facts and opinion

My Baby Was Premature P.17‘ I YER, KN, MSN

Thi., I S a-firrt person account c f the event., rurroundin,y the authori .son ’A prpmature birth and three-umk hospitalization. Suggestions are made as fo houi nurser can be more he1pJult0 the parentc qfpremature babies.

O n the occasion of my son’s third birthday I found myself reminiscing about the painful series of events which had surrounded his pre- mature birr h .

Perhaps an account of my child- birth experience will help nurses rec- ognize the opportunities which exist to help the frightened parents of pre- mature infants.

Labor and Delivery My membranes ruptured four

weeks early, at 36 weeks gestation. Earlier in the day I had painted a closet in what would be the baby’s room, carried paint cans down to the basement, rearranged a rocking chair and small bookcase, and made my first purchase of baby clothes. Fortunately, for nie, my membranes ruptured just a few minutes before my husband arrived home. We left immediately for our local hospital. My obstetrician then decided to send me by ambulance to a medical center one and a half hours away that had a regional neonatal in- tensive care unit.

Although I was disappointed by not being able to deliver at the hos- pital where I had been working until two weeks prior to the rupture of my membranes, I was not too apprehen- sive about the transfer to another hospital. My contractions were mild during the trip and the ambulance

attendants kept me laughing with their stories while my jittery hus- band followed behind in our car.

At 1 AM, on arrival at the medi- cal center, I was 2 cm dilated and anticipated a long labor. After ex- amining me, the resident went to sleep. An I.V. was started and a fetal monitor was s t rapped o n t o me. When the labor room nurse ob- served my husband coaching me on b rea t hi n g tech n i q u es we h a d learned in classes for prepared child- birth, she seemed to assume we needed little nursing attention. The nurse came into the room three times during the next three hours, and then only when my husband called her to ask her to empty a bed- pan or change the monitor paper. T h e absence of nurses made us uneasy and anxious.

Three hours after entering the medical center, I was fully dilated. Since I had been examined only once, upon admission, i t was fortu- nate that I knew the signs of full di- lation. My husband asked a nurse to come in to see me. Two nurses, a resident, and an intern arrived to coach me on pushing with the con- tractions. The monitor began show- ing fetal distress with a fetal heart rate of over 200. Tension in the staff was evident. Although I immedi- ately knew from their carefully phrased conversation that the baby

was in distress, I could not focus on anything but the contractions.

O n the delivery table, a few con- tractions away from delivery, I asked the resident if he was doing an episi- otomy. “Sure I a m , ” he replied, winking at my husband, when he had not even started the procedure. Believing that the episiotomy had been completed, I pushed again and tore through my anal sphincter.

At 5 AM our son was born and had an Apgar score of 9. My hus- band touched him and then the baby was held up so I could see him. “What do you think?” asked the nurse. “He’s awfully blue,” was my reply. She snapped. “They’re all blue at first!” Then m y son was weighed (5 Ibs., 1 oz . ) and hurried to the intensive care unit with m y hus- band following. I felt relief that i t was over, happiness that my hus- band had gotten the son he wanted, and a longing to touch my son and to assure myself that he was healthy.

Postpartum I had no choice but to lie on the

delivery room table during the time- consuming repair of my laceration. T o my discomfort, the Novocain 8 began wearing off during the sutur- ing. In response to niy repeated requests for more Novocain, the resi- dent said he was almost finished, then finally offered that he “did not want to distort the anatomical fea- tures”. At that time, the perfection of the anatomical features was the farthest thing from my mind. How- ever, i t is difficult to be assertive when you are lying on your back with your legs in stirrups.

During my obstetrical rotation as a student nurse, I had spent a month in the postpartum recovery room checking blood pressures and mas- saging fundi every 15 minutes for a few hours following delivery. Per- haps this is no longer done, but my expectations were based on this ex- perience. I expected more attention than I received. My stretcher was left in a hallway for two hours while I kept an eye on the I.V. As it was about to empty I got the attention of a nurse and she removed the intra- venous needle from my arm. I wor- ried about what was happening to my son in the ICU and wished that someone would give me information about him.

Unfortunately, one of the Ameri- can doctors made the mistaken as- sumption that my husband, who is from India, was a doctor. Without explanation, this doctor told my hus- band that our son’s chest x-ray showed hyaline membrane disease or respiratory distress syndrome (RDS). My husband, shocked by the sight of the umbilical I.V. that had been inserted, cardiac monitors, temperature probe and urine collec- tion bag, was unable to ask for an explanation of this diagnosis. He went home convinced that our son was going to die.

The first news I had that some- thing was wrong with our son, Raja, came from the medical center’s chief obstetrician. He arrived at the niedi- cal center after my delivery, met me and then examined the baby. At that time he did not know I was a nurse. He popped his head into the door of my room and said, “Your ti- ger is breathing immaturely so he will stay in the intensive care unit.” Without any further explanation, he left. I lay there wondering what “im- mature breathing” was. I felt too numb to deal with the information. Eight hours after delivery, when I was able to get up, I went to the ICU to see Raja and to get more in- formation. His grunting respirations and sternal retractions were notice- able but I did not know the signifi- cance of these symptoms. I felt an immediate need to put my hand through the porthole of the isolette to touch him. While I was holding my son’s hand, the pediatric resident

arrived to t a l k to me. H e repri- manded me for opening the porthole and allowing the oxygen to escape. He seemed unaware of my need to establish contact with my son.

