LITERATURE REVIEW: THE EFFECT OF PRONATION POSITION ON

HEMODYNAMIC CHANGE IN PREMATURE BABY WITH RDS

Siti RochmatulH(CA), Hotmaida S2, Kusmini3, Dony S4 Yetti Wilda5

(CA) Student in D3 Nursing Study Program in Sidoarjo, Majoring in Nursing, Health Polytechnic, Ministry
of Health, Surabaya, Sidoarjo; sitirhida0202@gmail.com (Corresponding Author)
2 Lecture in D3 Nursing Study Program in Sidoarjo, Poltekkes Kemenkes Surabaya; kepsida@gmail.com
3 Lecture in D3 Nursing Study Program in Sidoarjo, Poltekkes Kemenkes Surabaya; kepsida@gmail.com
4 Lecture in D3 Nursing Study Program in Sidoarjo, Poltekkes Kemenkes Surabaya; kepsida@gmail.com
5 Lecture in D3 Nursing Study Program in Sidoarjo, Poltekkes Kemenkes Surabaya; kepsida@gmail.com

ABSTRACT
The biggest cause of neonatal death is premature birth, reaching 35.2%. The mortality and morbidity rate in
premature infants is mostly caused by respiratory distress syndrome (RDS). One of the management is
giving pronation position. The design of this research is literature review using the compare technique is to
summarize and critize the similarities of articles and presented in new articles , with data sources : search for
research journals that have been carried out and published in national and international online journals
published in Indonesian and english from 2016-2020 using google scholar. The results of the analysis
showed that the average oxygen saturation of all initial journals was 93% to 96%. The average initial
respiratory rate was 55x/minute to 66x/minute. In addition, heart rate, temperature and pulse have improved.
Each duration can increase hemodynamic status due to after the pronation position given will provide calm
and comfort to the baby which has an impact on circulation in the body to be smooth. The results of the P
value in all journals used were <0.05, meaning that there was a significant effect before and after the
pronation position was carried out. This is because the heaviest part of the lungs is located on the back, so
patients who lie down with their weight on their back will have a harder time getting enough air. The
pronation position can be applied to premature babies to improve hemodynamic status which has an impact
on the baby's quality of life.
Keywords: Prone position, Hemodinamic, Premature baby

INTRODUCTION

Low Birth Weight (LBW) babies are babies born with a body weight of less than 2,500 grams (Arief,
2009). Low birth weight is caused by premature birth. Premature birth in babies occurs before 37 weeks of
gestation. The infant mortality rate is one of the indicators in determining the health status of children. In
2013 almost 1 million newborns died in the first 24 hours of life, meaning 16% of the total under-five
mortality and more than a third of neonatal deaths (Sri Wahyuni, 2020).
The main cause of neonatal death is respiratory distress at birth. Occurs in premature babies who have
respiratory problems will experience respiratory distress syndrome or commonly called Respiratory Distress
Syndrome.
Respiratory Distress Syndrome is a condition in premature infants that gives clinical features in the form
of increased respiratory effort, decreased lung complaints, atelectasis with decreased FRC, impaired gas
exchange and extensive interstitial edema. The incidence of respiratory distress syndrome is 60-80%
occurring in premature infants and only 5% in mature infants (Erlita, R, 2013).
The World Health Organization states that the prevalence of babies with LBW in the world is 15.5% or
about 20 million babies born every year (Journal of Development 2020). According to the results of the 2018
basic health research, the prevalence of LBW in Indonesia is around 6.2%. From 2012 to 2019, there was a
reduction from 20 million to only 14 million infant deaths (Ferdiyus, 109). LBW cases occurred in Indonesia,
which was ranked 6th out of 7 countries in Southeast Asia. The newborn mortality rate in East Java is still
high, currently East Java has not reached the SDGs target of infant and maternal mortality of 70/100,000
births, while East Java is still 90/100,000 births (Affanda, 2020). Sidoarjo Regency in 2018 the infant

