Dissertation for MMed (Obstetrics and Gynaecology) and FCOG Part II / Hypertensive disorders in pregnancy are common and their incidence appears to be on the increase. Preeclampsia is a multi-organ, heterogeneous disorder of pregnancy associated with significant maternal, fetal and neonatal morbidity and mortality. Because preeclampsia is a progressive disorder, invariably delivery remote from term is often necessary to halt disease progression to benefit the mother and fetus. Objectives:  To determine the maternal outcomes in women with severe preeclampsia  To determine fetal and neonatal outcomes of infants born preterm Methods This was a prospective, descriptive study performed in three academic hospitals affiliated to the University of the Witwatersrand in Johannesburg. Data was collected from women with severe preeclampsia, who delivered between gestational ages of 26 weeks and 33 weeks, with a minimum neonatal weight of 500g as determined by sonography. Results: In the sample of 92 patients enrolled, there were two maternal deaths as a result of severe preeclampsia. Eclampsia and HELLP syndrome were the most frequently observed maternal complications at 34% and 49% respectively. Caesarean section was the most frequent method used to expedite delivery in 84% of women. Of the 97 babies delivered, 20% were confirmed intra-uterine fetal deaths, 7% demised during the early neonatal period and a there was a 40% very low birth weight rate. Conclusion: Despite interventions to reduce maternal and neonatal morbidity and mortality in our setting, our outcomes are similar to those observed in other parts of the world.

As the capacity for saving smaller and smaller infants increases, the ethical dilemmas experienced by neonatal nurses who care for the smallest and most fragile of human beings will also increase. The current approaches to the resuscitation and management of extremely premature infants (24 weeks gestation and less) has resulted in the survival of infants with far less than optimal outcome. Neonatal nurses have begun to question saving the lives of extremely premature infants just because the technology exists to do so. This study explores the ethical issues faced by neonatal nurses caring for infants of 24 weeks gestation and less. The research question arose out of the need for neonatal nurses to articulate the ethical issues that they face in clinical practice when caring for extremely premature infants. The study design takes a dual approach to the research question, namely, a survey questionnaire and a qualitative analysis informed by phenomenology. Given the complexities of the issues within the topic, this combination of methods was deemed to be the most appropriate in gaining a convincing and authentic result. The results of this research are not generalisable to the experience of other nurses, or nurses caring for other groups of premature infants. In the first stage of the study neonatal nurses, members of the Australian Association of Neonatal Nurses (ANNA), were surveyed using a self-completion questionnaire. Then, in the qualitative component of this study fourteen (14) interviews with neonatal nurses were undertaken. These were either single or focus group interviews. In all, twenty four neonatal nurses from the state of New South Wales (NSW) and the Australian Capital Territory (ACT) were interviewed about their experiences of caring for infants of 24 weeks gestation and less. The questions asked during the interviews were based on findings from the questionnaire. The interview data was analysed using a qualitative approach informed by interpretative phenomenology. The qualitative analysis revealed that the ethical dilemmas faced by the nurses existed within four themes. The four themes are: • It’s all about this baby • Having a voice • Dealing with awfulness • Reflecting on the outcome. The qualitative description as given in the four themes reveals structures and meanings about what it is to be the neonatal nurse who experiences ethical dilemmas when caring for extremely premature infants. The study and its findings are a written account of the experiences of neonatal nurses and their ethical dilemmas in caring for infants of 24 weeks gestation and less. The meanings within the nurses’ experiences are offered and the final phenomenological description, Balancing hope with reality, is given. Hope has a buffering effect on the nurses. The nurses inspire and instil hope in themselves and a baby’s parents until the reality of a poor outcome dawns. Each time an extremely premature baby is born the nurses are hopeful for a good outcome, but the reality is that they have experienced many instances in which babies die or have a poor outcome. The neonatal nurses, affected by their experiences of ethical distress, attempted to find a pathway to achieve a balance between their emotions and caring for the baby. In doing so the nurses were able to remain productive the neonatal intensive care unit, and give high quality care to the baby and compassion to the parents. This study makes an important contribution to neonatal nursing knowledge and practice by exploring the ethical dilemmas and complexities associated with extremely premature infants. This study also makes a unique contribution to the body of literature on ethical dilemmas experienced by neonatal nurses.

Stabilisation and resuscitation in the delivery room is an integral part of the care of extremely premature newborns. The main task is to support essential life functions and to facilitate the adaptation of the immature organism to the extrauterine life. The current recommendations are well defined for the full term and late preterm newborns, but there is a lack of targeted recommendations for the stabilisation and resuscitation of extremely premature newborns. The research part of the submitted thesis summarises the most important results of clinical research performed in 2010-2015 at the Department of Neonatology of the Department of Gynecology and Obstetrics, VFN and First Faculty of Medicine, Charles University in Prague. The research evaluates the efficacy and side effects of the currently recommended methods of stabilisation and resuscitation of extremely premature neonates in the delivery room and presents some new and potentially useful techniques for delivery room care. A significant output of this work is the recommendation for practice, structured according to the gestational age of extremely premature newborns. The proposed guideline is based on our results of partial clinical trials and aims to improve the current level of stabilisation and resuscitation of extremely premature newborns...

