The Neonatal Unit

Die neonatale eenheid behoort só beplan te wees dat dit onnodige toegang uitskakel. Dit behoort verskillende versorgingsafdelings te he om vir verskillende vlakke intensiewe verpleegsorg voorsiening te maak. Gespesialiseerde sorg word verkieslik in ’n groot enkelkamer verskaf, maar opnam es in die afdeling behoort eers in ’n afsonderlike kamer aandag te kry. Hulpdienste behoort binne die neonatale eenheid of in die onm iddellike nabyheid van die neonatale intensiewe sorgeenheid geplaas te wees. Om die spanning van die versorging van ernstig sieke pasgeborenes te verm inder, is voldoende personeel nodig, en bewakingstoestelle behoort as hufp aan die versorgers verskaf te word. Met die oog op die gespesialiseerde aard van die werk in ’n intensiewe versorgeenheid, behoort personeel die regte opleiding daarvoor te kry.

C 4 T T I S T O R I C A L L Y , th ere has b een a ch an ge in X I attitude tow ard the new bom from one o f resigned acceptance o f neonatal m ortality rates o f the order o f 100-200/1 000 births to one of intense concern for survival which is now being tempered to a more balanced concern for quality survival" 1.
In the past a very small preterm infant might be left unattended and only be given treatment after a few hours of birth if he continued to show signs o f survival.To commence treatment at this stage o f his life is too late!His chance for normal developm ent might have been impaired during this period of neglect.The key to quality survival is the institution o f optimal care for infants in need of such care.And this can best be done in a neonatal intensive care unit (N1CU).
The purpose o f this paper is to describe the com ponents of such a NICU , and how it should function.The NICU, plus other areas o f newborn care together form the neonatal unit or nursery.

AREAS O F N EW BORN CARE
Before discussing the N ICU , it is important to very briefly point out the different areas o f newborn care in a maternity hospital.These are designed to provide nursing care of graded intensity, depending on the level o f risk o f each new born.M ovem ent of infants from one area o f care to another will obviously be dictated by the infants themselves.
Norm al term infants should remain with their mothers throughout hospitalisation, i.e. " room ing-in" .This greatly enhances bonding, and also facilitates instruction o f the m other as regards infant care and reduces the incidence of cross infection.
Transitional Care is the assessm ent and observation of infants at some risk, but not the very sick or small ones.
Infants cared for in this area are those at risk due to the m ethod o f their delivery, e.g .Caesarean section o r forceps, m aternal disease, e.g.diabetes m ellitus, by virtue o f their low birthw eight (l 600 -2 500 grm s), or if they have suf fered moderate asphyxia neonatorum .They receive care for varying periods often not longer than eight hours.The ap pearance and behaviour o f infants in this area determ ine the type of care that must follow.
The small num ber o f infants who have a delayed or com plicated transition are transferred to the N ICU , and others to the convalescent area for further care, but the m ajority are transferred to their mothers within 12 hours where they " ro om -in".
C onvalescent Care is tor infants from the NICU and the Transitional Care area as they no longer require constant surveillance, but are o f low birthw eight and still require incubator nursing.
Pre-discharge area is for ini ants who have progressed sufficiently to be m oved from the convalescent area, but who are not yet ready for home care.
M others should visit their infants frequently in all the areas of care, but once the infant has advanced to this area the m other is expected to remain with the infant during the day in order to handle the baby and to establish breast-feeding.In order for the m other to gain confidence, this arrangem ent may be continued for a week o r longer until discharge.W hen indicated, e.g. in the case of a very young m other, she should be re-adm itted and take care o f her baby entirely under the supervision of the stall.In this way greater confidence is achieved by the m other and inevitably the bonding process is also enhanced.
Although only 3% -5% o f all newborns will require intensive care, it is im perative (in order that optimal care be rendered), that a good liaison betw een medical and nursing stall exists so that the necessary preparation for each infant can be made betore delivery according to the problem ex pected, and a person experienced in neonatal resuscitation be present at the tim e of birth.
As it is estim ated that 60% o f all potential neonatal prob lems are identifiable before birth, m edical and nursing per sonnel caring for pregnant m others antenatally and during labour are at an advantage o f recognizing problem s early.Admissions from other hospitals are best done before deliv ery as this definitely enhances the outcom e for the fetus.
In this context it will be clear that not every m aternity hospital should have an N IC U , but that a regional or referral system be adopted as described elsew here2.