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mortality rate

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with LBW reached 4.38 per 1,000 live births. Sidoarjo is ranked 8th in East Java (Central Bureau of Statistics
East Java).
Respiratory Distress Syndrome is an immature development of the respiratory system, or an inadequate
amount of surfactant in the lungs in premature infants due to a lack of age at birth which causes physiological
functions in the body, especially the lungs, which have not been able to adapt to the external environment.
The most common cause of respiratory distress syndrome is a lack of surfactant in the lungs. Surfactant is a
liquid that coats the inside of the lungs. The fetal lungs begin to make surfactant during the third trimester of
pregnancy (week 26 through labor).
One of the treatments that support oxygen therapy in previous studies is setting the baby's position,
namely the provision of a pronation position. The pronation position is a lying position on the abdomen with
the head turned to the side (Guisterners 2020). Pronation position is performed to improve respiratory
physiology and cardiovascular stability by reducing abdominal compression. Giving the pronation position is
not spared in the baby's own efforts to breathe spontaneously. All journals said that giving the pronation
position had a positive effect in changing hemodynamic status which became more stable. For this reason, by
adjusting the pronation position in premature infants with Respiratory Distress Syndrome, it can be included
in neonatal care interventions. This is to help reduce infant mortality due to Respiratory Distress Syndrome.
This literature study was carried out by researchers because there are still many cases of infant mortality
with Respiratory Distress Syndrome that cannot be saved or even defects in the respiratory system. This
study aimed to analyze the effect of the prone position on the hemodynamic status of preterm infants with
respiratory distress
Identifying hemodynamic status before being given a prone position on a LBW (Low Birth Weight
Babies) with Respiratory Distress Syndrome through literature review.Mengidentifikasi hemodynamic status
is given after the prone position on LBW (Infants Low Birth Weight) with Respiratory Distress Syndrome
through literature review. Analyzing the effect of pronation position on hemodynamic changes in LBW
(Low Birth Weight Babies) with Respiratory Distress Syndrome through literature review.

METHODS
Design of this research is literature review using the compare technique is to summarize and critize the
similarities of articles and presented in new articles , with data sources : search for research journals that
have been carried out and publish in national and international online journals published in indonesian and
english from 2016-2020 using google scholar database with keywords: Effect, Change hemodynamic,
premature baby with respiratory distress syndrome. Research journals found according to keywords are then
filtered through the inclusion and exclusion that have been set. A total of 10 journals obtained were filtered
using inclusion and exclusion obtained as many 3 journals. Then 2 of 10 journals were search not full text.
So, that 5 fulltext articles were reviewed. With The respondents was 126. Gender characteristics of the
research respondents were male and female infants with an average gestational age of 24-36 weeks with
premature birth. Infant respondents in this study with the lowest body weight is 700 grams and the largest is
2500 grams. Reviewing the abstract whether it is in accordance with the chosen theme, then reading the full
text journal, analysis and identify of purpose in journals and reviewing it. To further clarify the analysis of
the abstract and the full text of the journals, read and identify. The method of data analysis is the summary of
the research journal data entered into the table and then analysis the contents contained in the research
objectives and research result. Based on the journals review as described in table 1 then the research grouped
the data as follows:
Study design :

Table 1. research designs from review journals

No Study design Total Percentage

1 Quasi experimental design 4 80%

2 pre-experimental with a one- group approach pre- 1 20%

test- post test design

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 Total 5 100%

The research design reviewed is an used a Quasi-experimental design with 4 journals (80%) and pre-
experimental with a one-group approach pre-test-post test design as many as 1 journals (20%).The Research
subject or samples used in the research reviewed are all elderly people with joint pain (100%).

RESULTS AND DISCUSSION

a. Hemodynamic status before being given a pronation position in LBW (Low Birth Weight Babies) with
Respiratory Distress Syndrome

1. Journal 1 (Effect of Pronation Position on Hemodynamic Changes)

Table 2 Heart Rate, RR, and SpO2 before the baby is given a pronation position

Variable Mean Median SD Min – Max

HR before 156.62 162.00 15.86 123.00-180.00

RR before 48.65 48.00 16.72 18.00-106

SpO2 before 92.87 92.00 4,331 84.00-100.00

2.Jurnal 2 (Effect of Position of pronation In Premature Babies With CPAP Installed Against
Hemodynamic Status In space Rs Nicu An-Nisa Tangerang )

Table 3 hemodynamic status before granting the prone position

variable Mean SD Min - Max

Frequency breath before 73.97 5,881 65-85

pulse rate before 162.60 7614 148-178

oxygen saturation before 94.00 1,114 92-99

Frequency temperature before 36 717 0.0950 36.5-36.9

3. Journals 3 (Comparison of the Effectiveness of Prone and Lateral Positions on Oxygenation Status in
Infants with Respiratory Distress Syndrome in the NICU Room at GUN Hospital UNG JATI)

