Connie von Köhler, MSN, RNC-OB, C-EFM, CPHQ

November 12, 2015

Program Director: Perinatal Outreach Education Program

Miller Children’s & Women’s Hospital, Long Beach

Describe Sudden Unexpected Postnatal Collapse

(SUPC)

Review safe skin-to-skin practices to prevent SUPC

Identify methods to monitor babies during skin-to-skin contact

OBJECTIVES:

Los Angeles Regional Hospital Breastfeeding Consortiums

Providence Holy Cross Hospital

Sharp Mary Birch, San Diego

Community Perinatal Network

Acknowledgements:

Depends on how it’s defined…..

What is SUPC?

SUPC Sudden unexpected postnatal collapse

eSIDS Early sudden infant death syndrome

ALTE Apparent life threatening event

SUDI Sudden unexpected death in infancy

SUEND Sudden unexpected early neonatal death

ENSUD Early neonatal sudden unexpected death

ESUDI Early Sudden Unexpected Death in Infancy

Inconsistent Definition

Sudden unexpected infant death (SUID) is the death of an infant less than 1 year of age that occurs suddenly and unexpectedly, and whose cause of death is not immediately obvious before investigation.

3 types: Sudden Infant Death Syndorme (SIDS)

Unknown Causes

Accidental Suffocation and Strangulation in Bed (ASSB) CDC

Sudden Unexpected Infant Death

Sudden unexpected postnatal collapse (SUPC)

is

the sudden collapse of an apparently healthy infant within the first days of postnatal life.

(>35 weeks gestation, 10 minute Apgar >7, considered healthy who collapse suddenly & unexpectedly within the

first postnatal week.)

SUPC

Herlenius & Kuhn, 2013

SUPC – SIDS Analogous Mechanisms & Risk Factors

SIDS – “triple risk” hypothesis underlying genetic or developmental predisposition

Infant Vulnerability

Development

Environment

Case of death unknown

Deaths in 1st week often not included in SIDS databases

SUPC is associated with prone position/skin-to-skin/ cobedding in 74% of reported cases.

SUPC Etiology

Herlenius & Kuhn, 2013

Published reported cases vary–

2.6 to 133 cases/100,000

Criteria varies: Definition

Inclusion criteria

Exclusion criteria

Sweden, France, England, Germany, Austria, Italy, US/NYC

Incidence

Davanzo, et al., 2015, Herlenius & Kuhn, 2013

Maya Angelou

“I did then what I knew how to do. Now that I know better,

I do better.”

Half of the infants die

No etiology found

Survivors half have neurological sequela

Developed hypoxic-ischaemic encephalopathy (HIE)

Hypothermia treatment successful in some cases

Outcomes:

Pejovic & Herlenius, 2013 Herlenius & Kuhn, 2013

1/3 during the first 2 hours of life

1/3 between 2 and 24 hours of life

1/3 between 1 and 7 days of life

Occurrences:

Herlenius & Kuhn, 2013

≥ 34 or 35 weeks or greater

Normal weight

No congenital anomaly or other issues

“Good condition”

Apgar of 7 or 8 at 5 minutes

No evidence of resuscitation beyond suction of the airway

Cases Reviewed:

Within 2 hours of birth

Baby PRONE or side position on mother

Baby covered head not visible

Mother supine

Mother primiparous

Mother and infant were not observed during the initiation of skin-to-skin & 1st breastfeeding

Parents left alone with baby during first hours after birth

Mother distracted with electronic device(s)

Common Denominators:

Pejovic & Herlenius, 2013 Herlenius & Kuhn, 2013

Recommended for all healthy term newborns due to

physiologic and bonding benefits which include: Regulation of infant’s temperature & prevention of

hypothermia

Neonatal blood glucose regulation and prevention of hypoglycemia

Initiation and maintenance of exclusive breastfeeding and enhanced milk production

Enhance the mother/infant relationship

Skin-to-Skin contact should be done immediately after birth until the first feeding at the breast has been achieved (AAP, 2012)

Skin to Skin Contact Benefits

What Do We Know?