Adm issions
The m ore com m on indications for adm ission to an NICU include: A

Physical Facilities
It is preferable to attend to adm issions in a separate room near the NICU as the many procedures and personnel in volved at this tim e are liable to cause disruption o f the routine in the unit and much distraction o f the staff.
Radiant w arm ers (with infant servo-control) have the ad vantage of easy access for providing critical care, but long term use is contra-indicated as the chance o f bacterial con tam ination increases.Specialised care is preferably adm inis tered in a single large room -large enough to accom m o date all the necessary equipm ent and personnel.
The ideal location is in a maternity hospital, as near to the labour ward as possible, and away from routine hospital traffic to m inim ize delay in transfer and the hazard o f infec tion.It should be easily reached from the am bulance entr ance.
V iew ing w indow s from the corridor are for officials or other visitors who have no need to enter the actual infant care area.This does not apply to parents who are allow ed in so that they can handle their infants.
Because a large num ber of nursing, medical and para medical personnel are normally in this area, am ple space should be allocated to each infant care station.Equipm ent used for m onitoring the infant and for giving supportive therapy requires space, therefore an average o f 9m 2 is re com m ended per infant.There should be 2m betw een in cubators and the aisles should be 2,5m w ide3.
C upboard, desk and sink space must be provided.The NICU should be a pleasant room with low w indow s to lessen the impact o f isolation from the outside world.
At each patient care station a m inim um o f 8 -10 electrical outlets is required, also two oxygen, one com pressed air and one suction outlet.
In addition to adequate lighting from fluorescent tubes in the ceiling, there should be an adjustable anglepoise lam p suspended above each incubator.
Because tem perature control in the room is more dif ficult to achieve with windows in the outer w alls, it is felt that windows should have double glazing in the units where climate is more tem perate.There should be a scrub area for staff to use before entering the NICU.In addition, a sink with foot or kn ee c o n tr o ls to serve fo u r p atien t sta tio n s minimizes the distance the nurse walks.
A cupboard with a work top adjacent to each incubator allows the nurse (and other staff) to write daily notes, etc., and also serves for storage of equipm ent, thereby m inimizing the walking distance, allowing the nurse to remain in the area to which she was assigned.An intercom system with the labour w ard, and the other areas of care makes provision for easy com m unication.

Ancillary Services
These should be in close proximity to the NICU, and other areas of care.
Laboratory Because emergency care is provided there must be laboratory facilities.This is best situated within the neonatal unit, so that immediate results are available, e.g.blood gases and acid base.
Radiology M oving a sick neonate for the purpose of radiology could have hazardous effects on the infant's condi tion.For this reason a portable X-ray unit is necessary.It is essential that the m achine remains in the neonatal unit as urgent diagnosis can often be confirm ed by an X-ray film.
Storage Facilities A large storage room is necessary for storing expendable items and respirators, incubators, photo therapy units and so on.Storage should be decentralised to allow access to most items without going into the corridor.However, there is still need for storage at some central supply within the neonatal unit.
A lecture room nearby is necessary for the education of staff and for meetings.

A feed preparation room
On the same floor is ideal but could elsewhere.Mothers should be encouraged to participate in the care of their sick or immature infants by expressing their milk.The collection and storage o f breast milk is best done by staff attached to the feed preparation room.
A clean utility room is required to set up for procedures and for storing sterile packs.In the event of the feed prepara tion room being some distance from the neonatal unit, the prepared feeds can be stored in a fridge in this room.
A dirty utility room is fordism antling trolleys and dispos ing o f used articles, and is best located near the exit of the neonatal unit.
Dressing rooms with locker and toilet facilities for nurs ing staff to change into clothes they will w ear in the neonatal unit.
Sleeping quarters with toilet and show er facilities for the doctor on call should be close by, or within neonatal unit.
Offices for the consultant paediatrician should be located within the neonatal unit, and that o f the nursing supervisor, (or matron) should be close to the NICU.
The clerk/secretary's station is the control point of pa tient care activities and should be located near the entrance so that she can supervise traffic and limit unnecessary entry to the unit.There should be a telephone and an intercom.
A parents' room for scrubbing and gowning should be situated near the entrance to the neonatal unit.There should be toilet facilities and seating should be provided.Parent interviewing and teaching can be done in this area as well.

