Preventing Hypothermia-Related Hypoglycaemia: A Midwife's Role

This essay critically analyzes the role of postnatal midwives in preventing hypothermia-related hypoglycaemia in newborns. It begins by defining hypothermia and hypoglycaemia, highlighting their risks and the importance of proper neonatal care. The essay explores the physiological challenges newborns face, including heat loss mechanisms, and discusses the impact of cold stress on glucose metabolism. It examines the current practices in neonatal care, emphasizing the significance of maintaining a neutral thermal environment, and evaluates the specific actions midwives can take to prevent hypothermia. The essay incorporates a reflective model, presenting a case study to illustrate the issues and analyzing relevant literature to support the recommendations. It concludes by proposing improvements in practice, such as ensuring axillary temperature checks, and outlines a method for auditing the proposed changes, all while adhering to professional codes of conduct.

How postnatal midwives could
prevent hypoglycaemia related
to hypothermia in newborns

INTRODUCTION
Proper and organized neonatal care is critical to preventing several complex issues in new
born babies. Hypoglycaemia, related to hypothermia, is the most common metabolic problem in
newborns. However, considering its long term consequences, it is a serious concern to prevent
this condition in the infants. Hypothermia is the state of having a body temperature which is
abnormally low. The likelihood of developing hypothermia is more in newborns because they
have a larger surface area as compared to body weight (What are the symptoms of hypothermia
in infants and children?, 2015). This makes them lose body heat at a faster rate. Neonatal
hypoglycaemia is defined as the condition in which blood glucose level is lower than the normal
(Hypoglycaemia in the Newborn, 2015). In order to keep the body warm, the neonates utilize
glucose stores of the body which lads to hypoglycaemia. Postnatal midwives play a crucial role
in providing care and support to the newborns and their family. The present essay critically
analyses the aspect of hypothermia related hypoglycaemia in newborns within the environment
of neonatal practice. It will explore the ways in which postnatal midwives can prevent
hypothermia related hypoglycaemia in newborns within the neonatal special and transition care
unit. Good practice with regard to prevention of hypothermia related hypoglycaemia will be
analysed. Further, a thorough literature search has been conducted so as to explore and discuss
issues surrounding this area of neonatal practice. On the basis of analysis, one improvement or
change in practice will be recommended in the essay. Lastly, method used for auditing the
proposed changed will be described.
As per the NMC code of professional conduct, the nurses and midwives should respect
people's confidentiality (The code, 2008). Therefore in order to maintain confidentiality, the
actual name of the baby and the family has not been disclosed. In this regard, all the names have
been changed. This essay is based on a personal experience which took place in a neonatal
intensive care unit. With the objective of obtaining a good learning outcome and and
implementing it in future, Gibbs Model of reflection has been followed for this essay. According
to Jayatilleke (2012) reflective practices help nurse make sense of their work and analyse it. It
contributes to learning and professional development of a person (Jayatilleke, 2012). As per the
views of Fleming (2007) reflection leads to self awareness and enhances personal development
(Fleming, 2007). Gibbs reflective cycle is capable of encouraging a clear description of the
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situation. The present essay is based on a situation in which Miley gave birth to a baby, Jack,
who was bought up to the unit by an SHO. Jack was suffering from low blood sugar and
vomiting. On assessing the temperature of the baby, it was found that it was below limits
defined. Jack was nearly eight hours after birth and had no cloths. He was only wrapped in two
towels. The midwives on post natal ward did not ensure that the baby was warm enough. This
led to hypothermia and hypoglycaemia. For these reasons, Jack had to be admitted to the unit for
dextrose infusion. He was also kept nil by mouth due to history of vomiting.
According to NHS choices, babies are more likely to develop hypothermia because the
ability of their body to regulate temperature is not fully developed (Hypothermia, 2015).
Waldron and Mackinnon (2007) assert that in the management of neonates, thermoregulation is
more important. Hypothermia at birth is a world wide problem. It can also occur when the
neonates are being transferred to neonatal units during routine care. If immediately after
delivery, appropriate action is not taken the core and skin temperatures of a newborn can
decrease at the rate of 0.1 and 0.3 degree Celsius per minute respectively. According to the
World Health Organization, mild hypothermia is defined as a core body temperature of 36- 36.4
degree Celsius while moderate hypothermia as 35.9- 32 degree Celsius. A core body temperature
of less than 32 degree Celsius is defined as severe hypothermia. Knobel, Wimmer and Holbert,
(2005) also explain that the physical characteristics of the newborns and environment of the
delivery room. In typical situations, a wet newborn who has a high ratio of surface area to
volume, moves from a warm aqueous environment to delivery room which is comparatively
cooler and dry (Knobel, Wimmer and Holbert, 2005). Soll (2008) agrees that one of the key
physiologic challenges that newborn infant faces after delivery is maintaining a neutral thermal
environment. By paying attention to the management of neutral thermal environment of a
newborn, clinical outcome can be improved. While in utero, there is heat production by the fetus.
