensure that the infant is in the best possible condition to be moved.
Infants must be in the best possible condition before transfer.
If possible, the hospital that will receive the infant should make the transfer arrangements. The hospital staff can then advise on management during transfer and be ready to receive the infant in the nursery. The unexpected arrival of an infant at the hospital must be avoided. The clinical notes and a referral letter must be sent with the infant. A sample of gastric aspirate, collected soon after delivery for microscopy and the shake test, is very helpful, especially in preterm infants, infants with respiratory distress and infants with suspected congenital pneumonia. Consent for surgery should also be sent if a surgical problem is diagnosed. The emergency management and plan for transfer must be discussed between the referring facility and the receiving facility before the infant is moved. Often the problem can be managed at the clinic following advice from the hospital.
The infant must be discussed with the hospital staff before transfer.
Vehicles to transfer patients must be provided by the local authority in each region. Ideally an ambulance should be used. If possible, ambulance personnel should be trained to care for sick infants during transfer. When this service is not available, the referral hospital should provide nursing or medical staff to care for the infant while it is being moved from the clinic to the hospital. A transport incubator, oxygen supply and emergency box of essential resuscitation equipment should always be available at the referral hospital for use in transferring newborn infants. Only as a last resort should the clinic provide a vehicle and staff to transfer a sick infant to hospital.
In contrast, well infants being transferred from a hospital back to a clinic can usually be safely transported in a car or van. KMC is very useful to keep these infants warm.
Yes, whenever possible, the mother should be transferred to hospital with her infant. Do not separate the mother and her infant if at all possible.
A very important method of measuring the perinatal health-care status within a health region, and comparing the status between health regions, is to determine the low birth weight rate, stillbirth rate, early neonatal mortality (death) rate and calculate the perinatal mortality rate of each region. This information is very useful if you want to improve the standard of perinatal care in your region.
The results of pregnancy outcome are usually given for a district, health region, province or whole country. The results for developing countries are similar to most developing communities within developed countries.
Perinatal information (data) is usually divided into 500 g categories.
The low birth weight, stillbirth and early neonatal mortality rates help to assess the perinatal health-care status of a region.
The low birth weight rate is the number of infants weighing less than 2500 g at birth per 1000 deliveries. It is usually expressed as a percentage. In a developed country the low birth weight rate is usually less than 10% while in a developing country the low birth weight rate is usually much more than 10%. In South Africa the low birth weight rate is about 15%. This is similar to many developing countries.
In South Africa the low birth weight rate is about 15%.
The stillbirth rate is the number of stillborn infants per 1000 total deliveries (i.e. liveborn and stillborn). The international definition of stillbirth, used for collecting information on perinatal mortality, is an infant that is born dead and weighs 500 g or more (i.e. about 22 weeks gestation or more). In a developed country the stillbirth rate is about 5 per 1000. In a developing country, however, the stillbirth rate is usually more than 20 per 1000. In South Africa the stillbirth rate is about 24/1000, typical of a developing country.
An early neonatal death occurs if a liveborn 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 shows any sign of life at birth (i.e. breathes or moves). However, liveborn infants below 500 g at birth are sometimes regarded as abortions, especially if they die soon after birth. The early neonatal mortality rate in a developed country is usually about 5 per 1000. In a developing country the early neonatal mortality rate is usually more than 10 per 1000. In South Africa the early neonatal mortality rate is about 12/1000 (half the stillbirth rate).
In a developing country the stillbirth rate is about double the early neonatal mortality rate. In contrast, the stillbirth and early neonatal mortality rates are about the same in most developed countries.
Most developing countries have a high stillbirth and early neonatal mortality rate.
The perinatal mortality rate is the number of stillbirths plus the number of early neonatal deaths per 1000 total deliveries (i.e. both stillborn and liveborn). The perinatal mortality rate is about the same as the stillbirth rate plus the early neonatal mortality rate. Most developed countries have a perinatal mortality rate of about 10/1000 while most developing countries have a perinatal mortality rate of more than 30/1000. South Africa has a perinatal mortality rate of about 36/1000.