Babies vulnerable during transition Prone position

Head covered

First time breastfeeding attempt

Mother Supine

Primiparous

Obese

Left alone (no RN supervision)

Tired or/& medicated (analgesia, sedated, Magnesium Sulfate)

Mobile devises—texting / social media

Bedsharing

Risk Factors:

What Should We Do?

AWHONN (2010) 2 nurses should be in attendance until the critical elements

for both patients are met

(1 nurse for the mother & 1 nurse for the baby).

After the critical elements are and when conditions of mother and baby are determined to be stable, 1 nurse can care for both the mother and the baby.

AAP/ACOG Guidelines for Care (7th ed)

The nursing staff in the labor, delivery, recovery, and postpartum areas should be trained in assessing and recognizing problems in the newborn.

Staffing Guidelines

1. Safe early skin-to-skin (SSC) in the delivery room

2. Safe breastfeeding establishment in the first days of life

3. Secure positioning of the infant during sleep

Recommendations:

Herlenius & Kuhn, 2013

Continuous surveillance

One caregiver focused on the baby during the first postnatal hours Always have a caregiver (nurse) in the room

Position self to see mom & baby

Reduce the risks of distractions (nurse & mother)

Assessment ongoing (NRP) & continue throughout the recovery period

Infant: breathing, activity, color and tone

Safe Early Skin-to-Skin (SSC) In The Delivery Room

Observe correct & safe positioning

Tummy to tummy / chest to chest

Nose free

uncovered by breast tissue

Uncovered by blanket

Head & neck aligned

Safe Breastfeeding Establishment In The First Days Of Life

All newborn infants should be placed in supine position within the first few hours after birth are emphasized in the reports of SUPC and in the guidelines to reduce the risk of SIDS.

Nurses need to “model” Safe Sleep behaviors and continuously educate parents to place the baby in the crib / bassinette on the back after feeding.

Secure Positioning Of The Infant During Sleep

AAP, 2011

Kathleen Rice Simpson:

MCN-July/August 2015

Newborn Safety in the Hospital

Common Sense Approaches to Newborn Safety

MCN-November/December 2015

Nurse Staffing and Care During the Immediate Postpartum Recovery Period

Perinatal Patient Safety

Tools

Checklists

Observation Checklist

Davanzo, et al., 2015

Do not leave mothers unattended, especially if primigravidas.

Ensure (and verify) appropriate infant position during skin-to-skin contact (SSC), with nose and mouth uncovered and well visible.

The prone position should be accepted if the infant is chest-to-chest (not over a breast, between breasts, or over the abdomen), with the head turned to one side, the neck straight, and mouth and nose uncovered.

Prone position of the newborn should be accepted only during supervised SSC.

Avoid SSC when mothers have been given analgesics and/or appear tired unless staff can provide continuous monitoring of the mother-newborn dyad.

First breastfeeding attempt should be supervised.

Advice to Health Care Professionals:

First 2 Hours of Life

Davanzo, et al., 2015

Bed sharing should be discouraged, if the mother is

sleepy/sleeping and the mother-newborn dyad is unattended.

Babies found bed sharing with a sleepy/sleeping mother should be placed in their cots. (bassinets)

Side and prone position of the newborn should be discouraged. (NOT DONE AAP-2011)

Prone position of the newborn should be accepted only during supervised SSC.

Recurrent checks of the mother and the infant are required and, if needed, position of the infant should be corrected.

Advice to Health Care Professionals:

After the First 2 Hours of Life

Davanzo, et al., 2015

Supine position is recommended when the infant is sleeping in the

bassinet or the crib/cot. (Safe Sleep)

Avoid Do Not (AAP) placing infants in prone/side position.

Prone position is accepted only during SSC and if the mother is not sleepy/sleeping.

During SSC, nose and mouth should be visible and uncovered at all times: the head should be turned to 1 side; neck should be straight and not bent; the infant should be chest-to-chest and not over a breast, between breasts, or over the abdomen.

Avoid distraction, particularly the use of electronic devices such as smart phones, during SSC and breastfeeds.

If mother feels tired and/or sleepy, the infant should be placed in his or her crib. (bassinet)

Ask for supervision for first and subsequent breastfeeding attempts.