This leads to half a degree higher fetal temperature as compared to the maternal temperature.
After birth, the environment to which newborn is exposed is much different (Soll, 2008).
Knobel and Davis (2007) study revealed that the newborns may lose heat by our basic
mechanisms of conduction, radiation, evaporation and conduction. Heat loss through radiation
involves the temperature of those surfaces which surround the baby but are not in direct contact.
Heat energy is emitted by the newborn in the form of infrared electromagnetic waves (Knobel
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and Davis, 2007). As per the views of Guyton and Hall (2006) for an infant that is older than 28
weeks gestational age, heat loss through radiation is the most important source of heat transfer.
Through connection, heat can be lost when it is carried away from the body through air currents.
Similarly, evaporation also leads to loss of heat from the infant's body (Guyton and Hall, 2006).
Knobel, Wimmer and Holbet (2005) assert that if the newborn is not attended adequately, it may
result in hypothermia and cold stress. Hypothermia, in turn is responsible for a variety of
physiologic stresses (Knobel, Wimmer and Holbet, 2005). The infant experiences increased
oxygen consumption, metabolic acidocis, decreased cardiac output, hypoglycaemia and
increased peripheral vascular disease. According to Page- Goertz (2007), concern about
hypoglycaemia in newborn is a common issues however it may adversely affect subsequent
neurologic development. Cold stress or hypothermia is considered to be risk factor for
hypoglycaemia in newborns. More energy is used by a colds baby who is more prone to
becoming stressed and hypoglycaemic (Page- Goertz, 2007). This is because, cold stress leads to
an increase in the metabolic demands of infants at the time when there is only marginal
availability of glucose.
Klossner (2006) also agrees that in response to heat loss and low glycogen stores, a
newborn typically experiences hypoglycaemia (Klossner, 2006). Study by Burdan, Botiu and
Teodorescu (2009) considered neonatal hypoglycaemia as one of the most common problems
experienced in neonatal intensive care units. But it is of serious concern was prolonged
hypoglycaemia results in brain damage and mental retardation (Burdan, Botiu and Teodorescu,
2009). Study by Laptook and Jackson explores unique challenges that are posed by late preterm
infants for doctors and nurses taking care of them. There can be lack of attention regarding
important components which depict successful transition after birth. According to authors, cold
stress and hypoglycaemia are two important problems which can be seen in infants (Laptook and
Jackson, 2006). These problems require immediate attention. Therefore, it is important to carry
out surveillance of physiological variables to ensure that these problems do not affect the
successful adaptation of infant during early hours after birth.
It order to prevent hypothermia related hypoglycaemia, it is important for the midwives
to create a neutral thermal environment in the birthing area. In addition to this, there is also need
to reduce the risk of cold stress in the new born which can be done by towel drying and
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maintaining skin to skin contact with the mother. As per the guidelines provided by NHS on
prevention and management of neonatal hypothermia, the labour ward should be kept warm and
draft-free. Healthy infants should be dried and hat should be placed on the baby's head. It should
also be covered in warm towels so as to prevent heat loss (Prevention and management of
neonatal hypothermia, 2012). On analyzing the situation, it can be said that the midwife made
cautious efforts to dry the infant and covered it in warm towels which was a good practice.
However, she did not cover baby's head with a hat. It was observed that the labour ward was kept
as warn as possible.
As per the guidelines provided by NHS, it is a good practice to take the axillary
temperature during initial examination after birth. This is in accordance with the Examination of
the Newborn Policy Register Number 04225. However, on analysing the practice, it can be
critically evaluated that axillary temperature of the newborn was not taken by the midwife. As
per the reason given to the senior nurse, she was busy and had to assist in other deliveries. But,
recording of axillary temperature of newborn is crucial. This is because, intermittent temperature
recording taken from axilla is the most common way of monitoring temperature. According to
Elzouki and et.al. (2012) axillary temperature is a reasonable guide to deep body temperature
(Elzouki and et.al. (2012). Important information is provided by it about the thermal state of
body of the infant.