Note that the early neonatal mortality rate is expressed per 1000 live births while the low birth weight rate, stillbirth rate and perinatal mortality rates are expressed per 1000 total births (i.e. live births plus stillbirths).
It is very important to know the low birth weight, stillbirth, early neonatal and perinatal mortality rates in your region as these rates reflect the living conditions, standard of health, and quality of perinatal health-care services in that region. It is far more important to know the mortality rate for the whole region than simply the rates for one clinic or hospital in the region.
An increased low birth weight rate and high stillbirth rate suggests a low standard of living with many socio-economic problems such as undernutrition, poor maternal education, hard physical activity, poor housing and low income in the community. A high early neonatal mortality rate, especially if the rate of low birth weight infants is not high, usually indicates poor perinatal health services. Therefore, both a poor standard of living and poor health services will increase the perinatal mortality rate.
An increased low birth rate usually reflects poor socio-economic conditions while a high early neonatal mortality rate usually indicates poor perinatal health services.
The low birth weight rate of 15% and stillbirth rate of 24/1000 in South Africa suggests a low standard of living while the early neonatal death rate of 12/1000 suggests that the standard of perinatal care can be improved.
In a developing country, the main causes of early neonatal death are:
These deaths are usually the result of pregnancy and labour complications such as intra-uterine growth restriction, maternal hypertension, placental abruption and syphilis. The causes of stillbirth are very similar. Many of these causes can be prevented or be identified and correctly managed with good perinatal care. It is essential that you determine the common causes of perinatal death in your area. The preventable causes of perinatal death can then be addressed.
An avoidable factor is something which could have caused the perinatal death and yet was potentially avoidable. If that event or condition was not present, the death may not have occurred. Avoidable factors include missed opportunities and substandard care.
Avoidable factors include no antenatal care, no fetal monitoring in labour and inadequate resuscitation after birth. Not screening the mother for syphilis and not giving vitamin K to the newborn infants are missed opportunities while substandard care is poor care before, during or after delivery which may have resulted in the perinatal death.
Avoidable factors may be associated with the mother (e.g. did not report poor fetal movements), the service (e.g. not enough well trained staff) or the health-care workers (e.g. did not follow standard protocols).
It is important to identify the avoidable factors before planning ways to improve maternal and newborn care.
Avoidable factors, missed opportunities and substandard care must be looked for in each perinatal death.
This is a regular meeting of staff to discuss all stillbirths and early neonatal deaths at that clinic or hospital. Perinatal mortality meetings are usually held weekly or monthly. The aim of a perinatal mortality meeting is to identify causes of death and avoidable (modifiable) factors. Ways of preventing these problems in future must be discussed. Care must be taken to review the management of perinatal deaths so that lessens can be learned rather than to use the meeting to blame individuals for poor care. The disciplining of staff should be done privately and never at a perinatal mortality meeting.
Some causative factors are avoidable (e.g. hypothermia) while others are not avoidable (e.g. abruptio placentae). Avoidable factors should be looked for whenever there is a stillbirth or neonatal death. Only by identifying avoidable factors can plans be made to improve perinatal care.
The perinatal care can only be improved if the causes of poor care are identified.
An infant of 1500 g has mpoor breathing at birth after a vaginal delivery. After resuscitation the infant is taken to the nursery and not shown to the mother. Only the mother, who is unmarried, is later allowed into the nursery but she is not allowed to touch her infant. The rest of the family can only view the infant 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 day after delivery. She is told to bind her breasts to suppress her milk.
The mother should have been shown her infant before it was moved to the nursery. Even if the infant is too small or too sick to be held and put to the breast, the parents should briefly see their infant.
The father of the infant and the grandparents should also be allowed to visit the infant in the nursery. This is particularly important if the mother is unmarried, as she needs her parents’ support. The grandparents must also bond with the infant as they often have to care for the infant when the mother returns to work.
This is a very important part of bonding. If a mother washes her hands first, there is very little risk of spreading infection to her infant. She can also help with simple nursing tasks such as changing the nappy and giving nasogastric feeds.
The mother should have been encouraged to give KMC as soon as the infant was stable. Probably within the first few hours with this infant. KMC in the labour ward may have been possible.
The mother should be kept in hospital with her infant for as long as possible. Mothers and infants should not be separated. In many hospitals, mothers stay until their infant is discharged. She should have been encouraged to express her breast milk for nasogastric feeds until the infant was old enough to start breastfeeding. Suppressing her milk will prevent her breastfeeding.
The mother, father and their families may not bond as well with this infant as they would have if the hospital policies had been different. The unmarried mother may abandon the infant.
An infant with severe intrapartum hypoxia dies when attempts at resuscitation fail. The body is immediately wrapped up and not shown to the parents. Only hours later is the mother told that her infant has died. The father is very angry when she tells him the news as he feels that the nursing staff are to blame for the infant’s death. No arrangements are made for the burial.
No. Most parents want to see their infant. The parents should have been allowed to spend some time with the dead infant before it was taken away.
As soon as possible. If the father was at the delivery, both parents could have been told together when it was realised that the infant was dying.
Anger is a common reaction to news of an infant’s death and is part of the normal mourning process. Staff must realise that the anger is usually not directed personally at them.
Yes. They should issue a notification of death certificate as quickly as possible and advise the family about arranging the burial.
A 1700 g infant is born at a peripheral clinic. The clinic staff call for an ambulance to take the infant to the nearest hospital. The hospital is not contacted. The infant, who appears well, is wrapped in a blanket and not given a feed. The mother is kept at the clinic. The note to the hospital reads ‘Please take over the management of this small infant’.
The clinic staff should have contacted the referral hospital and discussed the problem with them. The hospital staff should have advised the clinic staff as to further management. Only then should the infant have been transferred. With advice, the problem can often be managed at the clinic and the infant need not be transferred to hospital.
The infant should have been fed before referral. A transport incubator, KMC or silver swaddler should have been used to prevent hypothermia on the way to hospital.
The referral letter should give all the necessary details of the pregnancy, the delivery and the infant’s clinical condition.
Yes. If at all possible, the mother and infant should be kept together. She could have given her infant KMC on the way to hospital.
It is decided to determine the perinatal care status of a region. Therefore, all the birth weights of all infants, together with the number of live births and perinatal deaths in the hospitals, clinics and home deliveries in that region are recorded for a year. Only infants with a birth weight of 500 g or more are included in the survey. Of the 2000 births, 50 were stillborn and 1950 were born alive. There were 25 infants born alive who died in the first week of life. One hundred and twenty infants weighed less than 2500 g at birth.
Because many of these infants are salvageable. Therefore, all infants with a birth weight of 500 g or more must be included in a perinatal survey.
There were 50 stillbirths and 2000 total births. Therefore, the stillbirth rate was 50/2000 × 1000 = 25 per 1000.
A developing country, which usually has a stillbirth rate above 20/1000. In contrast, a developed country usually has a stillbirth rate of about 5/1000. Therefore the stillbirth rate of 25/1000 suggests a developing country.
Of the 1950 infants who were born alive, 25 died during the first week of life. Therefore, the early neonatal mortality rate was 25/1950 × 1000 = 12.8 per 1000.
Above 10/1000. Therefore, the rate of 12.8/1000 is what you would expect in a developing country. Note that the stillbirth rate of 25/1000 is about twice the early neonatal mortality rate of 12.8/1000. This is again what you would expect in a developing country.
There were 50 stillbirths and 25 early neonatal deaths with 2000 total deliveries. Therefore, the perinatal mortality rate was 50 + 25/2000 × 1000 = 37.5 per 1000. Note that the perinatal mortality rate is similar but not exactly the same as the stillbirth rate plus the early neonatal death rate.
Of the 2000 infants born during the year, 120 weighed less than 2500 g at delivery. Therefore, the low birth weight rate was 120/2000 × 100 = 6%.
No. Most developing countries have a low birth weight rate of more than 10% (100/1000).
It suggests that the living conditions of the mothers in the study region are satisfactory but the perinatal services are poor. Every effort must be made, therefore, to improve these services. Finding the common causes of perinatal death and the avoidable factors would be very useful in planned ways of improving care.