Developmentally supportive interventions with the high-risk newborn and family are often dismissed and not integrated into routine practices when caregiving is intense. This can easily occur in the delivery room and during admission to the newborn intensive care unit (NICU) where there are many caregiving demands. Yet, as the competition for healthcare dollars intensifies, the need to ensure patient satisfaction and long-term outcomes is a driving force in the way care is delivered. Family-centered developmental care during the birth process reflects a consumer-oriented perspective.1,2 Routine practices need to consider enhancement of long-term development and promotion of improved medical outcomes for infants and increasing family involvement through collaboration in clinical decision-making.2,3 Research has proven that the most influential variables for a child's development are the family and the home environment; thus, the overall goal of care must be integration of the child into the family unit.1-3 How can this be achieved in the demanding environment of the delivery room and during admission to the NICU?

ANTENATAL CARE

Much of the technology available today allows us to make better predictions about who might be admitted to the NICU and what kind of interventions will be required at birth and during hospitalization. The neonatal consult often begins with a referral well before birth, which allows the neonatal team to prepare for a particular infant. It also provides the opportunity for the family members to become involved in the planning and clinical decision-making for their infant's care.2,3 Information about the infant, medical diagnoses, possible interventions, and outcomes should be shared. Families should be asked about their desired expectations and outcomes. Do they want to continue this pregnancy, given the diagnosis or prognosis? Do they need support from others to make this decision? What would they like their role to be both in the delivery room and in the NICU? Who will be in the delivery room? What interventions will or will not be done and who will perform them (the medical team or the family)? Making sure that the parents are part of this planning is important. Providing options and choices is critical. Yet, it is seemingly small things that can make the biggest difference. Providing the father with the opportunity to cut the cord, giving the parents time with the infant before he is taken to the warmer, or calling the infant by name right from birth may seem of low priority to the medical team but can mean the world to parents and will often increase their satisfaction with the healthcare system.2,3

Once a plan of care has been formulated, it is important to share the plan with all the possible players and continue to keep the parents involved as their needs, wants, and decisions may change along the way. In addition, it is important to make sure that all members of the team, family and medical staff, are aware that it is only a plan based on expectations. In the delivery room, things do not always go as planned. Once the infant makes his or her appearance, everything could change so flexibility is a must. For everyone involved, knowing this and living with it can be the hardest part of formulating the plan.

At delivery

Normal maturation and development take 40 weeks in utero, and even for the full-term newborn, birth and transition are stressful since many body systems are making rapid changes. The newborn, who has been in the protective and supportive environment of the womb, is born most often into a bright, cold world, where he will be dried and stimulated with the expectation of crying to clear the lungs. He is dried and placed in warm blankets and returned to his mother's arms for the initial breastfeeding. The father is at the bedside and has been an active participant in the birth process. However, when an infant is born preterm or has difficulties with transition and/or the birthing process, the situation can be increasingly stressful for everyone involved. All expectations have abruptly changed.

When the NICU team is called to a delivery, there are many things that can be done to ensure that the family is a part of the process. Team members should knock at the door, instead of walking right in, introduce themselves, and explain their role to the parents first and then speak to the medical team. They should ask the name of the baby, or if the sex is known, and about the essentials of the birth plan and the medical history while preparing for the birth. These interventions acknowledge that parents are part of the team.

In the delivery room, interventions for the newborn support the physiologic changes occurring and developmental progress. Stabilization of the newborn requires attention to detail while still being aware of the big picture. Several studies have found the touch and stress experienced by the newborn in the delivery room to be inordinate.4,5 Touch is essential during resuscitation; however, accidental touch is avoidable and should be decreased. As soon as the newborn is physiologically stable, touch needs to be supportive of behavioral organization, maximizing optimal outcomes.3

During admission to the NICU

The NICU admission process is rote with routines. Often several staff members are working together to stabilize the newborn and at best the situation is chaotic. The infant is touched in relationship to the tasks that need to be accomplished. The father may be standing nearby watching this process. He may be provided with information about the infant's status, but he is seldom invited to be a participant in the admission process. He could be providing containment or speaking softly to and comforting his infant.6

The bedside nurse has been found to spend the most time with the infant during the admission process.5 One study found that infants received an average of 48 minutes of high-level stimulation which included 18 minutes of bright lights, 2 to 10 minutes of high levels of noise, and 2 to 14 minutes of increased activity. The more immature the infants, the more likely they were to experience higher amounts of touch and "disturbing contacts." These infants also exhibited a wide range of stress cues that often went either unnoticed or unheeded. The degree to which an infant was provided with developmentally supportive interventions was highly individualized and dependent on the sensitivity of the individual caregiver.5-7

Gathering essential data at admission about the infant's status is important however, deciding which data are necessary in the moment and which can wait until a more suitable time for physiologic and behavioral organization is of even higher priority. Providing developmentally supportive interventions prior to birth in the delivery room and at admission must be a priority if our overall goal is supporting the long-term outcomes for a newborn and family. Caregivers need to be knowledgeable about infant behavioral cues and integrate appropriate interventions into their caregiving practices. Interventions can include providing rest periods between stressful procedures, restraining the infant for procedures with flexion and containment, and using containment to provide comforting and limiting stimulation from the environment whenever possible. Priorities are set by the team and must be considered if practices are ever to change.5,6

Jacqueline M. McGrath, PhD, RN, NNP, FNAP

Associate Professor, Arizona State University College of Nursing, Tempe

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