Table 4 Average HR, RR and oxygen status before pronation position

Variable Mean

HR before 141.34

RR before 36.13

SpO2 before 94.65

4. Journal 4 (The Effect Of Prone Position To Oxygen Saturation Level And Respiratory Rate Among
Infants Who Being Installed mechanical Ventilation In NICU KOJA HOSPITAL)
Tabel 5 Distribusi Saturasi oksigen dan frekuensi pernapasan sebelum posisi pronasi

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variable Group Measurement Mean SD SE

of Oxygen Intervention Before 91.13 2,031 0718

Saturation Control Prior 87.75 3,370 1,191

Intervention Before 55.38 12 939 4,575

respiratory rate
Control Before 71 1,069 0378

5. Journal 5 (Quarter Turn From Prone Position Increases Oxygen Saturation In Premature Babies With
Respiratory Distress Syndrome)
Table 6 Oxygen saturation before pronation position

Median
Variable Mean ± SD P value
(minimum-maximum)

94(89-96)
Oxygen saturation before 93.25±2.17 0.000

From all the journals above, it can be seen that the hemodynamic status of LBW infants
who experience Respiratory Distress Syndrome is not yet in a stable state before being given a
pronation position. All of the above journals use oxygen saturation, respiratory rate, and temperature
in determining hemodynamic status. The mean gestational age in this study was 24-36 weeks with preterm
delivery. With the lowest weight is 700 grams and the largest is 2500 grams.

b. Hemodynamic status after being given a pronation position in LBW (Low Birth Weight Babies) with
Respiratory Distress Syndrome

1. Journal 1 (Effect of Pronation Position on Hemodynamic Changes)

Table 7 Heart Rate, RR, and SpO2 after 1 hour and after 2 hours the baby is given a pronation

position Variable Mean Median SD Min – Max P

value

HR after 1 hour 145.75 147.00 24.05 141.00-174.00 0.027

HR after 2 hours 141.10 144.00 15.39 118.00-176.00 0.008

RR after 1 hour 47.87 44.00 12.52 26.00-88.00 .748

RR after 2 hours 47.68 48.00 14.60 19.00-102.00 .733

SpO2 after 1 hour 96.46 97.00 2.86 90.00-100.00 0.000

SpO2 after 2 hours 97.25 98.00 2.68 91.00-100.00 0.000

2.Jurnal 2 (Effect of Pronation Position in Premature Babies with Cpap Attached to Hemodynamic
Status in the intensive care unit Rs An- Nisa Tanggerang)

Table 8 Hemodynamic status after giving the pronation position

Variable Mean SD Min – Max

Respiratory rate after 69.50 4.516 63-79

Pulse rate after 144.87 7.660 130-157 Overall

oxygen saturation 96.87 1,074 95-99've

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 temperatures afterFrequency 36 827 0907 36.7-37

3. Journal 3 (Comparative Effectiveness Prone Position Status With Lateral Against Oxygenation In
Infants With Respiratory Distress Syndrome In Hospital NICU Space MOUNTAIN TEAK)

Table 9 average HR, RR, and oxygen status after pronation position

Variable Average 95% CI P value

HR after 8.23 6.47-9.98 0.000

RR after 2.03 1.73-2.32 0.000

SpO2 after 1.52 1.25-1.79 0.000

4. Journal 4 (The Effect Of Prone Position To Oxygen Saturations level And Respiratory Rate
Among Infants Who Being Installed Mechanical Ventilation In NICU KOJA HOSPITAL)
Tabel 10 Distribusi Saturasi oksigen dan frekuensi pernapasan sesudah posisi pronasi

variable Group Measurement Mean SD SE P Value

Saturation
Intervention After 95.25 1488 0526 0002
Oxygen
Control After 85 4209 1488 0024
Frequency
interventions After 65.13 9891 3497 0026
Respiratory
Control After 62.38 3662 1.295 0.000
5. Journal 5 (Quarter Turn From Prone Position Increases Oxygen Saturation In Premature Babies
With Respiratory Distress Syndrome)
T able 11 Oxygen saturation after pronation position

Median
Variable Mean ± SD P value
(minimum-maximum)