Submitted by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-10-11T13:39:02Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO DANIELLE LATGE.pdf: 794878 bytes, checksum: 5cca76d4644dc8468ea35e9fb8e4dc67 (MD5) / Approved for entry into archive by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-10-11T13:39:16Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO DANIELLE LATGE.pdf: 794878 bytes, checksum: 5cca76d4644dc8468ea35e9fb8e4dc67 (MD5) / Made available in DSpace on 2017-10-11T13:39:16Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO DANIELLE LATGE.pdf: 794878 bytes, checksum: 5cca76d4644dc8468ea35e9fb8e4dc67 (MD5) Previous issue date: 2015 / Universidade Federal Fluminense. Hospital Universitário Antonio Pedro / Corpo de Bombeiros Militar do Estado do Rio de Janeiro / Atualmente, pode-se perceber um crescente aprimoramento na atenção prestada aos recém-nascidos de maneira geral e, de modo particular, aos recém-nascidos prematuros. É nítido o aumento da sobrevida de recém-nascidos, cada vez mais prematuros, em diversos lugares do mundo, incluindo o Brasil, o qual leva a diminuição dos limites de viabilidade. Diante de um cenário incerto, da possibilidade de graves sequelas e de sofrimento para o recém-nascido e sua família, a reanimação na sala de parto de um recém-nascido no limite de viabilidade envolve inúmeras questões bioéticas. Este estudo consistiu numa pesquisa qualitativa, na qual foram realizadas entrevistas semiestruturadas (em anexo) com os médicos da UTI neonatal de um Hospital de Ensino na Região Metropolitana do Rio de Janeiro que realizam salas de parto. Foram analisados aspectos relacionados à prática da assistência neonatal em sala de parto aos recém-nascidos extremamente prematuros, objetivando compreender os fatores associados à conduta médica diante destes recém-nascidos sob a ótica da bioética. O propósito deste trabalho é o de conhecer e analisar os valores éticos e/ou argumentos morais que embasavam a conduta médica ante ao nascimento de um recém-nascido no limite de viabilidade / Currently, it can be seen a growing improvement in the care provided to newborns in general and, particularly, to premature infants. It is clearly increased newborn survival of increasingly premature, in various parts of the world, including Brazil, which leads to decreased viability limit. Faced of an uncertain scenario, the possibility of serious consequences and suffering for the newborn and his/ her family, resuscitation in the delivery room of a newborn in the limit of viability involves numerous ethical issues. This study was a qualitative research in which semi-structured interviews with the doctors at the neonatal ICU of the University Hospital in a Metropolitan Region of Rio de Janeiro, who perform delivery rooms, were realized. There were analyzed practices related to aspects of neonatal care in the delivery room to extremely premature newborn, aiming at understanding the factors associated to medical management before these newborns from a bioethics perspective. The purpose of this work is to understand and analyze the ethical values and / or moral arguments which were based on a medical management before the birth of a newborn in the limit of viability

Syfte. Undersöka användningen av kängurumetoden hos extremt för tidigt födda barn. Bakgrund. Kängurumetoden (KM) är en evidensbaserad metod som innebär att barnet bärs hud mot hud på förälderns bröst i upprätt ställning. Metoden har många fördelar för det för tidigt födda barnet och har visat sig vara effektiv för att skapa starka band föräldrar och barn emellan. Forskning visar att det är en säker vårdmetod även för extremt för tidigt födda barn.   Design. En retrospektiv explorativ journalgranskningsstudie med både kvantitativ och kvalitativ ansats. Journaler granskades för de 49 extremt för tidigt födda barn vårdade vid Norrlands universitetssjukhus mellan oktober 2011 och oktober 2013. Metod. Statistiska beräkningar gjordes med icke parametrisk korrelation enligt Spearman och Wilcoxon signed ranks test. I den kvalitativa delen utfördes textanalys av journalanteckningar. Resultat. Medianålder vid kängurudebuten var fyra dagar. De flesta barn kängurudebuterade med mamman, och pappor utövade känguruvård i mindre utsträckning än mammor. Ju tidigare barnet var fött, desto längre dröjde kängurudebuten, men känguruvård har förekommit så tidigt som dag fyra hos de mest för tidigt födda barnen. Slutsats. Neonatalvården har mycket att vinna på om vårdpersonalen lyckas hjälpa föräldrar i allmänhet, och pappor i synnerhet, till att tidigt våga närma sig och känguruvårda sina extremt för tidigt födda barn. Med utbildning och träning för personal och stöd till föräldrarna, kan KM användas i större utsträckning för de extremt för tidigt födda barnen. Kliniska implikationer. Resultaten av denna studie bidrar till insikter och djupare kunskap om användningen av KM för extremt för tidigt födda barn. Resultatet kan användas för att identifiera utvecklingsmöjligheter men även för att utvärdera framtida förbättringsarbete. Kunskapen om och tron på vinsterna med KM kan rädda liv. / Aims. To study the use of the KMC for extremely preterm infants. Background. Kangaroo-Mother care (KMC) is an evidence-based method that involves carrying the infant skin to skin on the parent’s chest in an upright position. The method brings many benefits for the preterm infant and has proven to be effective for creating strong bonds between parents and infants. Research shows that KMC is a safe method even for extremely preterm infants. Design. A retrospective exploratory medical records review using both quantitative and qualitative approach. Medical records were reviewed for the 49 extremely preterm infants cared for at Norrland’s University Hospital between October 2011 and October 2013. Methods. Statistical analysis were made by non-parametric correlation by Spearman and Wilcoxon´s signed ranks test. In the qualitative part text analysis of medical records was performed. Results. KMC onset was in a median age of four days after birth. The kangaroo onset was most often with the mother, and fathers performed less KMC than mothers. The more preterm the infant was born, the later kangaroo onset, but KMC has occurred as early as day four for the most preterm infants. Conclusion. Neonatal care has much to gain if nursing staff succeed in helping parents in general, and fathers in particular, to an early KMC onset. With education and training for staff and support to the parents, KMC can be used for the extremely preterm infants to a greater extent. Relevance to clinical practice. The results of this study contribute to the understanding and deeper knowledge about the use of KMC for extremely preterm infants. The result can be used to identify needs for development, but also to evaluate future improvements. Knowledge of and belief in the benefits of KMC can save lives.