A critical evaluation of the study conducted by Dorina Rodica Burdan, Valentin Botiu,
Doina Teodorescu has been carried out. The study is based on an aim to analyze the incidence of
the risk factors related to neonatal hypoglycemia in Salvator Vuia obstetrics gynecology hospital
of Arad. The title chosen for the study is apt as it clearly reflects the content of report being risk
factors related to Neonatal hypoglycemia. The title has further mentioned the name of area
where the study is carried out. It has thus made the title a suitable one. The abstract section of
study has majorly focused on methodology. However, there has been a lack of content with
respect to background, conclusion and recommendations. This clearly needs an improvement as
merely reading the abstract may is not resulting in overall understanding of report. The
objectives framed for the study are apt as these reflect the aim to be covered by the researcher.
The methodology part has been presented by the researcher in a clear cut format. This is as the
researcher has clearly mentioned the study area as well as time frame in very beginning of the
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section. Statistical tools to be used for analysis are also mentioned clearly. The results section
has further focused on creation of tables, graphs and charts so as to depict a proper analysis.
However, the positioning of graphs and chart is not clear. It is quite difficult to understand as to
which text section represents the table and graph. Conclusion has further been written in to the
point format. These are enough to get a crux of entire study. But the researcher has failed to
present recommendation section as well as implication for further research. Overall the study has
followed a brief but presentable means of study. However, there exists a lack of understanding in
a few areas especially the results section which can be worked upon.
An another study was conducted by Zhou and et.al., 2014 on Hypoglycemia incidence
and risk factors assessment in hospitalized neonates. The title presented the basic understanding
of content but lacked in presenting the name of country where the study was to be carried out.
The name however appeared in abstract section. The abstract was well presented by making use
of proper headings and subheadings. These aided in better understanding of the areas that have
been covered in the study. The method section of study has analyzed the areas to be covered but
failed to mention the use of statistical tool from which the results have been derived. The result
section is apt as there has been presentation of numerical figures so as to show the incidence of
hypoglycemia in neonates. However, the author could have worked more on the presentation
section by adding more tables and charts. Conclusion further represents the major crux of study.
However the researcher lacks in presenting recommendation as well as implication of future
research. Overall the study has the presence of proper content but somewhere lacks in
presentation area.
The above studies selected for critical analysis were on the same topic being risk factors
related to neonatal hypoglycaemia. Both the studies made a fair attempt to research the risk
factors in a best possible manner. However, both of them missed the major section of
recommendations and future research impatiens. First study by Dorina Rodica Burdan, Valentin
Botiu, Doina Teodorescu was well presented but got a bit difficult to understand in the results
section. On the other hand the second study by Zhou and et.al., 2014 had all the necessary
content except for addition of tables and charts. Conclusion of both the studies was able to
provide the overall crux. One conclusion was in paragraph format while other was in points. Still
the areas were quite clear in both the studies.
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After the literaure has been crircally analuysed, improvement or change in practic can be
suggested. Considerin the literature there is requirement of a change in practice in the neonatal
intensive care unit. The intervention of dressing the baby in pre warmed clothes can be used by
postnatal midwives for preventing hypothermia related hypoglycaemia in newborns. McCall and
et.al. (2010) stress that hypoglycaemia results when the baby uses more glucose than is being
produced. Hypothermia can be prevented by two ways. The first way is through barriers to heat
loss while the second method is to provide external heat sources. The risk of cold stress in
newborns can be minimised by adhering to practice guidelines such as wrapping the baby in pre
warmed blankets and covering in pre warmed clothes. This intervention helps in keeping infant
warmer (McCall and et.al., 2010).
Mullany (2011) also agree that warm clothing help in preventing heat loss in infants. The
study found that there is a 10 step warm chain which should be followed for minimising the risks
of exposure to cold stress. Appropriate warm clothing forms an important step in this chain
(Mullany, 2011). Lunze and et.al. (2014) carried out 14 focus group discussions with mothers
and grandmothers in Zambia. It was found that it is important to dry the baby and keep it warm
by dressing in pre warmed clothes. Kumar and et.al. (2009) found that heat loss is a risk factor
that leads to hypothermia in newborns. The main method of heat loss from newborn is through
evaporation of amniotic fluid from the baby's body. However, it was also found that if the baby
is placed naked on a cold surface, heat from the body is lost due to conduction. At the time of
birth if the baby is exposed to a cold environment, considerable heat may be lost from its body in
the absence of thermal protection (Kumar and et.al., 2009). Lunze and Hamer (2012) asserted
that pre warmed clothes help in providing thermal protection to the baby. These also protect the
newborn from heat loss due to conduction and evaporation (Lunze and Hamer, 2012).