NURSING STAFF
A nursing supervisor should be in overall charge in the NICU.The nurse to patient ratio should be 1:1,5 -24.Registered nurses with special neonatal care training should undertake direct care o f these infants.Ideally three shifts o f 8 hours should be worked.In the transitional, convalescent or pre-discharge areas a lower staff-patient ratio of 1 :5 -8 would be acceptable.Preferably the staff should also have special, neonatal care training, although this would be impossible in practice.Student midwives and student nurses undertaking the integrated diplom a and degree course would rotate through these areas.
O f major im portance is the fact that the neonatal staff should be relatively fixed and not changed too often.
In view o f the demanding nature of the work, especially in the intensive care area, it is important to maintain staff morale at a high level.For their comfort the staff should wear cool cotton frocks, and an open shoe.The warm envi ronment in which they work calls for some form o f fruit drink being readily available to them.These are a few examples of small but important concessions.
The provision o f seating, e.g.high stools/rocking chairs makes not only for staff comfort while perform ing tasks such as feeding, but is more likely to ensure that the feeds are given less hurriedly.
Combined regular meetings (e.g.weekly), with nursing, medical and para-m edical staff, offer the opportunity of solving problems dealing with irritations or frustrations, e.g.difficulties in working relationships, overcrowded condi tions, and shortage o f staff.This lends support to emotional situations which arise from e.g. the death of an infant, and keeps lines of communication open.
Leave should be taken twice annually.

Functions of Nursing Staff
Although a detailed description of the clinical functions expected from sisters is not appropriate in this article, the following list provides an indication o f what is required: -Set up and maintain parenteral infusions -Perform a full physical examination of the infant to screen for abnormalities and assess gestational age -Identify risk factors from a history -Undertake resuscitative responsibility which includes: endotracheal intubation giving mechanical respiration working respirators adm inistering oxygen measuring blood pressure -Manage therm al environment for the various infants -Assess daily progress of infants -Take steps to develop a good parent-infant relationship The above nursing process is best taught by means of a neonatal care course, but many do not hold such a certificate.It is, therefore, essential that all staff concerned with the care of infants attend an in-service programme of an on-going nature.A person who is specifically released from other duties to provide orientation and instruction is vital to ensure in-service education.

/ Param edical Stall
The follow ing personnel are all essential to a large neonatal unit and form part of the work team: Most high-risk infants are a source ot anxiety to the parents and as the social worker is a supportive person, her services are invaluable.
The occupational therapist has an important role to play in the stimulation o f certain babies.
The radiographer should be readily at hand when re quired.
The physiotherapist has a place in the neonatal unit espe cially for babies receiving ventilatory support.
A laboratory technician should be attached to the neonatal unit in order to speedily perform the various tests and have the results available within minutes.

Equipment
Direct observation by the nurse is by far the best method of m onitoring the infant.H ow ever, the use o f m onitoring equipm ent has a place in the NICU, as several param eters can be measured sim ultaneously e.g.heartrate, blood pressure, respiration, tem perature.Handling of the infant is m inimized once the monitors are attached to the infant and this is especially important in the nursing of infants with hyaline membrane disease.Some infants have a bradycardia before apnoea occurs, and the alert nurse will detect this and stim u late the infant, thereby preventing apnoea.A detailed list of equipment will not be given.

Control of Infection
Neonates have a predisposition to infection because of illness and immaturity.Infections are spread by people and fomites and it is the nurse who cares for the baby constantly who should ensure that there is no slackness concerning hygiene practices, as it could become a serious threat to the infant's survival.
Apart from some procedures e.g.parenteral fluids, medi cations, and preparation o f feeds which require strict sterility one must follow the sim ple rules o f hygiene.
Equipment should be cleaned/disinfected before being put into use on another patient.Use disposable equipm ent where possible.B reathing circuits and hum idifiers should be ch a n g e d d a ily w hen in use.T he sp a c e b e tw e e n incubators/cots should be sufficient to prevent cross infection.
Personnel caring for neonates should be free o f infections such as 11 u, colds, sore throats, diarrhoea and septic foci.
Medical and nursing personnel who are constantly in close contact with infants should change street clothes before going into the neonatal unit.Short sleeve gow ns may be worn by personnel who make interm ittent contact with the infants.
H andwashing is the most important of all measures used to control infection.On entering the neonatal unit the hands and arms should be scrubbed with Hibiscrub or sim ilar solu tion.The hands should be washed using the same solution before and after handling the infant.
Pedal action bins lined with plastic bags should be used for the disposal of soiled linen and rubbish.These are easily sealed and removed.
In the case ot infants who have a com m unicable disease, e.g.gastro-enteritis, it is essential to isolate the infant to prevent spread of infection to the other infants.Even though this happens very rarely, it is essential to reserve a room for the isolation of such cases.

CONCLUSION
The nurse is the key person in caring for the newborn and without her no neonatal unit could function.Despite all the technological advances in electronic devices and all other types of equipm ent available in the major teaching hospitals, the statem ent that " The nurse is in a better position than anyone else to detect the subtle signs that often herald catas trophe" remains true5.Together with all the other categories of staff , they form a team whose aim is to ensure the best possible outcom e for each baby.
The exacting nature o f this type of nursing needs national recognition and every encouragem ent, including better staf-ting.Only thus will we ensure the future health of all our citizens.