Assessment of Hypothermia and the Thermoregulation measures received by neonates of a selected Medical College and Hospital, West Bengal

 

Mousumi Roy¹, Dr. Uma Rani Adhikari², Madhushri Roy³

¹Sister in-Charge, Trauma Centre, Asansol District. Hospital, Asansol, Pin 713301, W.B.

²Senior Lecturer, Govt. College of Nursing, Medical College and Hospital, 88 College Street, Kolkata-73.

³Senior Lecturer, Govt. College of Nursing, Purba Bardhaman, Aftab Avenue, P.O-Rajbati, West Bengal.

 

ABSTRACT:

Hypothermia is a significant cause of neonatal morbidity and mortality in developing countries like India and it is associated with variety of causes and many of which are preventable. An exploratory survey study was conducted for assessing the hypothermia and thermoregulation measures received by neonates of selected Medical college and hospital, WB. The purpose of the study was to identify the occurrence of hypothermia and the thermoregulation measures received by neonates. Through purposive sampling 61 neonates who were born vaginally, greater than 37 weeks of gestation and birth weight 2.5-3.5kg were recruited for the study. The tools used in this study were semi-structured interview schedule, digital thermometer, and structured observation checklist. Validity and reliability of tools were established before data collection. Collected data were finally analyzed using descriptive and inferential statistics. Findings of this study revealed that there is 32.78% occurrence of mild hypothermia in five time observation from birth to next four hours, even they all were full term healthy neonates. There was no evidence of moderate and severe form of hypothermia throughout the assessment period. Few immediate measures of thermoregulation which were 100% maintained by delivery room staffs i.e. closing door and windows of delivery room, radiant warmers on 30 min before delivery of a baby, prewarm two sheets were kept ready before delivery. Rest thermoregulation measures received by neonates were received neonates in prewarm sheet 60.7%, wrapped neonate with another pre warm sheet 70.5%, delay cord clamping was done for only 47.50% neonates, uninterrupted skin to skin (STS) contact with mother for one hour 59%, weighing after one hour STS for only 34.40% and early initiation for breast feeding was for 63.90% neonates. Thermoregulation measures during transportation like transportation with full cover of head, body and extremities and transportation with STS with mother received 70.49% and 57.38% of neonates. On the other hand 100% thermoregulation measures were maintained in postnatal ward like maintaining temperature of postnatal ward above 25 ⁰ C, put off fans and closed doors and windows on the head side of neonates whereas few more thermoregulation measures like kept the neonates full cover only face expose was maintained for 54.1%, touch the neonates were touches with dry hands72.1%, changed soil napkin immediately73.8%. The mothers of 86.9% of neonates provided breast feeding in every two hours or on demand in postnatal ward whereas in second and third observations interval of breastfeeding maintained for 70.5% and 83.5% of neonates. Selected factors of thermoregulation such as temperature of delivery room, temperature of post natal ward, uninterrupted skin to skin contact with mother for one hour, warm transportation with full cover of head, body and extremities of neonates significantly associated with hypothermia. The findings of this study have several implications in the field of nursing because thermoregulation measures which can prevent neonatal hypothermia is very important aspect of newborn care.

 

 

 

 

INTRODUCTION:

A newborn baby is God’s divine precious gift for a mother. 90% of newborns make the transition from intrauterine to extra uterine life without any difficulty. They require little bit of assistance to start spontaneous and normal regular respiration. Approximately 10% of them need some assistance to start breathing at the time of birth and only about 1% may be need extensive resuscitative measures for survive.¹

 

The infant in the period of birth to 28 days termed as neonate. The neonates are potential to develop various health problems even though they born average birth weight. So the morbidity and mortality rate of neonates are high. UNICEF on February 2018 reported that according to the rank of the countries as per newborn death per 1000 live birth, the rank of India was 12^th against 52 lower middle income nation.² Hypothermia is considered as a silent killer in neonates³. Neonates are more prone to develop hypothermia because they have large surface area per unit of body mass so there is increase rate of neonatal morbidity and mortality due to hypothermia⁴. Neonatal hypothermia is a major contributor to neonatal illness and death. The temperature of neonates tends to fall progressively after birth as part of transition from intrauterine to extra uterine life. Neonates are thermolabile³, so maintenance of proper thermal environment is essential for survival and growth of neonates because thermoregulatory mechanism is not fully develops at the time of birth of neonates.

 

Neonatal hypothermia is an abnormal thermal state in which the newborn’s body temperature drops below 36.5⁰C (WHO)⁵. Hypothermia is considered to be a major contributing factor to neonatal morbidity and in extreme cases mortality. Educated and trained health professionals decreased the risk of hypothermia in the newborn, while the development of professional guidelines promotes a safer and more accurate management of neonatal hypothermia and its effects.⁶

 

Hypothermia is one of the main causes of neonatal morbidity and mortality in developing countries⁷. In hospitals common reasons of neonatal hypothermia are incorrect care of the baby at birth, cool delivery room and inadequate drying and improper wrapping of the neonates. Warm chain (WHO)⁸ is a method of thermal management which includes immediate drying, warm resuscitation, skin-to-skin contact between the mothers and the baby, early initiation of breastfeeding, postponing bathing, postponed early weighing, warm environment, appropriate clothing and bedding, and bonding. Warm chain should be encouraged at all levels of healthcare delivery system especially in resource-poor setting where highly sophisticated warming devices are not usually available to prevent neonatal hypothermia. A few hospital based studies in India suggested that hypothermia has a serious health concern in developing country and it leads to develop short stature, delayed growth and even death in case of healthy full term neonates⁹. So it is very much important to assess the causes of neonatal hypothermia regularly in order to highlight the need for improved preventive measures. So the objectives of the study were to identify the occurrence of hypothermia among neonates, to assess the thermoregulation measures received by neonates and to identify the selected factor associated with hypothermia.

 

METHODOLOGY:

This exploratory survey research included neonates of a selected medical college and hospital through purposive sampling. Inclusion criteria for selection of the sample were: all neonates who were vaginally delivered, cried immediately after birth and having normal respiration after birth, birth weight 2.5-3.5kg and completed 37 weeks of gestation to 42 wks of gestation. The exclusion criteria for selection of the sample were: neonates with congenital anomaly, who were sick and place in warmer for observation or shifted to NICU after birth and neonates with intravenous fluid, intravenous antibiotics and phototherapy. Thermoregulation measures were observed through structured observation checklist from 61 neonates and hypothermia was assessed by measuring temperature through calibrated digital thermometer. Observation checklist was prepared on the basis of WHO guidelines for thermal protection of newborn. Observation checklist was validated and tested for reliability before final data collection. Reliability was assessed through test and retest method and r was 0.89. Ethical permission was taken before final data collection. In the present study assessment of hypothermia means ensuring the axillary temperature of neonates half and one hour after birth and hourly up to 4hours after birth. Hypothermia was considered for episode of deviation of axillary temperature below 36.5^oC (according to WHO). Here thermoregulation means the measures to maintain normal temperature of neonates (36.5^oC to 37.5^oC). Thermoregulation measures maintained by the investigator from birth of the neonates and continue up to four hours of birth. For this study stages of hypothermia considered as per WHO stages of hypothermia i.e-

·       Normothemia– Axillary temperature of neonates between 36.5⁰C to 37.5⁰C.

·       Mild hypothermia– Axillary temperature of neonates 36⁰C to 36.4⁰C.

·       Moderate hypothermia–Axillary temperature of neonates 32⁰C to 35.9⁰C.

·       Severe hypothermia–Axillary temperature of neonates less than 32⁰C.

 

RESULTS:

Table 1: Frequency and percentage distribution of demographic profile of mothers of neonates.                                       N= 61

Variables	Frequency	Percentage
Age
18 – 25 years	50	81.9
25 – 30 years	11	18.1
>30 years	0	0.0
Religion
Hindu	45	73.8
Muslim	16	26.2
Education
Illiterate	4	6.6
Primary	24	39.4
Secondary	20	32.7
Higher Secondary	10	16.4
Graduation and Above	3	4.9
Occupation
Homemaker	61	100.0
Others	0	0.0
Place of Residence
Rural	49	80.4
Urban	12	19.6
Living issue None	34	55.7
One	24	39.3
Two	2	3.3
More than two	1	1.7
Source of knowledge on hypothermia
Not known	22	36.1
Previous childbirth	25	40.9
Family member	6	9.8
Magazine	2	3.2
Television	6	9.8
Mode of delivery ND with Episiotomy ND without Episiotomy	34 27	55.73% 44.26%

 

The data presented in table-1 shows that the majority of the mothers are from the age group of 18–25 years that is 50 (81.9%) and 26- 30 years 11 (18.1%). There is no mother of less than 18 years and above 31 years. The table-1 also shows that maximum mothers belong to Hindu religion that is 45 (73.8%), 16 (26.2%) belongs to Muslim religion. It also shows that 4 (6.6%) mothers are illiterate, 20 (32.7%) mothers completed their primary level of education, 20 (32.7%) mothers passed secondary level of education,10 (16.4%) mother passed higher secondary level of education, and only 3 (4.9%) are reached in graduate and above level. All mothers that is 61 (100%) were housewife. 49 (80.4%) of mothers resides in rural area and only 12 (19.6%) were from urban area. 36% mothers have no knowledge regarding hypothermia.