Oxygen saturation after 96.5(95-99) 96.55±1.32 0.000

From all the journals above, it can be seen that the hemodynamic status of LBW infants with
Respiratory Distress Syndrome after being given intervention in the pronation position improved. This
means that the hemodynamic status of LBW infants can be said to be in a stable state or within normal
limits. In giving this intervention the pronation position uses a control system, by installing a pulse
oximeter on the baby to determine the state of hemodynamic status when the pronation position
intervention is given.

c. Effect of Pronation Position on the status of hemodynamic changes after giving the pronation position

Table 12 Effect of pronation position on hemodynamic status in LBW infants with RDS

NO TITLE RESULT

1EffectofPronationPositiononThere is an effect of pronation position on Hemodynamic Changeshemodynamic chan

SPO2) with P-Value = 0.008

2 Effect of Pronation Position on Premature Babies

There
with
is Cpap
an effect
Attached
of pronation
to Hemodynamic
position onStatus
hemodynamic
in the Nicu
status
Roomw

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3 Comparison of the Effectiveness of Prone Position

Therewith
is the
Lateral
effectto
ofStatus
the prone
Oxygenation
position with
in Infants
a valuewith
of P-value
Respirator
=0

4 The effect Of prone position to Oxygen saturations

ThereLevel
is a And Respiratory
government Rate Among
influence given aInfants Whoposition
pronation Being Insta
with

5QuarterTurnFromPronePositionThere is an effect of giving a pronation Increases Oxygen Saturation In Prematurepo

With
Babies Syndrome RespiratoryDistress

From the results of the analysis table above, it can be said All journals that conductresearch say that
giving the baby a pronation position can affect the hemodynamic status of LBW who experience Respiratory
Distress Syndrome. Based on the results of the above analysis, P value <0.05, it means that there is an effect
of pronation position with hemodynamic status.

Based on the 5 literature reviews used, it is known that before the pronation position was carried
out, most of the respondents did not experience an increase in hemodynamic status and depended on oxygen
therapy devices such as ventilators so that there were many cases of death in premature infants with
respiratory distress syndrome. Efforts to reduce cases of mortality in premature infants by giving pronation
position. Some literature mentions that giving the prone position to premature infants with respiratory
distress syndrome can improve the hemodynamic state of the body.

LBW is related to gestational age that is not yet full term besides that it is also caused by
dysmaturity. This problem occurs due to impaired growth of the baby while in the womb caused by maternal
diseases such as placental abnormalities, infections, hypertension. Good nutrition is needed by a pregnant
woman so that the growth of the fetus does not experience obstacles, and then it will give birth to a baby with
a normal birth weight. Mothers with chronic malnutrition during pregnancy will give birth with low birth
weight. The baby really needs adjustment to the environment, this is because his physiology is still mature.
With a lack of gestational age in the fetus, this can affect the physiological functions of the baby being born.
This causes hyaline membrane disease. Hyaline membrane disease is caused by surfactant deficiency.
Surfactant is found in the alveoli. The surface of the alveoli in the lungs is lined by a thin layer called the
alveolar lining layer. Pulmonary surfactant is a complex material consisting of lipids and proteins that is
secreted by type II pneumotocytes that line the alveoli. These cells begin to appear at about 21 weeks of
gestation and begin to produce surfactant for the first time between 28 and 32 weeks of gestation. The main
function of this surfactant layer is to reduce the surface tension at the air-water interface of the alveolar fluid
layer, so that the normal mechanism of breathing can continue. Second, is to maintain the stability of the
alveoli and prevent the alveoli from collapsing. Third, surfactants can prevent pulmonary edema. Surfactant
deficiency or dysfunction causes severe respiratory disease. Respiratory Distress Syndrome in neonates is a
form of disease due to surfactant deficiency that is often found and is closely related to prematurity. In
premature babies, they can experienceor a condition respiratory distress syndrome when the baby is deficient
in surfactant. This can cause the tension in the alveoli to increase so that the alveoli collapse. When the
alveoli collapse there will be decreased ventilation and hypoxia occurs. Babies who experience this will try
to compensate for the oxygen supply by doing rapid shallow breathing in an effort to expand the lungs.
However, this can result in slowing of respiration resulting in respiratory acidosis.
Unstable hemodynamic status in LBW with respiratory distress syndrome due to premature birth. This is in
line with the Christian theory (2014) that prematurity is a gestation period of less than 37 weeks and the body
weight corresponds to the gestation period. So that the production of surfactant in infants is not perfect.

