Wards of tiny charges

Anne O’Sullivan, an advanced nurse practitioner in neonatology at the Coombe hospital, cares for some of the tiniest and sickest babies in the State

THE NEONATAL Centre at the Coombe Women and Infants University Hospital in Dublin cares for some of the tiniest and sickest babies in the State. Some are born at just 24 weeks and can weigh less than 500g, the equivalent of just half a bag of sugar.

On the day I visited I was brought on a tour of the unit. Holding my breath for the entire time, afraid that even the slightest sound would disturb the tiny patients, I had to look twice into some of the incubators as tubes and wires dwarfed their precious inhabitants.

Anne O’Sullivan is one of just four advanced nurse practitioners in neonatology in the State and coupled with caring for tiny patients her role encompasses education, practice development and research. As an advanced nurse practitioner, O’Sullivan works closely with both medical and nursing staff and also promotes multidisciplinary teamwork within the unit.

With a capacity for 40 babies the neonatal centre in the Coombe is divided across two floors with the neonatal intensive care (NICU) and high dependency (HDU) on one floor and the special care baby unit (SCBU) on the other. The NICU is for babies who are critically ill and need intensive care.

“Intensive care is where babies have huge needs in relation to their respiratory management, their cardiovascular management. They are sick babies. They might have infections and they need a lot of supervision,” O’Sullivan explains.

As their condition improves, babies move from the NICU to high dependency and then upstairs to the SCBU from where, months after their birth, parents can finally prepare for their new baby’s homecoming.

Last year, 1,023 babies were cared for in the centre of which 125 were admitted weighing less than 1,500g or just over 3lbs.

O’Sullivan joined the neonatal centre in the early 1990s and has witnessed a number of advances in neonatal medicine and technology over the years. For example, medicines which help develop a premature baby’s lungs means that more babies are surviving today that sadly may not have done in the past.

“When I started in neonates if you had a 26-week [baby] everybody was on high alert. Now babies are living from 23 plus, 24 weeks . . . not every baby who is born at those gestations obviously survives but it can depend on lots of factors.”

O’Sullivan also says that advances in antenatal medicine mean that serious abnormalities or conditions can now be diagnosed in utero. This allows for the careful planning of the delivery of these babies and those with serious heart conditions, for example, are transferred immediately to Crumlin children’s hospital where a team of experts is on standby.

The Coombe accepts high-risk premature babies from all over the State with the help of its neonatal transport team which retrieves very sick babies by air or by road at all times of the day and night.

“If the baby moves to us obviously it is horrendous for the mother but as soon as she is stable the obstetric and midwifery staff here will try to facilitate the mother to move here as soon as she can,” O’Sullivan says.

Coupled with medical advances she says that neonatal nursing and multidisciplinary care have also evolved to very high levels in Ireland.

For example, the neonatal individualised developmental care programme (Nidcap) used in the Coombe works to promote the in utero environment.

Lighting and noise levels are kept to a minimum and dedicated nurses know to respond to the cues of their tiny charges. For example, a rise in heart rate may mean the baby is hungry, needs a nappy change or has to be repositioned.

According to O’Sullivan, an ICU nurse needs to be very responsive, “acutely aware” and “alert always to the changing condition of their baby” so they can pick up on the minutest change.

It is also hugely important to listen to the baby’s mother, she adds.

Nurses like O’Sullivan also have a responsibility to care for and support desperately worried parents. This includes supporting parents who receive the devastating news that their baby is not going to survive.

Neonatal nurses, therefore, support parents at one of the darkest times of their lives. Parents are also offered the supports of the hospital’s chaplaincy and bereavement counselling services.

The vast majority of O’Sullivan’s tiny patients suffer from complications of prematurity and in the initial hours after birth the main focus is on helping them to breathe with the aid of ventilation. She explains that as premature babies have paper-like skin, which must be kept intact to avoid infection, handling and positioning them can be hugely challenging. The sickest babies in the NICU therefore have one-to-one nursing.

“When we have a new 24-weeker in the unit the primary nurse would be very much at the bedside . . . observing the baby all the time,” she says.

According to O’Sullivan, in an ideal world, all of the babies in intensive care would have one-to-one nursing. However, the realities of working in a downturn means this is not always possible.

“We are working in very challenging times in relation to staffing levels. We are losing staff and staff aren’t being replaced and we are actually really trying hard not to use agency staff as is directed by the HSE . . . it puts huge pressure on you. But at some point in time you have to say no, I can’t manage because it is not safe and we are well supported in this hospital when those situations arise,” she says.

The majority of the babies cared for in the neonatology centre in the Coombe do very well and for O’Sullivan the best part of her job is meeting mothers and their babies months after discharge.

She says she often has difficulty recognising parents, as their faces are no longer transfixed with anxiety.

“It is all peaks and troughs when you are looking after babies in intensive care . . . and then when you see them getting to the stage where they go home . . . it is very rewarding. It’s what makes you do what you do.”