 

 

Findings related to frequency of occurrence of hypothermia.                                                                 

 

Figure 1: Comparative Bar diagram showing the frequency of occurrence of hypothermia in five observations.                        N = 61

 

 

Figure 2: Bar diagram showing the percentage distribution of immediate measures of thermoregulation.                               N = 61

 

 

Figure 1 shows that among 61 neonates 40 neonates were normothermic and 21 neonates were mildly hypothermic in first observation. Figure-1 also depicts that there is no incidence of moderate and severe hypothermia throughout the observation. It is also observed that from 4^th observation onward less number of neonates develops hypothermia.

 

Figure -2 exhibits that 100% neonates are received thermoregulation measures like the doors and windows are close in the time of delivery, room temperature is maintained in between 25⁰C – 28⁰C in all neonates and the radiant warmer was put on prior to 30 minute of delivery and two sheets were placed under the radiant warmer for prewarming for 100% of neonates. It also exhibits that other immediate thermoregulation measures those are 60.7% neonates are received in prewarmed sheets, 70.5% neonates are wrapped with another prewarm sheet, cord of 47.50% neonates are clamped after 1-3 minute of birth and uninterrupted skin-to-skin contact with mother in delivery room are maintained for 59% of neonates. Weight measurement procedure of neonates carried out after one hour of skin to skin contact with mother for 34.50% of neonates. The data also shows that early initiation of breast feeding within 30 minutes of birth was practiced for 63.90%of neonates only.

 

Figure-3: Bar diagram showing thermoregulation measures received by neonates during transportation                                   N = 61

 

Figure-4: Comparative Bar diagram showing thermoregulation measures maintained in postnatal ward during 1^st, 2^nd and 3^rd observations.                                                                                                                                                                                                     N = 61

 

The figure 3 depicts that 70.49% neonates were transported from delivery room to postnatal ward with full cover of head, body and extremity. The data also reveals that during transportation from delivery room to postnatal ward 57.38% neonates were maintained skin-to-skin contact with mother.

 

Figure 4 depicts that in postnatal ward during first, second and third observation 100% neonates received thermoregulation measures i.e. the room temperature are maintained above 25⁰C, all fans over the head of neonates are put off, and all doors and windows located at the head side of neonates are closed. In first observation in postnatal ward 54.1% neonates are found fully cover of head, body and extremities whereas in second and third observation it increased up to 72.1% and 73.8% respectively. The care givers touched the neonates with dry hands for 72.1%neonates in first observation, 70.5% neonates in second observation and 83.6% neonates in third observation in postnatal ward. The data of figure 4 also reveals that in first observation the caregivers of 80.3% neonates changed the soiled napkin immediately; same action was performed for 78.7% neonates in second observation and 88.5% neonates in third observation in postnatal ward. The mothers of 86.9% of neonates provided breast feeding in every two hours or on demand in postnatal ward whereas in second and third observations interval of breast feeding are decrease in percentage. The figure also shows that the neonates in postnatal ward maintained “bedding in” with their mothers for 70.5% in first observation, while in second and third observations it increased to 82.5%.

 

Table-2: Association between the hypothermia and selected factors.                                                                                    N= 61

Factors	Hypothermia	Normothermia	Chi-square Calculated (df)	Tabulated Value (0.05)	p-value	Significance
Temperature of delivery room
250C - ≤270C	16	13	5.803 (1)	3.84	0.016	Significant*
>270C – 280C	8	24
Skin to skin contact initiation
<30 min	18	7	18.920 (1)	3.84	0.01	Significant*
≥30 min	6	30
Early initiation of breast feeding
≤30 min	14	25	0.538 (1)	3.84	0.463	Not significant
>30 min	10	12
During transportation full cover of head, body and extremities of Neonates
Yes	12	31	7.988 (1)	3.84	0.005	Significant*
No	12	6
Skin to skin contact during transportation
Yes	14	22	0.008 (1)	3.84	0.930	Not significant
No	10	15
Temperature of Postnatal Ward
250C - ≤270C	19	16	7.862 (1)	3.84	0.006	Significant*
>270C – 280C	5	21
Mode of delivery
ND with Episiotomy	11	23	1.573 (1)	3.84	0.210	Not significant
ND without Episiotomy	13	14

 

Data presented in table 2 depict that there is a statistically significant association found between hypothermia with temperature of delivery room, skin to skin contact initiation and covering full hand, body and extremities of neonates during transportation. On the other hand there is no statistically significant association found between hypothermia with early initiation of breast feeding, skin to skin contact during transpiration and with mode of delivery.