I did not absorb much of the resi- dent’s explanation of RDS. My first thought was that Jackie Kennedy’s baby died of RDS in the 1960s. I re- membered that when I studied pedi- atrics in nursing school in 1968, babies with RDS usually did not survive. I believed that my son was not going to live, and that it would be my fault. I reasoned that if I had not lifted those paint cans and furni- ture, my membranes would not have ruptured, and Raja would not have been premature. Unconsciously, I wondered if I was being punished for the ambivalence I felt about hav- ing a baby. Guilt and a sense of being responsible for his prematurity weighed on me, and I returned to my room in tears.

The evening of my son’s birth, my husband and I stood by his isolette, admiring his beauty. I remember thinking, “He’s beautiful, but I bet- ter not get too attached to him. He might die.” Kaplan calls this “antic- ipatory grief’ or the preparation for the possible loss of a child whose life is in jeopardy.’ This reluctance to es- tablish a close relationship with our son lasted for five days, at which time we began to believe that he would survive.

A rude shock was awaiting me when I entered the ICU on the sec- ond day. The baby was out of the isolette and was lying on his back, arms restrained, with continuous positive airway pressure (CPAP) nasal prongs taped to his nose. Not knowing what this was, my immedi- ate thought was that he was being kept alive by a respirator. My con- trol c rumbled . While the nurse looked for the resident, I sat next to my crying baby and felt his misery. Why had no one prepared me for the sight of this equipment? Why didn’t the neonatologist feel respon- sible for keeping the parents of his patient informed?

Soon the resident appeared to ex- plain CPAP to me. In my state of shock, I did not understand much of the initial explanation, and needed to have it repeated again and again.

The ultimate blow came from the nurse who found me stroking Raja’s hand. I was stimulating him to cry, she said, and this interfered with his CPAP by allowing the pressure to fall when he opened his mouth to cry. Again, the message was clear: Do not touch. The explanations as to why I should not touch him made sense to me intellectually, but emo- tionally I needed to touch him. The inability to stroke him heightened my depression and guilt.

O n the third day the nasal prongs were removed and a CPAP head box or hood was placed over Raja. To me, he looked like an astronaut in a clear head hood with a flexible neck collar. It was explained to me that the hood was required because Raja had been crying too much, making i t difficult to maintain high CPAP pressure. The hood maintained more constant pressure in the airway, and he seemed to be more comfortable in it.

By this time, all of the physicians and nurses involved in our son’s care knew I was a nurse. This enabled me to assert my right to information about Raja’s condition a n d the equipment being used. I then inter- preted this information for my hus- band. We were particularly fright- ened by the head hood and asked for explanations about the safety fea- tures. We were afraid the pressure would increase and rupture his al- veoli. The nurses allayed my fears by pointing out the safety features.

The ICU followed a primary care system in which each child was cared for by the same nurse on each shift for the duration of his hospital- ization. As a parent, this was very helpful for obtaining information a n d developing a rappor t with Raja’s nurse. I began coping with the stress by asking his nurse for in- formation centering around changes in his condition. His blood gases, his CPAP pressure and percentage of oxygen, and the dosage of antibiotic being given were among my con- cerns. Although this approach al- lowed me to feel informed and in control of my emotions, it resulted in depersonalization of my son. I did not seek or receive information about his behavioral responses. Fo- cusing on numbers intensified my re-

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moteness. I still would not permit myself to believe that he would live.

Our son remained in the head hood for the fourth and fifth day. On the fourth day we sought out the resident, our chief source of informa- tion, and pressed him for his opinion of Raja’s chance for survival. He produced a chart indicating that Raja, based on his gestational age and birth weight, had a 75% chance of survival. We began to have hope. My husband agreed that he would now buy birth announcements, a step he had delayed. He had won- dered, “DO you send out birth an- nouncements, then death announce- ments?”

During that first crucial week, most of the postpartum staff nurses were not supportive. Only one nurse routinely inquired about my baby. When I began describing the CPAP equipment, her body language in- dicated she did not know what I was talking about and hoped I would not expose her ignorance. Because I was so busy intellectualizing and playing nurse to stay in control, I did not seek support from the postpartum nurses. To keep my mind off what was happening in ICU, I read. Oc- casionally, however, my control cracked and tears filled my eyes, even when I was not thinking about Raja.

I think it would have helped me if the postpartum nurses had made more of an effort to inquire about my baby’s condition and about me. An empathetic comment such as, “This must be difficult for you” would have given me the opportu- nity to share my fears and depres- sion. Instead, I felt alone.