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Surfactant is a liquid that coats the alveoli so that it helps the alveoli to develop the lungs which begin to
form at 22 weeks of gestation, only reaching sufficient amounts before term. The function of surfactants is to
keep the alveolar sacs growing and filled with air. Babies who have surfactant deficiency will experience
hypoxia so that the alveoli collapse. This condition will cause vascular constriction and decreased pulmonary
perfusion, which eventually results in respiratory distress syndrome. Factors that facilitate the occurrence of
RDS in premature are caused by the alveoli that are still small so that it is difficult to develop, the
development is not perfect because the thorax wall is still weak, and the production of surfactant is not
perfect.
This is in line with the theory expressed by Marcdante (2014), that gestational age less than 28
weeks is usually followed by immaturity of the lung parenchyma, chest wall and capillary helium which
causes lung collapse at the end of respiration.

There is an inverse correlation between the incidence of RDS and gestational age, the younger the
baby, the higher the risk of RDS. However, LBW infants who have RDS are more dependent on lung
maturity than gestational age.

Provision of pronation position intervention with different durations of time, namely 30 minutes, 1
hour and 2 hours and some use intervention and control systems. Every duration that is done has a significant
impact. Every 30 minutes the first pronation position gives the baby peace of mind which has an impact on
blood circulation, the next 1-2 hours the baby's blood circulation will become calmer so that it affects the
hemodynamic status to be more stable. It can be said that each increase in time in the intervention of the
pronation position makes the hemodynamic status much better. Because the pronation position is a position
given to reduce abdominal compression and cannot be separated from the distribution of pressure in the
lungs more evenly. The duration of giving the baby a pronation position is adjusted to the needs, comfort,
and state of hemodynamic status.
In all journals that have provided intervention in the pronation position, the results of oxygen
saturation in infants have increased with an average initial oxygen saturation of 93% to 96%. And the
average initial respiratory rate is 55x/minute to 66x/minute. In addition, heart rate, temperature frequency
and pulse have improved. The increase in oxygen saturation and respiratory rate is caused by the pronation
position which causes the intrapleural pressure, transpulmonary pressure, and lung inflation to be more
homogeneous, especially in the dorsal part of the thorax. Pronation position can reduce lung pressure by
intra-abdominal organs so that it will improve oxygenation and carbon dioxide clearance

Galiatsatos the heaviest part of the lungs is located on the back, so patients who lie with their weight
on their back will have a harder time getting enough air. This study is in line with Venus, et al (2020) stated
in their study that when the patient is in the supine position, the compressive effects of gravity are amplified
on the chest wall, thereby compressing the dorsal segment and expanding the ventral segment. On the other
hand, if the patient is in the prone position, the effect of the chest wall will counteract the gravimetric effect.

Anatomically it is also explained that the increase in oxygen due to where the anatomy of the heart
is on the left between the top and bottom of the lungs makes the pulmonary pressure increase. Arterial
pressure at the apex is lower than at the base of the lung. Low arterial pressure causes a decrease in blood
flow in the apex capillaries, while the basal capillaries distend and increase blood flow. The effect of gravity
affects ventilation and blood flow where blood and air flow increases at the lung bases.

Based on the results of the research on the 5 journals described above, it is known that after the
intervention of giving the pronation position to premature infants with respiratory distress syndrome showed
that almost the majority of respondents experienced stabilization and even an increase within normal limits in
hemodynamic status. This happens because giving the baby a pronation position reduces compression on the
abdomen and reduces the burden on the lungs on the back. So that the lungs on the back can develop
perfectly because there is no pressure.
CONCLUSION
Based on the results of the literature review from the five journals, it can be concluded that
hemodynamic status is unstable in low birth weight babies who experience RDS due to incomplete surfactant
production in the pulmonary alveoli due to premature birth. pronation, the more stable the hemodynamic
status, and there is a very significant effect between the pronation position and hemodynamic status with the
p-value (p<0.05).
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It is hoped that the world of education can complement the existing literature, especially theories
related to the effect of giving the pronation position to premature babies with respiratory distress syndrome
so that it can be useful for students who will conduct similar research. The results of this study are expected
to be input in conducting non-pharmacological treatment to overcome the problem of mortality in infants. It
is hoped that further researchers can conduct research using more samples and by using different research
methods so that comparisons can be seen and are expected to get even better results.

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