 

DISCUSSION RELATED TO OTHER STUDY:

The present study pointed out that occurrence of mild hypothermia in full term healthy neonates half and one hour after birth to hourly for next 4 four hours are 34.42%, 39.34%, 40.98%, 26.22% and 22.95% respectively. Findings of present study is supported by the study conducted by Develar MA et al¹⁰ in baby friendly hospital Babool, where axillary temperature showed 41.2%,47.5%,46.4% and 37.2% of moderate hypothermia immediatly after birth, at 1 hour, 2 hour, and 4 hour respectively in healthy full term neonates.

 

The result of present study also resembles with the study of Prof. Mrs. Meena Sonavane¹¹ who conducted a study to assess the practices affecting thermoregulation in newborn immediately after birth within four hours. The result of the study showed that immediately after birth, 66% babies were in normal temperature and 34% of babies were below the normal range. After transferring from labour room to resuscitation room 14% babies were below normal range and 86% were at normal temperature. After transferring to post natal ward 66% had normal temperature and 34% were hypothermic. This study also revealed that temperature of labour room and resuscitation room was maintained for 79% at 25⁰-28⁰C and 13% at 30⁰-32⁰C. Doors of the labour room were fully closed for 7% and partially closed for 93%. 49% babies were kept in warm clothes, 47% babies were kept in resuscitation room without drying. 90% baby’s cords were clamped after 15 minutes and 10% babies cord clamped and cut immediately.94% babies were dried with cold sheet, 6% babies were dried with warm sheet. Weighing of the baby was done 100% without keeping any cloth on the weighing scale.100% babies were transferred with inadequate clothes from labour room to postnatal ward. 100% babies were kept with closed skin-to-skin contact with mothers. According to this present study some immediate measures of thermoregulation like temperature of delivery room from 25⁰C-28⁰C, doors and windows were closed of delivery room, radiant warmer was on prior to 30 minutes of birth, two sheets were kept under radiant warmer before 30 minutes of birth got 100% of neonates. Rest of the measures like received neonates in prewarm sheet, wrapped neonates with another prewarm sheet, delay cord clamping for 1-3 minutes of birth, uninterrupted skin-to-skin(STS) contact with mother for one hour, weighing after one hour STS, early initiation of breast feeding got 60.7%,70.5%,47.50%,59%,34.40%,63.90% of neonates respectively. Thermoregulation measures during transportation like transportation with full cover of head, body and extremities and transportation with STS with mother received 70.49% and 57.38% of neonates.

 

The present study also showed that there was significant association between uninterrupted skin-to- skin contact for one hour with mother with hypothermia. This is supported by the study of Seyum and Ibrahim¹² study which showed that there was significant association with occurrence of hypothermia and skin-to-skin contact with mother.

 

The present study also showed that there was no significant association between early initiation of breast feeding and hypothermia but the study conducted by Mullany¹³ et al. showed that there was statistical significant association with delayed breast feeding with hypothermia. This study finding just opposed of present study findings and it may be because of small sample size.

 

So summarily it may be said that occurrence rate of mild hypothermia were 32.78% throughout the observation which is below the average level. Occurrence of hypothermia after 2 hours of birth when the neonates were transferred from delivery room to postnatal ward was 41%. It might be due to transfer of neonates from closed environment of delivery room to open environment of postnatal ward. Occurrence of hypothermia were minimum 26.22% in postnatal ward after 4 hours of birth, may be due to stabilization of neonates from intrauterine life to extra uterine life four hours after birth.

 

IMPLICATIONS:

The findings of the study have several implications for nursing practice, nursing education, nursing administration and nursing research.

 

Nursing education:

The nursing education should consist of knowledge to thermoregulation measures using different methods of teaching. Nurses at postgraduate level need to develop their skills in preparing health teaching materials according to institutional level of understanding. During training period, emphasis needs to be given on skilled practice on thermoregulation measures, and early recognition of hypothermia by the student or mother or by the health workers because it is crucial for institute to take corrective action to reduce the severity of hypothermia and improve the survival of newborn baby.

 

Nursing practice:

In order to provide quality care to neonates health personnel should have adequate knowledge and skill regarding thermoregulation measures.