Ayaz and Efe (2008) suggest it is good practice to cover the newborn in pre warmed
clothes including a hat. Warm clothes prevent hypothermia by preventing the escape of heat
from unprotected surfaces of the body. Head of the newborn has a large surface are which
increases the amount of heat loss thus exposing the baby to the risk of hypothermia. Clothing
such as mittens, hat etc. play an important role in keeping the newborn warm (Ayaz and Efe,
2008). According to Leadford and et.al. (2013), air currents also remove the heat from body by
carrying away thin layer of warm air on the surface of skin (Leadford and et.al., 2013).
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The intervention of dressing the newborn in pre warmed clothes can be implemented by
making it as a part of newly released practice guidelines. Along with these guidelines, the
midwives will be asked to fill a checklist pertaining to each newborn baby. This checklist will
include all the measures taken to prevent hypothermia in that particular newborn. The checklist
can be inspected and monitored by the senior nurse. . Ayaz and Saleem (2010) agree that practice
guidelines are an effective way of implementing a change in practice. New practice guidelines
will help in effectively implementing this change in practice (Ayaz and Saleem, 2010). The post
natal midwives would be aware of the need and importance of covering the baby in pre warmed
clothes. However, this was not practised by them. In order to encourage the nurses to adopt the
practice of covering baby in pre warmed clothes, sessions and meetings can be held whereby
they can be informed about the new intervention.
For auditing the effectiveness of the proposed intervention of covering newborn in pre
warmed clothes, questionnaires will be provided to the health care professionals in the neonatal
ward. This audit will be carried out with the purpose of finding out the effectiveness of using pre
warmed clothes by postnatal midwives for preventing hypoglycaemia related to hypothermia in
newborns. The questionnaire will consists of open and close ended questions. Open ended
questions will help the health care professionals to provide detailed information about the
loopholes that the intervention possesses as well as the further improvements that can be
brought.
Hypoglycaemia related to hypothermia is a common problem in newborns. It is
extremely important to consider temperature changes that a newborn undergoes throughout its
journey from mother's womb to the outside world. The environment inside the womb is warm.
Hence, if the newborn is not provided a warmer environment after birth, it may experience cold
stress which leads to hypoglycaemia. This poses serious complications in the newborn which
may even lead to mental retardation. Therefore, prevention of hypothermia related
hypoglycaemia should b the major concern of postnatal midwives. For preventing cold stress, the
intervention of dressing the newborn in pre warmed clothes can be implemented. This success
and benefit of this intervention has been verified by different studies which state that pre warmed
clothes help in preventing hypothermia related hypoglycaemia in newborns.
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REFERENCES
Journals and Books
Elzouki, Y. A. and et.al., 2012. Textbook of Clinical Pediatrics. Springer Science & Business
Media.
Waldron, S. and Mackinnon, R., 2007. Neonatal thermoregulation. Infant. 3(3). pp.101-104.
Soll, F. S., 2008. Heat loss prevention in neonates. Journal of Perinatology. 28. pp.57–59.
Knobel R, Holditch-Davis D. 2007. Thermoregulation and heat loss prevention after birth and
during neonatal intensive care unit stabilization of extremely low birth weight infants. J
Obstet Gynecol Neonatal Nurs. 36. pp.280–287.
Guyton, A. and Hall, J., 2006. Textbook of Medical Physiology. 11th ed.. W.B. Saunders.
Knobel, R., Wimmer, J. and Holbert, D., 2005. Heat loss prevention for preterm infants in the
delivery room. J Perin. 25. pp.304–309.
Klossner, J., 2006. Introductory Maternity Nursing. Lippincott Williams & Wilkins.
Burdan, R. D., Botiu, V. and Teodorescu, D., 2009. Neonatal Hypoglycemia. The Incidence Of
The Risk Factors In Salvator Vuia Obstetricsgynecology Hospital, Arad. TMJ. 59(1).
pp.77-80.
Laptook, A. and Jackson, G. L., 2006. Cold stress and hypoglycemia in the late preterm ("near-
term") infant: impact on nursery of admission. Semin Perinatol. 30(1). pp.24-7.
McCall, M. E. and et.al. (2010). Interventions to prevent hypothermia at birth in preterm and/or
low birthweight infants. Cochrane Database of Systematic Reviews. 3.