Advice to Mothers Davanzo, et al. 2015

Respiratory Effort

Activity

Perfusion

Position

R.A.P.P.™ Assessment Tool

Ludington-Hoe, & Morgan, 2014

The RAPP™ Assessment

Ludington-Hoe, & Morgan, 2014

www.femtique.org

www.wholeparentingfamily.com

valdmanis.blogspot.com

www.northeastern.edu

www.asklenore.info

www.nursingnurture.com

www.yourbirth.ie

trevorerin.blogspot.com

1. Safe positioning education a. Educate health care professionals

b. Educate the new mother (prenatal and in-hospital)

c. Educate family members / support persons

2. Posters &/or Checklists on room walls

3. “Model” the items on the checklist

4. Nursing staff need to KNOW the risk factors & vigilantly screen (who is not a candidate for SSC or needs additional observation)

5. Develop a routine assessment parameters

6. Continuously monitor the dyad during SSC & breastfeeding in the L/D & Mother/baby units

Strategies to Minimize SUPC Risk

Ludington-Hoe, & Morgan, 2014

Andres V, Garcia P, Rimet Y, Nicaise C, Simeoni U. (2011). Apparent life-threatening events in presumably healthy

newborns during early skin-to-skin contact. Pediatrics.127(4):e1073-6. doi: 10.1542/peds.2009-3095.

AAP/ACOG (2012). Guidelines for Perinatal Care 7th Ed.

AWHONN, (2010). Guidelines for professional registered nurse staffing for perinatal units. Washington. D.C.

Becher, J., Bhushan, S. S., & Lyon, A. J. (2012). Unexpected collapse in apparently healthy newborns--a prospective

national study of a missing cohort of neonatal deaths and near-death events. Archives Of Disease In Childhood.

Fetal And Neonatal Edition, 97(1), F30-F34. doi:10.1136/adc.2010.208736

Branger B, Savagner C, Roze JC, Winer N. (2007). [Eleven cases of early neonatal sudden death ou near death of full

term and healthy neonates in maternity wards]. J Gynecol Obstet Biol Reprod (Paris). 2007 Nov;36(7):671-9.

[Article in French]Pédiatres des Maternités des Pays-de-la-Loire.

Dageville, C., Pignol, J. & De Smet, S. (2008). Very early neonatal apparent life-threatening events and sudden

unexpected deaths: incidence and risk factors. Acta Paediatr., 97(7):866-9. doi: 10.1111/j.1651-

2227.2008.00863.x.

Davanzo, R., De Cunto, A., Paviotti, G., Travan, L., Inglese, S., Brovedani, P., & ... Demarini, S. (2015). Making the

first days of life safer: preventing sudden unexpected postnatal collapse while promoting breastfeeding. Journal

Of Human Lactation: Official Journal Of International Lactation Consultant Association, 31(1), 47-52.

doi:10.1177/0890334414554927

References:

Gnigler, M., Ralser, E., Karall, D., Reiter, G., & Kiechl-Kohlendorfer, U. (2013). Early sudden unexpected

death in infancy ( ESUDI) - three case reports and review of the literature. Acta Paediatrica, 102(5), e235. doi:10.1111/apa.12165

Herlenius E. & Kuhn P. (2013). Sudden unexpected postnatal collapse of newborn infants: a review of cases,

definitions, risks, and preventive measures. Transl Stroke Res., 4(2):236-47. doi: 10.1007/s12975-013-

0255-4. Epub 2013 Feb 23.

Leow, J. Y., & Platt, M. W. (2011). Sudden, unexpected and unexplained early neonatal deaths in the North of England. Archives Of Disease In Childhood -- Fetal & Neonatal Edition, 96(6), F440.

doi:10.1136/adc.2010.206649

Ludington-Hoe, S. M., & Morgan, K. (2014). Article: Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact. Newborn And Infant Nursing

Reviews, 14(Hot Topics), 28-33. doi:10.1053/j.nainr.2013.12.009

Pejovic, N. J., & Herlenius, E. (2013). Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment. Acta Paediatrica, 102(7), 680-688. doi:10.1111/apa.12244

References: