Terri Russell, MS, NNP, RN, met Peter when he weighed less than 1½ pounds. The premature baby was born at 24 weeks-16 weeks early. Peter's mother was forced to deliver early because of pregnancy-induced hypertension. Had he been born much earlier, doctors would not have been able to save him.

Russell, a nurse in the neonatal intensive care unit at Loyola University Medical Center in Chicago, kept a close watch on Peter. She had to be alert for signs of eating problems, breathing difficulties, brain bleeding and a slew of other dangers specific to preemies.

Although Peter's outcome was uncertain, modern technology is the primary reason he had at least a fighting chance. Advances in medicine not only have reduced the ages of babies in NICUs, but also have transformed the experiences of the nurses who work in these units.

The technology is introducing challenging ethical questions and changing the nature of neonatal nurses' interactions with parents.

Artificial surfactant is one of the most pivotal innovations in NICUs nationwide, Russell said.

Preemies often fail to produce enough natural surfactant, a fluid that helps the alveoli remain open for normal breathing. Doctors today can administer artificial surfactant to assist babies who have immature lungs.

Preemies today also have the advantage of specialized baby ventilators. In the past, NICUs were filled with adult ventilators that were adjusted to breathe for newborns, but these machines inevitably put out too much oxygen and damaged the babies' lungs, said Elaine Eike, MSN, NNP, RN, a neonatal nurse at Seton Medical Center in Austin, Texas.

Job satisfaction
Eike said these advancements make her job even more satisfying.

"The job is much more enjoyable because I can honestly tell parents that in most cases, there is a reasonable chance that their child will live and do well," Eike explained.

In contrast, babies born at 34 weeks in the early 1960s had only a 3 percent chance of survival, according to a report from the Coalition for Prematurity Awareness.

In the early 1980s, preemies born at 26 weeks had about a 30 percent chance of survival.

Since the invention of artificial surfactant, these babies have about an 80 percent survival rate, and babies born at 34 weeks now have a 97 percent chance of living, according to the coalition's report.

Even with the aid of modern advancements, Peter was struggling to function smoothly. Russell and the other neonatal nurses vigilantly watched for any changes in his condition-a challenging job when the patients aren't even developed enough to cry when in pain, let alone talk.

Monitoring babies
The nurses use other clues as signs that something is wrong, such as changes in heart rate or sugar levels, or failure to respond to touch.

In addition to monitoring babies, Russell also has the job of relating information to the parents of preemies. She explains the purpose of the tubes and monitors to parents, who often are overwhelmed by spending the first months of their baby's life in a high-tech environment.

In fact, neonatal nurses today spend more time with the parents than ever before. Now, fathers and mothers are encouraged to bond with their babies and are considered important caregivers, despite the tubes and machines.

"Parents can get fixated with numbers on the monitors," said Susan Greenleaf, RN, a neonatal nurse at Tacoma General Hospital in Washington.

Greenleaf teaches parents that the technology is a valuable tool, but that they are still the baby's primary caregivers. Parents know the baby's needs because they usually spend more consistent time with the infant than the nurses who are in and out, depending on their shifts, Greenleaf said.

NICUs today also are populated with the older siblings of the preemies to encourage bonding, as well as to help the other children understand why their parents are at the hospital much of the time, nurses said.

For Russell, interacting with parents can be the greatest joy at times and a painful experience at others.

"In the early days, it was hard to see [Peter's father] so concerned for his wife and baby," Russell said. "It's also hard being the bearer of bad news. As time went on, though, they learned to trust me. They see that we're going through this together."

One of the pieces of bad news was that Peter had some bleeding in his brain. This put him at risk for cerebral palsy and other motor problems, Russell said. At 1 month of age, he needed surgery for another problem. The procedure would close a connection between two major blood vessels that usually close naturally in term babies.

Peter survived the surgery and, at 6 weeks, he was ready to breathe without a ventilator. He steadily grew to 4 pounds 10 ounces, and went home with his parents June 14.

The effects of brain bleeding likely will not show up until he is older, Greenleaf said.

Although the new technology allows babies like Peter to live, it also broaches complicated questions for neonatal nurses. Preemies are particularly at risk of suffering from impairments such as cerebral palsy, loss of sight, hearing loss and mental retardation, Greenleaf said.

"My job [poses] an ethical question because we are saving babies that shouldn't survive at all," she said. "Some turn out perfect, but some end up with a lot of damage."

At times, modern technology can make the job more emotionally trying for nurses. Babies who would have died soon after birth in the past now can be sustained for months in the NICU.

Greenleaf said it's more difficult to watch babies die after caring for them for several months, and because fewer babies die today than 10 years ago, it's even more of a blow when one doesn't make it, she said.

She remembers Dylan, one of two male twins born at 27 weeks. Dylan's twin brother died soon after birth, but Dylan was sustained in the NICU. He had lung problems and remained dependent on a ventilator to breathe. He also had feeding problems.

Dylan fought for life for six months, but then died of heart failure.

"You feel sad, and you feel a huge loss for the parents," Greenleaf said. "But you learn how to leave it at work because if you don't separate from the pain, you won't survive."

But Greenleaf, Eike and Russell all agree that one of the best sources of perspective is when former NICU babies come back to visit.

Eike remembers one boy who had been born extremely premature who stopped by the hospital to tell her he was studying chemical engineering in college. "When you have these little ones who weren't supposed to survive and they come back, it's pretty amazing," Eike said.