Removing the stress from moment of birth can boost neonate health
The goal: Smoothing the infant’s transition
Imagine that you’ve spent your entire life someplace warm, safe, and comfortable. Suddenly you’re dragged from there, placed under bright lights, strapped down by all fours, and subjected to all manner of strange noises.You’ve just imagined the start of post-delivery life for a premature baby in a traditional neonatal ICU. It’s not pleasant, and the staff at Atlanta’s Crawford Long Hospital believes there is a better way.
The NICU there employs a technique called Developmentally Supportive Care (DSC) that it says is reducing stress for both infants and their mothers in that crucial time after birth. The result, say staff members, is discharged babies with better motor skills and attitudes and who are less susceptible to long-term chronic ailments or physiologic problems. Specifically, the program has babies going home about a week earlier than other infants, going home with a younger corrected gestational age, and with better dispositions.
"What we try to do is provide babies with an atmosphere in which they can remain organized and calm, and in a state in which they can appropriately deal with the environment without having physiological consequences to stressors in the environment," says Maribeth White, NNP, who helped implement the program.
The program Crawford Long follows was pioneered two decades ago by Heidelise Als, PhD, director of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) at Harvard University in Boston. It’s being used in approximately 75 hospitals across the country.
A key goal of DSC is to improve babies’ health by reducing the stress they experience. "When babies are in a stressful physiologic state because of illness or stressors in the environment, that can increase their blood pressure and drop their oxygen saturation," notes White. "They become agitated, and that exacerbates the desaturation. They lose calories, and it’s hard to maintain their weights."
For small preemies, DSC begins in the delivery room. Once the baby’s respiratory and cardiovascular systems are stabilized he or she is placed in a device which White says has something of "papoose" appearance. The device includes a cloth "envelope" in which the baby is placed. The infant’s arms and legs are flexed, similar to the position in the womb. A piece of flexible metal covered in foam rubber is bent around the head and shoulders, the infant is wrapped in a blanket, and double hats are placed on the head. The result is that the baby has a 360-degree boundary. When the infant is moved to the nursery, he or she is placed in a isolette that is covered to block the light.
That’s a major change from traditional neonatal care, and it was one that caused lots of worry, admits Judy Gretz, RN, director of the NICU. "As a manager I thought, You mean we’re going to put these babies back in the dark? What if we have problems with the UAC [umbilical artery catheter] lines coming undone, or babies bleeding out of the catheters? Or what if they kick and expedite themselves?’ I was concerned because you can’t see them without lifting the [isolette] shade.
"But we didn’t have any of that. What we found was that because they had such secure boundaries, they did not expedite themselves and they did not kick their lines out. They were very comfortable and just felt very secure."
The idea is to ease the infant’s adjustment to the new environment. "The baby is used to being in a confined space and being able to feel the boundaries of the interuterine wall," adds White. "When that’s abruptly removed the baby will start flailing around, searching for that boundary. He or she will actually become agitated trying to find that boundary. When we provide an artificial boundary the infant will settle down into a relaxed mode, fall asleep, and that will improve the blood saturation and blood pressure."
Emphasis on baby/mother bonding
The DSC program also deviates from traditional NICU’s in its emphasis on the mother-infant bond. As soon as newborns are bundled up following delivery — vents, tubes, and all — they are given to their mothers. "The mother is the most important caregiver," White says. "She is more important than any of us will ever be, so we want her to be involved as much as possible from the start."Also, previous restrictions on when mothers can visit their babies in the nursery have been dropped; they can now visit anytime.
"We want her to be empowered," White says of the new moms. "We want them to come in, and without asking us, take their babies out and hold them, take their temperatures, feed them, and change their diapers." (For other DSC procedures, see story, p. XXX.)
Gretz also notes that the DSC procedure is much less disturbing for mothers than traditional NICU procedures which include restraining infants by all four limbs. "It’s much less intimidating to come in and see your baby quietly snuggled in, even though, yes, there is an intubation tube, and, yes, there are lines. But they see that they are quietly lying there, maybe sleeping, maybe half alert, and they’re comfortable. If you’re the mother or father you feel better, because you have some guilt because this baby has come early. That’s common problem the mothers have."
Gretz advises NICU managers interested in moving to the DSC approach to start by forming a broad-based committee to see if there is a philosophical commitment to the new approach. "You really have to ask yourself, what vision do we have for our nursery, and what vision do we have for our mothers and fathers and families?’"
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