 

Nursing administration:

Nursing administrators should actively participate in implementing the policy related to neonatal hypothermia in hospital setting.

 

Nursing research:

With rapid advancement of newer findings in context of prevention of neonatal hypothermia previous practices has been changed drastically. Nurse should recognize the need of evidence based care in the area of maternity and child health nursing. This has been made possible through various researches to find effective and safest ways of prevention of hypothermia of neonates.

 

This study covered an important aspect of newborn care. In this study researcher herself observed and collected data so variability related to data collection is zero. This study has limitation too those are: firstly small sample size, secondly the temperature of neonates measures only for birth to next four hours and lastly only full term neonates were included in this study and the occurrence and association of neonatal hypothermia with of preterm and low birth weight neonates was not included.

 

Findings of this study indicating that there is less than average 32.78% prevalence rate of mild hypothermia among full term healthy neonates and this result may be useful in order to develop “warm chain” for preventing neonatal hypothermia. According to the study result it is suggested that regular monitoring of axillary temperature of neonates through digital thermometer should be added as one step of maintaining warm chain as it is cost effective to diagnose the early stage of hypothermia of neonates ultimately it prevent hypothermia of neonates in the first day of their life.

 

CONFLICT OF INTEREST:

None.

 

ACKNOWLEDGEMENT:

The investigators express cordial thanks to the staffs of the selected hospital for their support. The investigator expresses her gratitude to mother of neonates for extending their co-operation. We are thankful to the West Bengal University of Health Sciences for facilitating this work.

 

REFERENCES:

1.        National Rural Health Mission. Basic Newborn care and Resuscitation Program Manual. Ministry of Health and Family welfare: Govt. of India; Page no 2.

2.        UNICEF report. Newborn Mortality rate. New Delhi: UNICEF India; 2018 Available from https://data.unicef.org.

3.        Datta P. Paediatric Nursing. Jaypee Brothers Medical Publishers P (Ltd), 3rd Edition, Chapter 6;

4.        Page no.82-84. Available at http://www.ijmprs.com/ Ghai OP. Essential of Paediatrics. Menta Publishers. 5^th edition; Page no 130.

5.        WHO. Thermal Control of the Newborn: a practical guide. Maternal Health and safe Motherhood Programme Division of Family Health. Geneva: World Health Organization; 2006.

6.        Aliona Vilinsky Ann Sheridan. Hypothermia. British Journal of Midwifery, August 2014; 22 (8): 395-400.

7.        Demissie B.W, Abera B.B, Chichiabellu T. Y, Astawesegn F.H. Neonatal hypothermia and associated factors among neonates admitted to neonatal intensive care unit of public hospitals in Addis Ababa, Ethiopia.BMC Pediatric. 2018; 18:263. Available at https://doi.org/10.1186/s12887- 018-1238-0.

8.        WHO. Tharmal protection of Newborn: a practice guide, maternal and newborn health/safe motherhood unit. Geneva: World Health Organization; 1997. WHO/RHT/MSM/97.2. Available from www.int/hq/1997/WHO_RHT_MSM_97.2.

9.        Jeffery P. R, Sathish K.T, Suganthy K. K. Prevalence of hypothermia among normal term neonates in a South Indian city and assessment of practice and knowledge risk factors among mothers-A hospital based cross sectional study. Indian Journal of Medical Research and Pharmaceutical Sciences. December 2015; 2(12):

10.     Delavar MA, Akbarianrad Z, Mansouri MM, Yahyapour M. Neonatal hypothermia and associated risk factors at baby friendly hospital. Annals of Medical and Health Sciences Research, 2014; 4(Suppl2): S99-103. Available at: https://www.ncbi.nlm.nih. gov>articles.

11.     Prof. Snavane Meena. A study to assess the practices affecting thermoregulation in Newborn immediate after birth within four hours. Sinhgad. e Journal of Nursing, 2014;4(1):1-3.

12.     Seyum T. Ebrahim E. Proportion of neonatal hypothermia and associated factors among newborns. Gen Med (Los Angel) 2015; 03(04):1–7. Available from http: // dx, doi.org/10.4172

13.     Luke C Mullany, Joanne Katz, Subarna K Khatry, Steven C Le Clerq, Gary L Darmstadt, James M Tielsch, Mullany et al. BMC Medicine 2010;8:43. http://www.biomedcentral.com/1741- 7015/8/43.

 

 

Received on 28.03.2020          Modified on 18.04.2020

Accepted on 30.04.2020      ©AandV Publications All right reserved