Mullany, C. L., 2011. Neonatal hypothermia in low-resource settings. Semin Perinatol. 34(6).
pp.426–433.
Lunze, K. and et.al., 2014. Prevention and Management of Neonatal Hypothermia in Rural
Zambia. PLOS ONE. 9(4).
Kumar, V. and et.al., 2009. Neonatal hypothermia in low resource settings: a review. Journal of
Perinatology. 29. pp.401–412
Lunze, K. and Hamer, D. H., 2012. Thermal protection of the newborn in resourcelimited
environments. J Perinatol. 32. pp.317–324.
Leadford, A. E. and et.al., 2013. Plastic bags for prevention of hypothermia in preterm and low
birth weight infants. Pediatrics. 132. pp.128–134.
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Ayaz, S. and Efe, S. Y., 2008. Potentially harmful traditional practices during pregnancy and
postpartum. Eur J Contracept Reprod Health Care. 13. pp.282–288.
Ayaz, A. and Saleem, S., 2010. Neonatal mortality and prevalence of practices for newborn care
in a squatter settlement of Karachi, Pakistan: a cross-sectional study. PLoS One. 5.
p.13783.
Jayatilleke, N., 2012. Reflection as part of continuous professional development for public
health professionals: a literature review. Journal of Public Health. pp.1-5.
Fleming, P. 2007. Reflection a neglected art in health promotion. Health education research.
22(5). pp.658-64.
Online
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APPENDIX 1: REFLECTION
Description:
I was working in Neonatal Intensive Care Unit during my night shift when a baby was
brought to the unit by an SHO. The baby was suffering from low blood sugar and vomiting.
Assessment of the baby was done in the ICU. It was found that the temperature is below the
normal limits. Nearly 8 hours had passed after the birth of the baby but it was not dressed in
clothes. There were only two towels wrapped around the newborn.
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The postnatal midwives had not covered the baby in enough warm clothes. This made the baby
suffer from hypothermia. The glycogen stores were depleted in covering the heat loss and it in
turn led to hypoglycaemia in the newborn. The baby was admitted to the unit and was given
dextrose infusion. As it had a history of vomiting, the baby was kept nil by mouth. The baby was
also separated from mother ad could not be breast fed.
Feelings:
I felt bad about the situation because I expected that the post natal midwives were
experienced and knowledgeable enough to cover the baby in clothes. This was important to save
the baby from cold stress. I felt that the midwives were aware that a newborn comes from
mother's womb where the environment is much warmer. Hence, if adequate measures to prevent
heat loss are not taken, the newborn could suffer from hypothermia and later hypoglycaemia. I
felt sympathetic with the mother as well as the baby who were separated from each other and
hence skin to skin contact could not be fostered. The SHO realized the irresponsible behaviour of
post natal midwives. I think that post natal midwives play the most important role in the care of
newborn as well as the mother. Therefore, it is their responsibility to take care of maintaining
appropriate temperature so that newborn does not suffer from cold stress.
Evaluation:
The incident was an example of careless attitude of postnatal midwives. However, this
situation was helpful in bringing the loopholes in the care of newborns before the senior staff of
the department. But, it proved to be a negative experience for the baby and mother. Hypothermia
related hypoglycaemia has many serious consequences and could even have impacted the mental
growth of the baby. It was good that the baby was admitted to the NICU where it was assessed
properly and provided the necessary treatment. Along with the other nurses, I was alert to
provide appropriate treatment to the baby.
Analysis:
It can be analysed that it is a good practice to cover the newborn in clothes after drying
the baby. This is because baby has a larger surface area as compared to volume and hence suffer
from cold stress if appropriate measures to prevent heat loss are not taken. According to NHS
choices, babies are more likely to develop hypothermia because the ability of their body to
regulate temperature is not fully developed. As per the guidelines provided by NHS on
12

prevention and management of neonatal hypothermia, healthy infants should be dried and hat
should be placed on the baby's head. They should be dressed in warm clothes so as to prevent
heat loss.
Conclusion:
Looking back at the incident, the baby could have been prevented from becoming
hypoglycaemic if he was covered with warm clothes instead of towels. If faced with similar
situation in future, I would talk about it with the senior staff and bing forward the issue of
careless attitude of postnatal midwives.
Action:
On analysing the situation, I feel that the intervention of dressing the baby in pre warmed
clothes should be taken so as to avoid similar situations in future. In future, I will aim to develop
my assertive skills so that this one and other similar issues could be brought forward before the
senior staff of NICU.
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