A surprise awaited us on the sixth day when we arrived at the hospital to visit our son. Raja was off CPAP and in an isolette. For the first time he was breathing room air at atmo- spheric pressure. What a thrill I felt when he was handed to me to hold! With his temperature probe and car- d iac moni tor leads discretely wrapped inside his blanket, he looked, at last, like a normal baby. We were reluctant to leave him that night.

A series of medical problems ne- cessitated two additional weeks of hospitalization. When Raja’s biliru-

bin rose he required a week of pho- totherapy. And since he was weak, he had trouble sucking. We often spent an hour trying to feed him an ounce of formula. I felt hopelessly inadequate and questioned how I would manage at home. The ICU nurses assured me that his feeding problems were not my fault and sug- gested that when feeding him I should place him on my knee in a sitting position with one hand under his neck. This advice, although use- ful at the time, led to future feeding problems. For months after he started taking his bottle well, I con- tinued to feed him in this awkward position. I did not feel comfortable enough when feeding him to cradle him in my arms.

Another problem arose when the pediatric cardiologist detected pat- ent ductus arteriosus. When I asked about symptoms I should observe af- ter Raja was discharged, I was told that the baby could go into con- gestive heart failure at any time. How would I know he was in fail- ure? He would be unusually fussy, might refuse a bottle, would be rest- less and irritable, have tachycardia, and his liver would be enlarged. There are indeed dangers in giving parents too much information. This information was more than we could handle emotionally. When at last Raja came home, my husband inter- preted his fussiness as heart failure. He wanted me to count his heart rate once an hour and record it, and was constantly anxious about Raja’s heart. Consequently we were elated when the patent ductus arteriosus closed spontaneously a t th ree months of age.

The effects of separation caused by three weeks of hospitalization be- came evident when Raja came home. Initially I was terrified of him. When I fed him, I found myself grinding my teeth, and then I wor- ried that I would transmit my ten- sion to him. Lack of sleep due to 2 AM feedings and my inability to re- lax left me in a constant state of fa- tigue.

As the only one in a rural neigh- borhood with a baby, I was sur- rounded by working neighbors, and with all my friends working, I felt completely isolated. This feeling was

intensified when, one week after Raja came home, my husband had to go to Europe on a business trip for three weeks. This forced me to learn how to cope with my new role as mother. Was it always so painful to become a mother? I wondered. The one concept that helped me the most was that without change, there is no growth. I believed growth was desir- able and realized that the pain of learning how to mother would even- tually lessen. By the time Raja was three months old and beginning to smile, I felt comfortable enough to cuddle him and begin talking to him. Today he is a healthy, outgoing and affectionate boy.

Recommendations Based on my experience, I recom-

mend the following nursing actions: Labor nurses need to be accessible. Keep the parents informed. My hus-

band and I would have benefitted from information about Raja’s con- dition as soon as he was evaluated. At that time we should have re- ceived an explanation of RDS and the purpose of the equipment in use. Being required to seek that informa- tion several hours later made us question the willingness of the staff to communicate.

H e l p parents become aware of their feelings and express them. The guilt and depression I felt when I blamed my- self for Raja’s prematurity might have been lessened by an opportu- nity to talk about it with nurses. I would have been relieved to know that the guilt I felt was a common reaction, and the anticipatory grief was also an expected reaction.

Encourage the parents to interact wzth thezr baby. Opportunities to visit the baby, touch, feed and hold him as soon a s possible are vital to the attach- ment process. The delay before I could begin these caretaking activi- ties created a distance between me and Raja that took months to over- come.

Frequently praise and reassure lhe par- ents a s they handle their baby. The air of competence of the ICU nurses made me feel unequal to the task of caring for Raja at home. Through their pa- tient and understanding encourage- ment, we learned to diaper, feed, and burp Raja.

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Prepare the parents for taking the baby home. Let them know that most par- ents are anxious about their ability to assume full-time care of their in- fant. Assure them that they will be- come more comfortable with their role. Discuss the special needs of the premature baby, making that infor- mation specific to their baby. Also assess their need for information about baby care in general. The ICU nurses assumed that since I am a nurse they did not need to discuss baby care with me. But I knew little

about the basics of baby care and thus spent hours seeking information from friends and books.

Lastly, make sure the parents have a phone number to call whenever they have questions. Parents need support and information during the difficult transition to parenthood.

Reference 1 . Kaplan D, Mason E: Maternal reac-

tions to premature birth viewed as an acute emotional disorder. Am J Or- thopsychiatry, 30:543, 1960

Address correspondence to Pat Iyer, RN, R D # 1, Box 369, Stockton, NJ 08559.

Pat her received her nursing diploma from Muhlenberg Hospital in Plainjeld, New Jer- sey, and her BSN and M S N degrees from the University of Pennrylvania in Philadelphia. A member of A N A , Ms. Iyer has taught in a di- ploma school, was a staffnurse in medical-sur- gical nursing, and is now in-service education coordinator at Mercer Medical Center in Tren- ton, New Jersey, and president of Trenton Re- gional Area In-service Nurses.

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